What is the priority nursing intervention for

What is the priority nursing intervention for a child who has ingested a corrosive substance? Minimize potential vomiting. Observation for seizure activity. Remove gastric content by lavage. Maintenance of hydration Which behaviors would the nurse most likely find when assessing a child with Autism? Solitary play, repeated seemingly meaningless activities, odd body movements, obsessive about environment. Shows a wide range of emotions, moving from labile to aggressive and constant, unrecognizable verbal communication. Quietly engaged in parallel play with others, hugging everyone at times, and getting excited about seeing familiar people. Repetitions, hearing sounds, hurting others, hurting self, preoccupation with objects or sounds. Which findings and behaviors in the elementary school setting raise the concern that a child is being physically neglected? Select all that apply. Takes food from other children in the lunch room. Comes to school dirty, with body odor and uncombed hair. Wears summer clothes in the winter months. Shows bruises in various stages of healing. At a well-child visit, parents of a 3 week old infant report that when the baby is sleeping, her breathing stops for 25-30 seconds. What should be included in the initial plan of care? Changing from bottle feeding to nasogastric feeds Positioning with the neck hyperflexed Teaching parents cluster care to avoid over stimulation Teaching parents and other caregivers CPR The nurse is preparing home care instructions for an infant who has been diagnosed with Cystic Fibrosis. Which instruction would the nurse include in her plan? Select all that apply. Administer CPT treatments 1 hour before meals or 2 hours after meals Immunizations will be delayed until the child is free from any infections Avoid contact with individuals who are ill, especially with resp. infections Maintain respiratory isolation so infant will not spread a resp. infection Pancreatic enzymes will not be administered until the infant can eat solid food The nurse can obtain assessment information about a possible failure to thrive infant through which nursing actions? Select all that apply. Observe the mother and child during care and feedings Asking the mother to have someone else feed the child for one week and assess the weight difference Having the mother keep a written record of the child’s food intake Periodically call the mother to ask what the child has had to eat on a certain day During a visit to the clinic for a dressing change, a preschooler is told by his mother, “Be good or the nurse will give you a shot.” The best response for the nurse is: Explain to the child that nurses don’t give shots to children for not being good Smile and give the child a sticker when the dressing change is complete Continue the dressing change since the child is quiet and cooperative Explain to the parent that threatening the child is not necessary A child has been hospitalized for aspirin ingestion. Treatment includes administration of activated charcoal and IV fluids. What will the nurse closely monitor? Palpation for liver enlargement Blood pressure level Abdominal pain assessment Respiratory rate When performing a pain assessment on a child, which information should the nurse consider? Children can tolerate pain better than adults Opiods are more dangerous for children Vital signs reflect pain intensity Pain is an individualized experience An infant’s parents have been using a rear facing convertible car seat since birth. Parents should be encouraged to keep their child rear facing until the child has met which recommendation? 24 months and exceeds weight recommended by car seat manufacturer 18 month of age and weight of at least 28 lbs 16 months and meets the height and weight recommended by car seat manufacturer 12 months of age and weight of at least 20 lbs Which of the following actions by the school nurse is important in the prevention of Rheumatic fever? Ensure students are compliant with vaccination recommendations Recommend aspirin use for pain associated with sore throats Enforce recommendations for rest with Strept. Infection Stress importance of compliance with antibiotic therapy The father of a child with Kawasaki disease asks “Why is my son getting aspirin? I thought children should not take it.” What would be the nurse’s best response? It will help decrease the amount of desquamation that occurs on the fingers, toes, palms, and soles of feet You will have to speak with the physician why he has ordered that medication We can probably change to Tylenol if you are concerned with the possible problems with aspirin In this disease, aspirin is effective in reducing the risks of aneurysms and decreases temperature Following an immunization with DTap, nursing instruction includes the physician be immediately notified if which of the following occurs? Mild rash and arthralgia Anorexia and malaise Fever and erythema at the site Swelling of lips and hives How would the nurse respond to an expectant parent who asks, How can I protect my newborn from pertussis? See the doctor when the baby gets a respiratory infection Make sure you and your family gets the updated pertussis vaccine As long as you get your baby immunized, you won’t have to worry Cover your mouth when you cough near the baby Which intervention is appropriate for a hospitalized child who develops crops of lesions on the trunk that appear as a macular rash and vesicles? Continue to practice standard precautions Avoid contact with the child if caregiver is pregnant Screen visitors for immunity to measles Place the child in strict isolation RATIONAL: Which of the following would the nurse expect to observe in the prodomal phase of Rubeola? Koplik spots in the mouth Macular rash on the face Crops of vesicles on the trunk Petechiae on the soft palate RATIONAL: The nurse should include which of the following interventions when preparing a 4 year old for a diagnostic procedure? Keep equipment out of the child’s view during teaching Use correct medical and scientific terminology in explanations Tell the child procedures are never a form of punishment Communicate during a teaching session of about 30 minutes RATIONAL: The nurse is having difficulty communicating with a hospitalized 6 year old child. What technique might be the most helpful in developing trusting relationship? Ask the child to draw a picture about a child in the hospital Suggest that the mother read fairy tales to the child Discussing with the mother why the child is uncommunicative Suggest that the child keep a diary about his/her stay in the hospital RATIONAL: Which of the following suggests that a nurse has a non-therapeutic relationship with a patient and family? The nurse is able to withdraw when emotionally overload occurs but still remains in control Staff assignments allow the nurse to care for the same patient and family over extended time The staff nurse meets the family and patient every day in the cafeteria for lunch The nurse uses teaching skills to instruct patient an d family rather than doing everything for them RATIONAL: Parents of a 6 year old child demonstrate understanding of car seat safety when they report which information? The child is now able to ride with a parent in the front seat The child can share a seat belt with a sibling in the back seat The child is riding in the back seat in a shoulder and lap seat belt The child is using a booster seat since the child is 4’2 RATIONAL: A post-op tonsillectomy patient is restless and agitated, swallowing frequently, and has an increased heart rate. Which is the priority nursing intervention? Assessing the tonsil area with using a flashlight Rechecking the patient’s vital signs Visualizing the tonsil area using a tongue blade Suctioning the mouth for any fresh blood RATIONAL: A child is admitted to the floor with low grade fever, malaise, purulent conjunctivitis, mouth sores, intact bullae on her face and genitals. Mom reports the child just had a mild respiratory illness and started a new anticonvulsant, Dilantin, 2 days ago for an existing seizure disorder. The patient was due to take her Dilantin 1 hr ago. Which of the following orders should the nurse question? Topical lidocaine swish and spit QID Start D5 0.45 NS at maintenance rate Dilantin by mouth STAT IV Morphine for mouth pain, prn Q2h RATIONAL: DCE: The hourly maintenance IV fluid rate for a child weighing 68.5 lbs is how may ml/hr? Round to the first decimal place at the end of the question DCE:A 26 lb toddler is to receive 9.5mg/kg of Solumedrol over 15 minutes via the IV syringe pump. The Solumedrol is concentrated 62.5mg/ml. The IV rate would be ml/hr. Round answer to the 1st decimal place. A nurse is planning to speak with a parent support group about childhood autism. What will the nurse include? The earliest signs of autism are impulsivity and overactivity The majority of children affected by Autism experience learning delays Autism is usually diagnosed when the child goes to elementary school Significant signs of the disorder often manifest by 1 year of age RATIONAL: What is the most appropriate action for the nurse to take when a crying toddler has a blood pressure measurement of 120/70 mmHg? Quiet the child and retake the blood pressure Ask the parent if the child has had hypertension before Document the reading and check again in 1 hr Notify the physician of the measurement RATIONAL: The nurse assesses a 6 month old who weighs 7 lbs and 8oz. The infant’s birth weight was 5 lbs and 8oz. What should be the first action of the nurse? Discuss the baby’s wight with the mother and notify the physician that you are concerned there is a very significant change Perform a Denver Development Screening test and refer as necessary for treatment Assess the interaction between the mother and the child while discussing the child’s diet with the mom Reassure the mom that a baby who is small at birth may not gain weight as quickly and at this time the weight is normal RATIONAL: When planning automobile safety with the adolescent which of the following concepts explains risk taking behaviors? Engaging in separation from their parents Having a desire to master their environment Believing that they are invincible Demonstrating a defiant attitude RATIONAL: Which behaviors by parents and/or teachers will best assist the child in negotiating the developmental task of industry? Asking the child what he thinks he wants to achieve Decreasing expectations to eliminate potential failures Identifying failures and asking the child’s peers for feedback Structuring the environment so the child can master tasks RATIONAL: In evaluating the outcome of respiratory therapy for a child with Cystic Fibrosis, what would be the nurse’s expectation? Respiratory infections have been avoided Improved endurance for desired activity Improvement in the child’s appetite Secretions are cleared from the airways RATIONAL: Which of the following are the priority home care instructions for a child with a croup syndrome? During an attack, hold the child in a bathroom filled with cold humidified air for at least 30 minutes Maintain a calm environment, reducing crying which aggravates laryngospasm and increase hypoxia Use OTC decongestants or cough medications per labeled instructions Encourage the child to drink 500 to 1000ml of their favorite ice cold liquid daily? RATIONAL: The nurse prepares a 4 month old for a well child exam. Which statement by the parents demonstrates understanding of recommendations to prevent SIDS? We put her on her back on a soft surface We do not offer a pacifier at bedtime We avoid toys and soft blankets in the crib We use a pillow to position her in the bed RATIONAL: The initial plan of care for a 3 year old child with mild acute otitis media would include which treatment? Surgery for the insertion of tympanostomy tubes Administration of antihistamines and decongestants Symptomatic treatment and observation for the first 48 to 72 hr Oral antibiotics several times per day for 7 to 10 days RATIONAL: A nurse is called to assist a conscious 10 month old who is noted to be choking. What action does the nurse take first? Call for help from bystanders or 911 Begin CPR with rescue breaths Perform finger sweep of the mouth Deliver back blows and chest thrusts RATIONAL: New parents are asking the nurse about how infants acquire immunity. Which is the most appropriate response made by the nurse? Passive immunity develops in response to immunizations The infant acquires humoral and cell mediated immunity in response to infections Active immunity is acquired from the mother and lasts 6 to 7 months The infant acquires maternal antibodies that ensure immunity up to 12 months RATIONAL: A child who is 3 years old, is being admitted for about 1 week of hospitalization. Her parents tell the nurse that they are going to buy her a lot of new toys since she will be in the hospital. The nurse’s reply should be based on an understanding of which concept? Toys from home should not be brought since they may be carrying infectious organisms Buying new toys for the child is a maladaptive way to cope with parental guilt New toys will make the stress of hospitalization easier because the child feels loved Preschoolers often need the comfort and reassurance of familiar toys RATIONAL: The nurse is caring for an adolescent who had an external fixator placed after suffering a fracture of the wrist during a bicycle accident. Which statements by the adolescent would be expected about separation anxiety? I think I would like for my siblings to visit me but not my friends I hope my friends don’t forget about visiting me I will be embarrassed if my friends come to the hospital to visit I wish my parents could spend the night with me while I am in the hospital RATIONAL: A 10 year old requires daily medications for a chronic illness. Her mother has relayed to the nurse that she has to constantly nag her child to take her medicine before going to school. Which of the following is the most appropriate nursing action to promote the child’s compliance? Establish a contract with her with guidelines, rewards, and consequences Discuss with the mother the damaging effects of nagging her child Have her bring her medicine containers to her appointment so the medicine can be counted Suggest mom uses time outs when the child forgets her medicine RATIONAL: Which of the following actions is appropriate when the nurse is assessing breath sounds of an 18 month old crying child? Allow child to play with the stethoscope to distract and calm down before auscultating Auscultate breath sounds and chart that the child was crying Document that data are not available secondary to noncompliance Ask the parent to quiet the child so the nurse can listen RATIONAL: Which assessment would the nurse perform last when examining a 5 year old child? Lungs Throat Abdomen Heart RATIONAL: Which statement indicates that the parents of a toddler need more education about preventing foreign body aspiration? I won’t permit my child to have peanuts My toddler loves to play with balloons I keep objects with small parts out of reach I never leave coins where my child could get them RATIONAL: A child is born with inner epicanthal folds, transverse palmar creases, hypotonia, and hyperflexibility. During the first year of life, the child should be closely monitored for which conditions? Orthopedic malformations Ophthalmic and thyroid complications Dental malformation Cardiac and gastrointestinal complications RATIONAL: The nurse is screening for developmental delays and risk of cognitive impairment. Which early infant behaviors would warrant a referral for evaluation for cognitive impairment? Shrill cry, neurologically irritable, arching the back in response to touch, and pulling away from touch Poor eye contact while feeding, not responsive to contact, and diminished spontaneous activity Sleeping all the time and refusing to take a bottle or nurse, weight loss, and failure to gain weight Hypervigilance, scanning the environment, and only sleeping for short periods RATIONAL: The nurse teaches the child with cystic fibrosis that dosing of pancreatic enzymes is adjusted by which factor? Vitamin K levels Stool formation Nausea and vomiting Liver enzyme RATIONAL: A 3 month old with bronchiolitis has these assessment findings, T- 103.6, P- 160bpm, R- 70bpm, SaO2- 88%. The infant is fussy and coughs frequently. What is the priority nursing interventions? Administer humidified oxygen by nasal cannula Call the doctor to obtain an order for an antibiotic Start IV fluids D5W 1/2 NS to ensure adequate hydration Administer Tylenol to decrease the fever and oxygen demands. RATIONAL: A 6 year old in for his well child visit is due immunizations. Mom reports he had an asthma exacerbation and is taking high dose oral corticosteroids. Which vaccines could he receive at this time? DTap Varicella LAIV (live attenuated influenza vaccine) MMR

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