Peds Nclex

At what point during the physical exam should a child with asthma be assessed for the presence or absence of intercostal retractions?Rationale:Intercostal retractions result from respiratory effort to draw air into restricted airways (A). The retractions will not be noticeable when air is expelled from the lungs, such as when the client is coughing (B) or expiring (D). During apnea (C), the client is not attempting to draw air into the airways. Apnea indicates that the respiratory effort is absent. A. Inspiration

B. Coughing

C. Apneic episodes

D. ExpirationSubmit

Incorrect | Correct Answer: AA father of a 5-year-old calls the nurse to report that his son, who has had an upper respiratory infection, is complaining of a headache, and his temperature has increased to 103° F, rectally. Which intervention has the highest priority?Rationale:The child is exhibiting symptoms that may indicate possible meningitis, and the parents should be encouraged to get immediate evaluation (D). (A, B, and C) are all valuable interventions after the client is assessed and diagnosed. A. Determine if the child has any allergies to antibiotics.

B. Instruct the parent to give the child tepid baths.

C. Instruct the parent to increase the child's fluid intake.

D. Tell the parent to take the child to the emergency department.

Submit Incorrect | Correct Answer: D

The nurse is planning postoperative care for a child who has had a cleft lip repair. What is the most important reason to minimize this child's crying during the recovery period?Rationale:Prevention of stress on the lip suture line (D) is essential for optimum healing and the cosmetic appearance of a cleft lip repair. Although crying also causes (A, B, and C), these conditions do not create a problem for the child with a cleft lip repair. A. Tear formation increases salivation.

B. This behavior increases respirations.

C. Excessive hysteria can lead to vomiting.

D. Crying stresses the suture line.Submit

Correct | Correct Answer: D

Prophylactic antibiotics are prescribed for a child who has mitral valve damage. The nurse should advise the parents to give the antibiotics prior to which occurrence?

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Rationale:Prophylactic antibiotics are usually prescribed prior to any invasive procedure for children who have valvular damage. Of the occurrences listed, only urinary catheterization (C) is an invasive procedure. (A, B, and D) are not invasive and do not require administration of prophylactic antibiotics. A. Adjustment of orthodontic appliances or braces

B. Loss of deciduous teeth (baby teeth)

C. Urinary catheterization

D. Insect bitesSubmit

Correct | Correct Answer: CThe school nurse notes that many 15-year-old middle school students are admitting to being sexually active. In developing a plan to try and delay the age at which students become sexually active, which intervention is likely to be most effective?Rationale:Family support and guidance regarding sexual activity have been shown to be the most influential factor in delaying adolescents' first sexual encounter (C). While (A, B, and D) might also be helpful in guiding responsible sexual behavior among adolescents, they are not likely to be as effective as (A). A. Encourage students to help each other remain celibate.

B. Write television advertisers requesting responsible advertising.

C. Enlist families' support in guiding their adolescents toward responsible sexual behavior.

D. Distribute educational materials about sexually transmitted diseases.

Submit Incorrect | Correct Answer: C

An infant is receiving digoxin (Lanoxin) for congestive heart failure. The baby's apical heart rate is assessed at 80 beats/minute. What intervention should the nurse implement?Rationale:Sinus bradycardia (rate of less than 90 to 110 in an infant) is an indication of digoxin toxicity, so assessment of the client's digoxin level has the highest priority (B). (A) is not indicated at this time. (C) provides helpful assessment data but does not address the cause of the problem and delays needed intervention. (D) is indicated for serious life-threatening overdose with digoxin. A. Call for a portable chest radiograph.

B. Obtain a therapeutic drug level.

C. Reassess the heart rate in 30 minutes.

D. Administer digoxin immune Fab (Digibind) stat.Submit

Correct | Correct Answer: B

A 6-month-old male infant is admitted to the postanesthesia care unit with elbow restraints in place. He has an endotracheal tube and is ventilator-dependent but will

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be extubated soon following recovery from anesthesia. What nursing intervention should be included in this child's plan of care?Rationale:Removing restraints one at a time (B) is safer than (C). The infant should have the restrained extremities assessed frequently for signs of neurologic or vascular impairment, and range-of-motion exercises should be performed with these assessments. Under no circumstances should restraints be applied to the client continuously (A). Documentation of assessment findings regarding the restrained extremities must occur much more frequently than every 72 hours (D); however, it is true that the reason for using restraints must be justified and should be stated in the medical record. A. Keep restraints on at all times to prevent unplanned

extubation.

B. Remove restraints one at a time and provide range-of-motion exercises.

C. Remove all restraints simultaneously and provide play activities.

D. Document the reason for application of the restraints q72h.Submit


The nurse admits a child to the intensive care unit with a diagnosis of acquired aplastic anemia. What is the most common cause of this type of anemia?Rationale:Aplastic anemia often follows exposure to certain drugs (D), such as chloramphenicol, sulfonamides, phenylbutazone (Butazolidin); insecticides, such as DDT; and chemicals, in particular, benzene. (A and C) are not related to the development of anemia. (B) is related to iron deficiency anemia. A. Bacterial infections

B. A diet deficient in iron

C. Heart-lung congenital defects

D. Exposure to certain drugsSubmit

Correct | Correct Answer: D

A 12-month-old boy is admitted to the hospital with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant?Rationale:Humidification liquefies the nasal secretions and increases the amount of secretions, thus making a patent airway (C) the highest priority. (A) maintains hydration and prevents tiring, but an open airway has a higher priority. (B) is important for evaluation of therapy. When asked "priority" questions, remember Maslow. Physical needs usually have a higher priority than psychosocial needs (D), and an open airway is the highest physiologic need. A. Give small, frequent feedings of fluids.

B. Accurately chart observations regarding breath sounds.

C. Have a bulb syringe readily available to remove

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secretions.

D. Encourage older siblings to visit.Submit

Incorrect | Correct Answer: C

What preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis?Rationale:Projectile vomiting (D), the classic sign of pyloric stenosis, contributes to metabolic alkalosis. Metabolic acidosis (A) is the opposite imbalance from alkalosis, and is not an expected finding. An antidiarrheal agent is not indicated (B). (C) is dangerous, due to the potential for aspiration with frequent vomiting. A. Monitor for signs of metabolic acidosis.

B. Estimate the quantity of diarrhea stools.

C. Place in a supine position after feeding.

D. Observe for projectile vomiting.Submit

Incorrect | Correct Answer: D

The nurse observes a 4-year-old boy in a daycare setting. Which behavior should the nurse expect this child to exhibit?Rationale:Four-year-old children are aggressive in their behavior and enjoy "tale telling" (C). (A and D) are typical toddler behaviors. A preschooler's play is usually cooperative, so playing alone (B) is not typical. A. Throws a temper tantrum when told he must share the toys

B. Plays by himself for most of the day

C. Boasts aggressively when telling a story

D. Cries and is fearful when separated from his parentsSubmit


Which nursing diagnosis has the highest priority when planning care for an infant with eczema?Rationale:Altered comfort (pruritus) (B) has the highest priority because itching will cause the infant to scratch, creating complications such as scarring or infection. (A, C, and D) are all important nursing diagnoses and should be considered when developing the infant's plan of care, but they do not have the priority of (B). A. High risk for altered parenting related to feelings of

inadequacy

B. Altered comfort (pruritus) related to vesicular skin eruptions

C. Altered health maintenance related to knowledge deficit of treatment

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D. Risk for impaired skin integrity related to eczemaSubmit

Incorrect | Correct Answer: B

A nurse is preparing to end the shift and receives a lab report stating that a child with asthma has a theophylline level of 15 mcg/dl. What action should the nurse take?Rationale:The therapeutic level of theophylline is 10 to 20 mcg/dl, so the child's level is within the therapeutic range. This information evaluates the prescribed therapy and should be communicated in the nurse's report (A). Based on the laboratory finding, (B, C, and D) are not indicated. A. Communicate the result to the oncoming nurse and

document.

B. Tell the oncoming nurse that the level is dangerously high.

C. Ask the lab to redo the test because the result is faulty.

D. Hold the next dose of theophylline based on this finding.Submit

Incorrect | Correct Answer: A

The nurse is assessing a male adolescent client's knowledge of contraception. The teen states, "I have all the info I need." What is the best response by the nurse?Rationale:Teens often obtain information from peers, which may not be accurate. Knowing the source of the information may assist the nurse in evaluating the information the teenager has regarding contraception (A). It would be best for the nurse to ask a more general question, such as (A); (B) is narrow in focus. (C and D) are blocks to any further communication. A. "Tell me what you know about birth control."

B. "Do you know how to apply a condom?"

C. "Teen pregnancy should not be taken lightly."

D. "You need to visit with your guidance counselor."Submit

Incorrect | Correct Answer: AWhich intervention(s) should the nurse include in the teaching plan for the mother of a 6-year-old who is experiencing encopresis secondary to a fecal impaction? (Select all that apply.)Rationale:Correct choices are (B, C, E, and F). Encopresis is fecal incontinence usually as the result of recurring fecal impaction and an enlarged rectum caused by chronic constipation. Encopresis is managed through bowel retraining with mineral oil (B) and saline enemas (C), eliminating dairy products (E), and initiating a regular toileting routine (F). A high-fiber diet, not (A), and increased daily fluids, not (D), are components of care for a child with encopresis. A. Provide a low-fiber diet.

B. Administer mineral oil daily.

C. Give a saline enema.

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D. Decrease the daily fluids.

E. Eliminate dairy products.

F. Initiate consistent toileting routine.Submit

Incorrect | Correct Answer: B,C,E,F

To take the vital signs of a 4-month-old child, which sequence should the nurse use to give the most accurate results?Rationale:The respiratory rate should be taken first (A) in infants, since touching them or performing unpleasant procedures usually makes them cry, which elevates the heart rate and makes respirations difficult to count (B). Temperature is the most invasive procedure and is most likely to precipitate crying and thus should be done last (C and D). A. Respiratory rate, heart rate, then axillary temperature

B. Heart rate, axillary temperature, then respiratory rate

C. Axillary temperature, heart rate, then respiratory rate

D. Axillary temperature, respiratory rate, then heart rateSubmit


During routine screening at a school clinic, an otoscope examination of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. Based on these findings, what action should the nurse take?Rationale:More information is needed to interpret these findings (B). The tympanic membrane is normally pearly gray, not bulging, and moves when a client blows against resistance or when a small puff of air is blown into the ear canal. Since these findings are not completely normal, further assessment of history and related signs and symptoms are needed to accurately interpret the findings. Based on the data obtained from the otoscope examination, (A, C, and D) are not indicated. A. No action required, as this is an expected finding for a

school-aged child.

B. Ask the child if he/she has had a cold, runny nose, or any ear pain lately.

C. Send a note home advising the parents to have the child evaluated by a healthcare provider as soon as possible.

D. Call the parents and have them take the child home from school for the rest of the day.

Submit Incorrect | Correct Answer: B

Ampicillin 75 mg/kg is prescribed for a 22-lb child. It is available in a solution that contains 250 mg/5 ml. How many milliliters should the nurse administer in one dose?Rationale:2.2 lb/1 kg = 22 lb/X kg

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X = 10 kg

1 kg/75 mg = 10 kg/X mg X = 750 mg

250 mg/5 ml = 750 mg/X mlX = 15 ml A. 10

B. 15

C. 20

D. 25Submit


The nurse is teaching an adolescent girl with scoliosis about a Milwaukee brace that her healthcare provider has prescribed. Which instruction should the nurse provide to this client?Rationale:The Milwaukee brace is designed to slow the progression in spinal curvature while the adolescent is growing. The brace should be worn 23 hours a day and removed a total of 1 hour a day for hygiene (A). There are no specific exercises for increasing the range of motion in the back that should be performed (B). A T-shirt should be worn next to the body and the brace put on over the T-shirt to protect the skin (C). The brace will not cure the spinal curvature (D), but should slow the progression of the scoliosis. A. Remove the brace 1 hour each day for bathing only.

B. Remove the brace only for back range-of-motion exercises.

C. Wear the brace against the bare skin to ensure a good fit.

D. Wearing the brace will cure the spinal curvature.Submit


When inserting a nasogastric tube into the stomach of a 3-month-old infant, which nursing intervention is most important to implement?Rationale:All interventions may be implemented during nasogastric tube insertion, but the most important nursing action is to monitor the infant's heart rate (B), which may decrease because of vagal nerve stimulation, and which can occur when the tube is inserted. (A, C, and D) are of less priority than (B). A. Use a blanket as a mummy restraint.

B. Monitor the infant's heart rate.

C. Lubricate the catheter with saline.

D. Explain the procedure to the parents.Submit

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A 7-month-old infant with a rotavirus causing severe diarrhea is admitted for treatment. Which intervention should the nurse implement first?Rationale:An infant with severe diarrhea is at high risk for dehydration, so the nurse's priority is to initiate IV fluids (C) to rehydrate the infant. (A, B and D) can then be implemented as needed. A. Obtain a scale to weigh the infant's diapers.

B. Instruct the mother to offer Pedialyte regularly.

C. Insert an intravenous (IV) line and begin IV fluids.

D. Obtain a stool specimen for analysis.Submit

Correct | Correct Answer: C

A woman whose first child died at 6 weeks of age due to sudden infant death syndrome (SIDS) is being discharged following the birth of her second child. The mother tells the nurse that she is fearful that this infant will also develop SIDS. Which response is best for the nurse to provide this woman?Rationale:The most effective way to provide emotional support is to acknowledge what the client may be feeling, be a sounding board for them to listen to themselves, and allow them to discover their own solutions (B). (A) implies to the mother that she can prevent SIDS from occurring, which is an unrealistic expectation. Offering personal opinion about what will help this client (C) or about what helped a neighbor (D) is not as effective as helping the client discover what would be best for herself. A. "You can prevent SIDS if your baby sleeps on his side or

back. You will have to monitor him carefully."

B. "The fear of losing another child to SIDS is very realistic. Have you thought about what you are going to do?"

C. "An apnea monitor will alert you if the baby stops breathing. This will give you the peace of mind you need."

D. "My neighbor's baby died of SIDS last year and she went to an SIDS support group. That really helped her."

Submit Correct | Correct Answer: B

A child with a permanent tracheostomy is confined to a wheelchair and is going to school for the first time tomorrow. During the school day, what intervention should be implemented for this child?Rationale:Suctioning supplies (D) should always be readily available for use with any client who has a tracheostomy. (A, B, and C) do not describe safe practices for this child with a tracheostomy. A. Cover the trach site with clothing so that other children

will not notice.

B. Apply suction for 30 seconds when inserting a catheter

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into the stoma.

C. Discourage the child from coughing deeply to remove mucous secretions.

D. Place suctioning supplies on the back of the wheelchair when transporting.

Submit Correct | Correct Answer: D

Which approach by the nurse is most helpful in communicating with a 2-year-old boy?Rationale:A 2-year-old child is usually afraid of strangers, but when the nurse assumes (B), it is soothing and nonthreatening to the toddler. (A) may cause fear or mistrust, and should not be done initially. Trust is established when the nurse talks to the mother and child, rather than (C). Saying the child's name is a good approach, but a toddler probably does not understand the concept of (D). A. Call the child by name while picking him up.

B. Talk quietly and assume an eye-level position.

C. Smile at the child while talking to the mother.

D. Say the child's name and say, "I am your nurse." Submit


The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about prevention of accidental poisonings. It is most important for the nurse to include which instruction?Rationale:The only reliable way to prevent poisonings in young children is to make the items inaccessible (B). Teaching children not to taste is important (A), but ineffective for young children. (C and D) will not control a child's curiosity. A. Tell children they should not taste anything but food.

B. Store all toxic agents and medicines in locked cabinets.

C. Provide special play areas in the house and restrict play in other areas.

D. Punish children if they open cabinets that contain household chemicals.

Submit Correct | Correct Answer: B

The nurse is taking the family history of a 2-year-old child with atopic dermatitis (eczema). Which statement by the mother is most important in formulating a plan of care for this child?Rationale:Environmental exposure to allergens (milk) and a positive family history for milk allergies are important data in planning care of the child with atopic dermatitis (D), since milk allergies can contribute to the child's outbreaks. (A) is not a contributing factor. (B)

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is an environmental factor in other skin diseases but does not have a strong correlation with eczema in children. (C) is not unusual and occurs in the diaper area, while atopic dermatitis occurs most often on the face and extensor aspects of the arms and legs. A. "Our first child was born with a cleft lip."

B. "We are very careful not to get sunburns in our family."

C. "My first child sometimes got a diaper rash."

D. "My husband and our daughter are both lactose intolerant."


The nurse expects a 2-year-old child to exhibit which behavior?Rationale:Two-year-old children are egocentric and unable to share (C) with other children. (A, B, and D) are behaviors of a preschooler. A. Build a house with blocks.

B. Ride a small tricycle 6 feet.

C. Display possessiveness with toys.

D. Look at a picture book for 15 minutes.Submit


A mother phones the clinic because her 6-year-old son, who has been taking prescribed antibiotics for 7 of the previous 10 days, continues to have a cough that she reports is worsening. Further questioning by the nurse reveals that the cough is non-productive. What advice should the nurse provide to this mother?Rationale:The child should be evaluated as soon as possible for pneumonia (D). Antibiotics usually improve symptoms during the first few days of treatment but should be continued for the full prescribed course. A continued cough after 7 days of antibiotic treatment may indicate an infectious process in the lower lungs, which could cause a nonproductive cough. Children with pneumonia can deteriorate unexpectedly and rapidly and can become seriously ill with no sputum production (A). (B) delays evaluation too long. While giving fluids is advisable, cough suppressants might mask symptoms of a serious condition (D). A. "Watch the boy a few more days and see if the cough

begins to produce sputum."

B. "The full 10-day course of antibiotics must be completed before effectiveness can be evaluated."

C. "Give the child plenty of fluids and an over-the-counter cough suppressant."

D. "Bring the child to the clinic today for an examination related to the cough."


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The nurse is preparing a child with an intussusception for a prescribed barium enema. What is the main purpose of conducting this procedure prior to surgical intervention?Rationale:Intussusception, an invagination or telescoping of one portion of the intestine into another, causes intestinal obstruction in children (usually occurs between 3 months and 5 years of age). Nonsurgical treatment is attempted with hydrostatic pressure created by barium instillation which often reduces the area of bowel intussusception (B), thereby negating the need for surgical intervention. A barium enema is likely to cause (A). A barium enema could be used to detect (C), but is not the reason for its use with intussusception. (D) is not a use for a barium enema. A. Evacuate the bowel of impacted feces.

B. Reduce the invaginated bowel segment.

C. Locate the presence of diverticula.

D. Identify the area of esophageal atresia.Submit


The nurse is examining a male child experiencing an exacerbation of juvenile rheumatoid arthritis and notes that his mobility is greatly reduced. What is the most likely etiology of the child's impaired mobility?Rationale:Joint inflammation and pain are the typical manifestations of an exacerbation of JRA (D). (A, B, and C) are not specifically related to JRA. A. Pathologic fractures

B. Poor alignment of joints

C. Dyspnea on exertion

D. Joint inflammationSubmit


A 4-year-old has cystic fibrosis. Which stage of Erikson's theory of psychosocial development is the nurse addressing when teaching inhalation therapy?Rationale:Children 4 to 5 years of age are in the "Initiative vs. Guilt" stage of Erikson's theory of psychosocial development (D). They enjoy being active and participating in role playing. "Autonomy vs. Shame and Doubt" occurs at 1 to 3 years of age (A). "Industry vs. Inferiority" occurs at 6 to 11 years (B), while "Trust vs. Mistrust" (C) occurs from birth to 1 year of age. A. Autonomy

B. Industry

C. Trust

D. InitiativeSubmit


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A 3-month-old weighing 10 lb 15 oz has an axillary temperature of 98.9° F. What caloric amount does this child need?Rationale:An infant requires 108 calories/kg/day. First step is to change 10 lb, 15 oz = 10.9 lb. Then convert lb to kg by dividing pounds by 2.2; 10.9/2.2 = 4.954 kg, rounded to 5 kg. Second step: multiply 108 calories/kg/day (108 x 5 = 540 calories/day). However, this infant requires 10% more calories because of the one degree temperature elevation. Ten percent of 540 (calories/day) is 54 and 540 + 54 = 594. This infant will require approximately 600 calories/day (C). (A, B, and D) are incorrect. A. 400 calories per day

B. 500 calories per day

C. 600 calories per day

D. 700 calories per daySubmit


the nurse implement to maintain suture line integrity during the initial postoperative period?Rationale:The use of an infant seat simulates a supine position with the head elevated (A) and also prevents aspiration. Prone positioning should be avoided to prevent disruption of the protective Logan's bow and prevent the infant from rubbing the face on the bed surface. Mittens (B) are not necessary and decrease the ability to provide sensory comfort, such as hand holding. Nasal suctioning (C) should be avoided to prevent trauma or dislodging clots at the surgical site. Water-soluble lubricant (D) will dry the suture line and cause crusting, which predisposes the suture line to poor healing and scarring. A. Place infant upright in an infant seat position.

B. Provide mittens with the use of elbow restraints.

C. Use soft rubber catheters for nasal suctioning.

D. Apply water soluble lubricant to the suture line.Submit


Following the administration of immunizations to a 6-month-old girl, the nurse provides the family with home care instructions. Which statement by the mother indicates that further teaching is needed?Rationale:Although fever may occur, non–aspirin-containing medications should be used due to the risk of Reye's syndrome (A). (B) indicates a severe reaction, while (C) is a common side affect. (D) decreases soreness in the thigh injection site. A. "I will give her a baby aspirin every 4 hours as needed for

fever."

B. "I will call the clinic if her cry becomes high-pitched or unusual."

C. "I know I can expect her to be irritable over the next 2

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days."

D. "I will exercise her legs regularly to decrease the soreness."

Submit Incorrect | Correct Answer: A

A child comes to the school nurse complaining of itching. Further assessment reveals that the child has impetigo. What action should the nurse take?Rationale:Impetigo is a staphylococcal infection and is transmitted by person to person contact. The child should be sent home with a note to the parents explaining the condition (A). (B) is not necessary as this is not a public health hazard. (C) slows the healing process and can contribute to spread of the infection. The lesions should be washed with soap and water and left open to air, but antimicrobial soap (D) should not be used on the lesions. A. Send the child home with a note to the parents about how

to care for the lesions.

B. Send the child home and report the occurrence to the health department.

C. Cover the lesion with a gauze dressing and send the child back to class.

D. Wash the lesion with antimicrobial soap and send the child back to class.

Submit Incorrect | Correct Answer: A

Which type of restraint is most useful for a toddler after a cleft palate repair?Rationale:Elbow restraints (C) prevent children from bending their arms and bringing their hands to the oral surgical site. (A) restrains the hands, but the child can still bend the head down and reach the hands. (B) is useful for short-term restraint during invasive procedures, but is impractical for use postoperatively for several hours. (D) restrains the body torso and is not appropriate to use following cleft palate repair. A. Wrist

B. Mummy

C. Elbow

D. JacketSubmit


A burned child is brought to the emergency department, and the nurse uses a modified "Rule of Nines" to estimate the percentage of the body burned. When calculating percentage of burn, which part of the child's body is proportionally larger than an adult's?Rationale:The standard "Rule of Nines" is inaccurate for determining burned body surface areas with children because a child's head and neck are proportionately larger than an adult's

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(A). Specially designed charts are commonly used to measure the percentage of burn in children. (B, C, and D) are not proportionately different. A. Head and neck

B. Arms and chest

C. Legs and abdomen

D. Back and abdomenSubmit

Incorrect | Correct Answer: AA 12-year-old boy complains to the nurse that he is "short" (4' 5" or 53 inches). His twin sister is 5 inches taller than he is (4' 10" or 58 inches). Based on these findings, what conclusion should the nurse reach?Rationale:Females experience a growth spurt at 9.5 to 14.5 years of age and males at 10.5 to 16 years of age (C). There are insufficient data to support (A); growth trends must be assessed to reach such a conclusion. (B) is not unexpected. The fact that the children are twins has less to do with their growth than the fact that they are male and female (D). A. The boy is not growing as normally expected.

B. The girl is experiencing a period of unexpected growth.

C. The normal growth spurt occurs in girls 1 to 2 years earlier than boys.

D. Male/female twins are not identical; therefore, their growth cannot be compared to each other.


The nurse should teach the parents of a child with a cyanotic heart defect to perform which action when a hypercyanotic spell occurs?Rationale:Assuming a knee-chest position with head and chest slightly elevated (C) will help restore hemodynamic equilibrium. (A and B) are incorrect positions and may in fact hinder the child's condition. (D) may cause chest pain or vasovagal response with resulting hypotension. A. Place the child's head flat with the knees on pillows above

the level of the heart.

B. Have the child lie on his right side with his head elevated on one pillow.

C. Allow the child to assume a knee-chest position with head and chest slightly elevated.

D. Encourage the child to sit up at a 45-degree angle, drink cold water, and take deep breaths.


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The nurse is teaching the parents of a 2-year-old child with a congenital heart defect about signs and symptoms of congestive heart failure. Which information about the child is most important for the parents to report to the healthcare provider?Rationale:Sudden and unexplained weight gain (B) can indicate fluid retention and is a sign of congestive heart failure. (A) is used by the child to reduce chronic hypoxia, especially during exercise. (C) is common: 2-year-olds are not expected to be toilet trained. (D) is normal. A. Sits or squats frequently when playing outdoors

B. Exhibits a sudden and unexplained weight gain

C. Is not completely toilet trained and has some "accidents"

D. Demonstrates irritation and fatigue 1 hour before bedtimeSubmit


A 7-month-old male infant diagnosed with spastic cerebral palsy is seen by the nurse in the clinic. Which statement by the parent warrants immediate intervention by the nurse?Rationale:Airway obstruction (A) is always a priority when caring for any client. (B and C) are characteristics of spastic cerebral palsy and may involve one or both sides. These children have difficulty with fine motor skills, and attempts at motion increase abnormal postures. (D) is an expected behavior and may need to be addressed but is not priority over choking. A. "My son often chokes while I am feeding him."

B. "Is it normal for my child's legs to cross each other?"

C. "He gets stiff when I pull him up to a sitting position."

D. "My 4-year-old son is jealous of his little brother."Submit


A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic for a routine evaluation. What assessment finding suggests the presence of a common complication often experienced by those with Down syndrome?Rationale:Congenital heart disease occurs in 40% to 50% of children with trisomy 21 (Down syndrome). Defects of the atrial or ventricular septum that create systolic murmurs (A) are the most common heart defects associated with this congenital anomaly. (B, C, and D) are not recognized as common complications of trisomy 21. A. Presence of a systolic murmur

B. New onset of patchy alopecia

C. Complaints of long bone pain

D. Recent projectile vomitingSubmit


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The nurse assigns an unlicensed assistive personnel (UAP) to provide morning care to a newly admitted child with bacterial meningitis. What is the most important instruction for the nurse to review with the UAP?Rationale:All of these are important measures to review with the UAP, but the most important is (A). Improper use of isolation precautions can place other staff and clients at risk for infection. (B, C, and D) promote client comfort and reduce anxiety, but are of less priority than (A). A. Use designated isolation precautions.

B. Keep the lighting in the room dim.

C. Allow the parents to assist with care.

D. Report any pain the child experiences.Submit

Incorrect | Correct Answer: AA newborn female whose mother is HIV positive is scheduled for the first follow-up assessment with the nurse. If the child is HIV positive, which initial symptom is she most likely to exhibit?Rationale:Respiratory tract infections commonly occur in the pediatric population, but the child with AIDS has a decreased ability to defend the body against these common infections. Thus, the most typical presenting symptom of a child who contracted AIDS through vertical transmission (i.e., from the mother during delivery) is a persistent cold or respiratory infection (C). (A, B, and D) are symptoms of AIDS complications that may occur later as the disease progresses. A. Shortness of breath

B. Joint pain

C. Persistent cold

D. OrganomegalySubmit

Correct | Correct Answer: CAn 18-month-old returns to the unit following a cardiac catheterization with a cannulated femoral artery site. Which intervention should the nurse implement?Rationale:The extremity should be extended to prevent trauma to the femoral catheterization site (B). (A or D) increases the risk for complications and are contraindicated. (C) is not necessary. Only the extremity that was catheterized requires immobilization. A. Teach the parents how to ambulate the child in the room

safely.

B. Show the parents how to hold the child with the extremity extended.

C. Restrain the child's lower extremities for a minimum of 4 hours.

D. Place the child in a prone position to apply pressure to the site.


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A child is admitted to the hospital for confirmation of a diagnosis of acute lymphoblastic leukemia. When performing the initial nursing assessment, which symptoms will this child most likely exhibit?Rationale:(A) lists the most common presenting symptoms of leukemia. Leukemic cells invade the bone marrow, gradually causing a weakening of the bone and a tendency toward pathologic fractures. As leukemic cells invade the periosteum, increasing pressure causes severe pain, and anemia results from decreased erythrocytes causing pallor. (B and C) could be associated with central nervous system disorders. (D) commonly occurs in children, but is not specific for leukemia. A. Bone pain, pallor

B. Weakness, tremors

C. Nystagmus, anorexia

D. Fever, abdominal distentionSubmit

Incorrect | Correct Answer: AThe nurse notes that a 16-year-old male client is refusing visits from his classmates. Further assessment reveals that he is concerned about his edematous facial features. Based on these assessment findings, the nurse should plan interventions related to the nursing diagnosis ofRationale:Peer acceptance and body image are significant issues in the growth and development of adolescents. (A) addresses the problem of a lack of contact with peers stemming from his desire to protect his ego. (B, C, and D) are not supported by the assessment finding. A. Social isolation.

B. Altered health maintenance.

C. Knowledge deficit.

D. Ineffective coping.Submit

Incorrect | Correct Answer: AA child breaks out with varicella infection (chickenpox) while hospitalized for a minor surgical procedure. What intervention should the nurse implement first?Rationale:The period of communicability of varicella is 2 days before the rash appears until all lesions are crusted and is spread by direct or indirect contact of saliva or vesicles. Strict isolation (C) is indicated to prevent further exposure to staff and others. Staff who have had varicella or the vaccine are not susceptible to contracting or spreading the virus and should be the only ones assigned to care for this client (D). (A) is not sufficient to prevent exposure to others. (B) must be done prior to exposure. A. Place a mask on the child before transporting outside the

room.

B. Immunize exposed family members with the varicella vaccine.

C. Place the child in strict isolation to prevent an outbreak on the unit.

D. Determine which staff have had varicella before making

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assignments.Submit

Correct | Correct Answer: CThe nurse is conducting an initial admission assessment of a 12-month-old child in celiac crisis. Which intervention is most important for the nurse to implement?Rationale:An infant having a celiac crisis has severe diarrhea and is at high risk for fluid volume deficit. The nurse should first assess for indications of fluid volume deficit (A), then implement (B, C, and D). A. Assess the child's mucous membranes and skin turgor.

B. Contact food services about needed menu restrictions.

C. Determine the child's food likes and dislikes.

D. Ask the parents about the child's recent dietary intake.Submit

Incorrect | Correct Answer: AIn making the initial assessment of a 2-hour-old infant, which finding should lead the nurse to suspect a congenital heart defect?Rationale:Diminished femoral pulses (D) could indicate coarctation of the aorta. In the normal transition period, (A and B) occur during the 4 to 6 hours after birth (second period of reactivity). (C) is a normal finding in the newborn. A. Irregular respiration and heart rate

B. Gagging

C. Blue feet and hands

D. Diminished femoral pulsesSubmit

Correct | Correct Answer: DA child with nephrotic syndrome is receiving prednisone (Deltasone). Which choice of breakfast foods at a fast food restaurant indicates that the mother understands the dietary guidelines necessary for her child?Rationale:A child receiving a corticosteroid for nephrotic syndrome should follow a low-sodium, low-fat, and low-sugar diet. Based on these guidelines, the best breakfast choice is (D). (A) is high in fat and sugar. (B and C) are high in fat and sodium. A. French toast sticks and orange juice

B. Sausage-egg muffin and grape juice

C. Canadian bacon slices and hot chocolate

D. Toasted oat cereal and low-fat milkSubmit

Incorrect | Correct Answer: DFollowing the reduction of an incarcerated inguinal hernia, a 4-month-old boy is scheduled for surgical repair of the inguinal hernia. Under which circumstance should the parents notify the healthcare provider prior to surgery?Rationale:The parents should notify the healthcare provider if the hernia remains irreducible (B) after implementing simple measures, such as gentle palpation, warm bath, and comforting

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to reduce crying. If a loop of intestines is forced into the inguinal ring or scrotum and incarcerates, swelling can follow and possible strangulation of the bowel, intestinal obstruction, or gangrene of the bowel loop can occur, necessitating emergency surgical release. (A and D) may cause the hernia to protrude, but do not necessitate notification of the healthcare provider. (C) may not be specific to the hernia. A. Crying that is unrelieved by comforting measures

B. Presence of an inguinal bulge after gentle palpation

C. Refusal to take oral feedings

D. Straining during defecationSubmit

Incorrect | Correct Answer: BFollowing the reduction of an incarcerated inguinal hernia, a 4-month-old boy is scheduled for surgical repair of the inguinal hernia. Under which circumstance should the parents notify the healthcare provider prior to surgery?Rationale:The parents should notify the healthcare provider if the hernia remains irreducible (B) after implementing simple measures, such as gentle palpation, warm bath, and comforting to reduce crying. If a loop of intestines is forced into the inguinal ring or scrotum and incarcerates, swelling can follow and possible strangulation of the bowel, intestinal obstruction, or gangrene of the bowel loop can occur, necessitating emergency surgical release. (A and D) may cause the hernia to protrude, but do not necessitate notification of the healthcare provider. (C) may not be specific to the hernia. A. Crying that is unrelieved by comforting measures

B. Presence of an inguinal bulge after gentle palpation

C. Refusal to take oral feedings

D. Straining during defecationSubmit

Incorrect | Correct Answer: BWhen caring for a child with congenital heart disease and polycythemia, which nursing intervention has the highest priority?Rationale:The key word in this question is polycythemia. Hydration (C) decreases blood viscosity and the risk for thrombus formation, the most common complication of polycythemia. (A and D) are nursing interventions for the cardiac client, but do not treat polycythemia. Fluid intake should be increased, not restricted (B). A. Administering oxygen therapy continuously

B. Restricting fluids as ordered

C. Maintaining adequate hydration

D. Maintaining digoxin levelsSubmit

Incorrect | Correct Answer: CA 3-week-old infant is referred to an orthopedic clinic because the pediatrician heard a click when flexing the child's right hip during a routine physical exam. The orthopedic physician suspects that the child might have developmental dysplasia of the hip (DDH). The parents ask the nurse to identify risk factors that are commonly associated with DDH. Which response is accurate?

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Rationale:Developmental dysplasia of the hip (DDH) occurs more often in infants who present in the breech position (C), not the vertex (head-first) position (A). Twice as many females as males present in breech position; thus 80% of children with DDH are females, not males (B). Sixty percent of breech presentations occur with first-born children, not subsequent siblings (D), possibly due to the unstretched uterus and compaction of surrounding abdominal contents, which tend to increase compression on the uterus in the nulliparous woman. A. Vertex delivery

B. Male gender

C. Breech presentation

D. Second-born childSubmit

Correct | Correct Answer: CThe nurse is preparing a teaching plan for the mother of a child who has been diagnosed with celiac disease. Choosing which lunch is in keeping with the therapeutic management of a child with celiac disease?Rationale:A child with celiac disease is managed on a gluten-free diet (B), which eliminates food products containing oats (A), wheat (C) rye (D), or barley. A. Turkey salad, milk, and oatmeal cookies

B. Baked chicken, cole slaw, soda, and frozen fruit dessert

C. Tuna salad sandwich on whole wheat bread, milk, and ice cream

D. A turkey sandwich on rye bread, orange juice, and fresh fruit


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Peds Nclex

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