Final Flashcards
A nurse is caring for an adolescent who presents to the emergency department.
The nurse reassesses the adolescent at 1930. For each assessment finding, click to specify if the finding indicates that the adolescent’s condition has improved or has not changed.
Assessment Finding :
Heart rate
Oxygen saturation
Blood pressure
Oral intake
Dyspnea
Lung sounds
Respiratory rate
Improved:
- RR
- O2 sat
- oral intake
- HR
- BP
Not changed:
- lung sounds
- dyspnea
A nurse is caring for an adolescent in an emergency department.
History of rheumatic fever with resulting cardiac valve damage.
Manifestations presented a few days after having dental work performed. Now they are worse.
Which of the following should the nurse anticipate the provider will prescribe? For each potential provider’s prescription, specify if the potential prescription is anticipated or contraindicated for the client.
Obtain blood cultures x 3.
Administer antibiotic therapy.
Obtain an echocardiogram.
Restrict dental hygiene.
Perform strenuous exercise regimen twice daily.
Anticipated:
- Obtain blood cultures x 3.
- Administer antibiotic therapy.
- Obtain an echocardiogram.
Contraindicated:
- Restrict dental hygiene.
- Perform strenuous exercise regimen twice daily.
2 year old toddler admitted into ER. TEMP 102.2, HR 148, RR 42, BP 87/44, O2 89. Now → TEMP 100.3, HR 150, RR 28, BP 86/42, O2 95. Initially came in due to breathing problem. History of asthma. Currently restless and crying, clinging to parents. What would indicate that respiratory treatment has been effective?
- decreased RR
- increased O2 sat
- breath sounds in both bases
- decreased cough
- decreased nasal flaring
A nurse is caring for a school-age child who has leukemia.
Which of the following assessment findings should the nurse report to the provider?
Select the 6 findings that should be reported to the provider.
Respiratory rate
WBC count
Hemoglobin
Retractions
Breath sounds
Skin assessment
Upper respiratory infection
Oxygen saturation
Respiratory rate
WBC count
Retractions
Skin assessment
Upper respiratory infection
Oxygen saturation
A nurse is caring for a 2-month-old in the emergency department. infant is displaying nasal flaring, retractions, and diminished breath sounds in the left lobe, as well as poor feeding. the nurse places the patient on contact and droplet precautions. What is the most likely diagnosis, as evidenced by what?
RSV as evidenced by retractions
A nurse in the provider’s office is assisting with the care of a child.
Upon review of the child’s electronic medical record (EMR), the nurse should determine the child is at risk for developing which of the following conditions as evidenced by what?
seizures as evidenced by phenytoin level
A child was brought in for unexplained bruising, and red spots on shoulders/thighs/back. Has had cold for 2 months with no OTC relief. Lungs clear, moves all extremities with some swelling in knees and elbows. Patient had small nosebleed a few min ago, reports “my arms and legs hurt all over” nosebleed resolved with only a small amount of blood on tissues.
Differentiate the assessment findings for each diagnosis Leukemia, sickle cell or hemophilia
Temp- leukemia and sickle cell
Bruising- leukemia and hemophilia
Bleeding- leukemia and hemophilia
Elevated WBC- leukemia and sickle cell
Pain- ALL 3
What are the characteristics of duchenne muscular dystrophy?
Waddling gait
Lordosis
Calf muscle hypertrophy
The nurse is conducting a staff in-service on congenital heart defects. Which structural defect constitutes tetralogy of Fallot?
a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy
a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect?
A. Lateral incisors
B. Closed posterior fontanel
C. Sitting steadily without support
D. Uses thumb and index fingers in a pincer grasp
B. Closed posterior fontanel
A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant’s pain level
a. FLACC
b. Oucher
c. Faces
d. Visual Analog Scale
a. FLACC
A nurse is caring for a school-age child who has a systemic disorder and is
receiving antibiotics, immunosuppressants, and corticosteroids. Both of the child’s parents have a smoking history.
The child reports soreness in his mouth and refuses to eat.
Inspection of his mouth reveals a white, milky plaque that does not come off with
rubbing.
The nurse should suspect which of the following conditions?
A. Dermatitis
B. Candidiasis
C. Herpes simplex
D. Squamous cell carcinoma.
B. Candidiasis
A provider is caring for a preschool age child who has been diagnosed with pinworm infection. Which of the following symptoms is the child expected to exhibit?
perineal itching
A school-age child is admitted in vasoocclusive sickle cell crisis (pain episode). The child’s care should include which therapeutic interventions?
a. Hydration and pain management
b. Oxygenation and factor VIII replacement
c. Electrolyte replacement and administration of heparin
d. Correction of alkalosis and reduction of energy expenditure
a. Hydration and pain management
During an assessment of a newborn infant, the nurse suspects the infant has pyloric stenosis. What finding would cause the nurse to suspect this?
a.Projectile vomiting
b.Hypoactive bowel activity
c.Palpable olive-sized mass in the right lower quadrant
d.Pronounced peristaltic waves crossing from right to left
a.Projectile vomiting
A nurse is preparing to assist with applying a cast to a preschooler’s arm. Which of the following actions should the nurse take?
A. Wrap the arm of the child’s doll or toy prior to the procedure
B. Tell the child, “this will make your arm feel better”
C. Place a heated fan at the bedside to facilitate drying
D. Support the casted arm with a firm grasp
A. Wrap the arm of the child’s doll or toy prior to the procedure
A school-age child has been diagnosed with Kawasaki disease. What teaching should the nurse provide the family about the pharmacological management of Kawasaki disease?
A. Inactivated vaccines are permissible while receiving IV immunoglobulin for Kawasaki disease
B. The benefits of taking aspirin for Kawasaki disease outweigh the risk for Reye syndrome
C. Corticosteroids are often needed to control inflammation in Kawasaki disease
D. Platelet infusions are needed with Kawasaki disease to prevent internal bleeding
B. The benefits of taking aspirin for Kawasaki disease outweigh the risk for Reye syndrome
What is a clinical manifestation of bed bugs?
red rash
What does the surgical closure of the ductus arteriosus do?
a. Stop the loss of unoxygenated blood to the systemic circulation
b. Decrease the edema in legs and feet
c. Increase the oxygenation of blood
d. Prevent the return of oxygenated blood to the lungs
d. Prevent the return of oxygenated blood to the lungs
Which defect results in increased pulmonary blood flow?
a. Pulmonic stenosis
b. Tricuspid atresia
c. Atrial septal defect
d. Transposition of the great arteries
c. Atrial septal defect
An appropriate nursing intervention to minimize separation anxiety in a hospitalized toddler is to:
A. Explain procedures and routines.
B. Provide for privacy.
C. Encourage the parents to room in.
D. Encourage contact with children the same age.
C. Encourage the parents to room in.
A nurse is administering a steroid to a child diagnosed with idiopathic thrombocytopenic purpura (ITP); which of the following should the nurse monitor?
A. Infection
B. Anemia
C. Bleeding
D. Bruising
A. Infection
A 13-year-old girl asks the nurse how much taller she will become. She has been growing about 2 inches per year but grew 4 inches this past year. Menarche recently occurred. The nurse should base her response on knowing that:
a. Growth cannot be predicted.
b. The pubertal growth spurt lasts about 1 year.
c. Mature height is achieved when menarche occurs.
d. Approximately 95% of mature height is achieved when menarche occurs.
d. Approximately 95% of mature height is achieved when menarche occurs.
A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse?
A. “The teacher says my child has to squint to see the board.”
B. “My child has recently lost both front top teeth.”
C. “My child often cheats when we play board games.”
D. “Sometimes my child acts bossy with his friends.”
A. “The teacher says my child has to squint to see the board.”
A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?
a. Body weight
b. Skin integrity
c. Blood pressure
d. Respiratory rate
a. Body weight
A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client’s psychosocial needs according to Erikson?
A. Discourage visits from the client’s friends
B. Provide a daily session with a play therapist
C. Encourage the client to complete school work
D. Vary the child’s schedule each day
C. Encourage the client to complete school work
A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy.
Which of the following goals is the priority for the nurse to include in the plan of care?
A. Improve the client’s communication skills.
B. Provide respite services for the parents.
C. Foster self-care activities.
D. Modify the environment.
D. Modify the environment.
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?
A. Position the child laterally
B. Use a padded tongue blade.
C. Attempt to stop the seizure
D. Restrain the child’s arms,
A. Position the child laterally
A nurse is caring for a child who has pertussis. The child’s parent asks the nurse what the common name for this disease is. The nurse should respond with which of the following common names?
A. Mumps
B. Whooping cough
C. Fifth disease
D. Chickenpox
B. Whooping cough
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?
A: Place a pillow under the child’s head.
B: Position the child side-lying.
C: Loosen restrictive clothing.
D: Clear the area of hazards.
B: Position the child side-lying.
A nurse is assessing the psychosocial development of a toddler. The nurse should recognize that this stage is characterized by which of the following?
A. Imaginary playmates
B. Negative behaviors characterized by the need for autonomy
C. Demonstrations of sexual curiosity
D.Erikson’s stage of initiative versus guilt
B. Negative behaviors characterized by the need for autonomy
A nurse is providing health promotion teaching to an adolescent. Which of the following information should the nurse include in the teaching?
A. “Share piercing needles only with close friends you trust.”
B. “Limit your caloric intake to avoid becoming overweight.”
C. “Tanning beds are much safer than lying in the sun.”
D. “Your need for sleep will increase during periods of growth.”
D. “Your need for sleep will increase during periods of growth.”
Eriksons stages in order
Trust vs mistrust (infants)
Autonomy vs shame (toddlers)
Initiative vs guilt (preschool)
Industry vs inferiority (school age)
Identity vs role confusion (adolescent)
A four month old is losing weight vomiting has a distended abdomen hypoactive bowel sounds not tolerating formula feeding meconium was past 56 hours after birth.
What would the nurse suspect?
What will the nurse do (action)?
What will the nurse monitor?
Hirschsprung’s dx
action:
- rectal biopsy
- rectal pull through
monitor:
- abdominal circumference
- temp
5 year in acute care setting with sickle cell anemia. Admitted for vaso occlusive crisis. Tylenol is given to decrease pain but pain is getting worse. Recent upper respiratory infection 2 weeks ago. VS → TEMP 100, HR 120, RR 24, BP 90/48, O2 98. Pain in both knees and elbows 10 out of 10. Mucous membrane is dry. Has not been drinking or eating much last few hours. On 2L of O2. IV fluids are now infusing, and IV morphine given for pain. What assessment findings require additional action by the nurse?
- retractions/nasal flaring
- wheezing
- joint and chest pain of 4
- uncooperative/agitated
- O2 decreased
A nurse is collecting data from a child who is descending stairs by placing both feet on each step and holding on to the railing. The nurse should understand that these actions are developmentally appropriate at which of the following ages?
A. 3 years
B. 4 years
C. 5 years
D. 6 years
A. 3 years
A nurse in a clinic is assessing a 7 month-old infant. Which of the following indicates a need for further evaluation?
a. Uses a unidextrous grasp
b. Has a fear of stranger
c. Shows preferences towards foods
d. Babbles one-syllable sounds
d. Babbles one-syllable sounds
