Final Flashcards
the process by which development proceeds from the head downward through the body and toward the feet
cephalocaudal development
the process by which development proceeds from the center of the body outward to the extremities
proximodistal development
How do children grow?
Cephalocaudal (head-to-toe)
Proximodistal (center-to-periphery)
The term used to refer to growth assessment of various parts of the body.
anthropometric measurement
Anthropometric measurements include:
- Weight (monitors nutrition and overall health)
- Height/Length (assesses skeletal growth)
- Head Circumference (important for brain development in infants and toddlers)
- BMI (Body Mass Index) (evaluates weight-for-height ratio, detecting undernutrition or obesity)
Why are anthropometric measurements so important?
These measurements are crucial for monitoring normal growth, detecting developmental concerns, and ensuring proper nutrition.
Match the growth development with the correct age group.
Birth weight doubles by 5-6 months and triples by 1 year. Length increases by 50% in the first year.
a. Infants (0-12 months)
b. Toddlers (1-3 years)
c. Preschoolers (3-5 years)
d. School-age (6-12 years)
e. Adolescents (12-18 years)
a. Infants (0-12 months)
How much should the infant weigh by the time they are six months old?
double their birth weight
How much should the infant weigh by the time they are 12 months old?
triple their birth weight
Match the growth development with the correct age group.
Growth slows; weight gain is about 4-6 lbs/year, height increases ~3 inches/year.
a. Infants (0-12 months)
b. Toddlers (1-3 years)
c. Preschoolers (3-5 years)
d. School-age (6-12 years)
e. Adolescents (12-18 years)
b. Toddlers (1-3 years)
Match the growth development with the correct age group.
Steady growth, about 4-6 lbs and 2.5-3 inches per year.
a. Infants (0-12 months)
b. Toddlers (1-3 years)
c. Preschoolers (3-5 years)
d. School-age (6-12 years)
e. Adolescents (12-18 years)
c. Preschoolers (3-5 years)
Match the growth development with the correct age group.
Consistent growth of 4-7 lbs and 2 inches per year.
a. Infants (0-12 months)
b. Toddlers (1-3 years)
c. Preschoolers (3-5 years)
d. School-age (6-12 years)
e. Adolescents (12-18 years)
d. School-age (6-12 years)
Match the growth development with the correct age group.
Growth spurts occur, with girls reaching peak height earlier than boys.
a. Infants (0-12 months)
b. Toddlers (1-3 years)
c. Preschoolers (3-5 years)
d. School-age (6-12 years)
e. Adolescents (12-18 years)
e. Adolescents (12-18 years)
Breast milk is the optimal source of nutrition for the first ________, providing essential antibodies and nutrients.
a. 3 months
b. 6 months
c. 9 months
d. year
b. 6 months
Which type of formula is the best to use if breastfeeding is not an option/.
iron-fortified formula
When should solids be introduced to the infant?
a. 2-3 months
b. 3-5 months
c. 4-6 months
d. 5-9 months
c. 4-6 months
Why should parents avoid giving their infants cow’s milk before they reach the age of 12 months old?
it lacks essential nutrients and can cause anemia
What is important about immunizations?
- Prevention of disease
- Herd immunity
Why is it important to document vaccinations?
Proper documentation ensures accurate records for school entry, travel, and future healthcare needs.
A nurse is educating a group of parents about the growth patterns of children. Which statement by a parent indicates an understanding of the information?
A. “My baby will develop fine motor skills before gross motor skills.”
B. “Growth occurs in a cephalocaudal pattern, meaning my baby will develop head control before walking.”
C. “My child’s growth will always be consistent each month without variation.”
D. “Proximodistal growth means my baby’s hands will develop before their shoulders.”
B. “Growth occurs in a cephalocaudal pattern, meaning my baby will develop head control before walking.”
Rationale: Growth follows a cephalocaudal pattern, meaning it progresses from head to toe. Infants develop head control first, then trunk stability, and eventually walking. Proximodistal growth occurs from the center outward, meaning the shoulders develop before the hands. Fine motor skills develop after gross motor skills. Growth is not always linear and can occur in spurts.
The nurse is assessing a 12-month-old infant during a well-child visit. Which anthropometric measurement is most crucial to assess brain development at this age?
A. Weight
B. Length
C. Head circumference
D. BMI
C. Head circumference
Rationale: Head circumference is a critical anthropometric measurement in infants, as it assesses brain growth and development. Abnormal head circumference may indicate conditions such as hydrocephalus or microcephaly. Weight and length are important but do not specifically assess brain growth. BMI is used in older children to evaluate weight-for-height status.
A mother brings her 2-year-old child to the pediatric clinic for a routine check-up. Which statement by the mother indicates normal growth for this age?
A. “My child has gained about 10 pounds this year.”
B. “My child’s weight is the same as it was last year.”
C. “My child is gaining about 4-6 pounds per year.”
D. “My child’s height has increased by 6 inches since last year.”
C. “My child is gaining about 4-6 pounds per year.”
Rationale: Toddlers (1-3 years) experience a slower rate of growth compared to infancy, with an expected weight gain of about 4-6 pounds per year. Height increases by approximately 3 inches per year. A weight gain of 10 pounds would be excessive, and no weight gain would be concerning.
The nurse is teaching a new mother about infant nutrition. Which statement by the mother indicates a need for further teaching?
A. “I will introduce solid foods around 4-6 months.”
B. “Breast milk or iron-fortified formula should be the main source of nutrition for the first year.”
C. “I will introduce new foods one at a time to watch for allergies.”
D. “I can give my baby whole cow’s milk at 6 months.”
D. “I can give my baby whole cow’s milk at 6 months.”
Rationale: Whole cow’s milk should not be introduced before 12 months because it lacks essential nutrients like iron and may lead to anemia. Breast milk or iron-fortified formula should remain the primary source of nutrition for the first year. Solid foods can be introduced at 4-6 months, and new foods should be introduced one at a time to monitor for allergies.
A nurse is reviewing immunization documentation in a child’s medical record. Which entry is correctly documented?
A. “DTaP vaccine given, lot #56789, left thigh, administered by Nurse B.”
B. “MMR given today by nurse in the clinic.”
C. “Varicella vaccine administered with no complications.”
D. “Influenza shot given, parents informed.”
A. “DTaP vaccine given, lot #56789, left thigh, administered by Nurse B.”
Rationale: Proper vaccine documentation includes the vaccine name, lot number, administration site, date, and the nurse who administered it. Entries without lot numbers, specific sites, or provider information are incomplete and do not meet proper documentation standards.
Match the appropriate toys and development with the correct age group.
Soft rattles, teething toys, mobiles, mirrors, soft books, and textured toys that promote sensory development.
a. Infants (0-12 months)
b. Toddlers (1-3 years)
c. Preschoolers (3-5 years)
d. School-age children (6-12 years)
e. Adolescents (12+ years)
a. Infants (0-12 months)
Match the appropriate toys and development with the correct age group.
Stacking blocks, shape sorters, push-and-pull toys, musical instruments, and large-piece puzzles to encourage fine and gross motor skills.
a. Infants (0-12 months)
b. Toddlers (1-3 years)
c. Preschoolers (3-5 years)
d. School-age children (6-12 years)
e. Adolescents (12+ years)
b. Toddlers (1-3 years)
Match the appropriate toys and development with the correct age group.
Pretend play toys (dolls, play kitchens), coloring books, tricycles, and simple board games to develop imagination, coordination, and social skills.
a. Infants (0-12 months)
b. Toddlers (1-3 years)
c. Preschoolers (3-5 years)
d. School-age children (6-12 years)
e. Adolescents (12+ years)
c. Preschoolers (3-5 years)
Match the appropriate toys and development with the correct age group.
Bicycles, arts and crafts kits, science kits, sports equipment, and board games that promote problem-solving and teamwork.
a. Infants (0-12 months)
b. Toddlers (1-3 years)
c. Preschoolers (3-5 years)
d. School-age children (6-12 years)
e. Adolescents (12+ years)
d. School-age children (6-12 years)
Match the appropriate toys and development with the correct age group.
Books, video games with educational value, sports equipment, musical instruments, and technology-based learning tools to enhance critical thinking and creativity.
a. Infants (0-12 months)
b. Toddlers (1-3 years)
c. Preschoolers (3-5 years)
d. School-age children (6-12 years)
e. Adolescents (12+ years)
e. Adolescents (12+ years)
When the nurse communicates with a patient for assessment and education, what is important for the nurse to understand when speaking to them?
Effective communication involves understanding the patient’s age, developmental level, language, and cultural background.
What is important to know when teaching about the prevention of SIDS?
SIDS prevention focuses on safe sleep practices to reduce the risk of sudden infant death.
The nurse is educating a group of parents on age-appropriate toys. Which toy would be most appropriate for a 9-month-old infant?
A. Small building blocks
B. Jump rope
C. Soft teething rings
D. Jigsaw puzzle
C. Soft teething rings
Rationale: Infants explore their environment through their mouths, making teething rings an appropriate choice. Small building blocks pose a choking hazard, jump ropes are for older children, and jigsaw puzzles require fine motor skills beyond an infant’s developmental level.
A mother asks the nurse about the best toys for her 3-year-old. Which response by the nurse is most appropriate?
A. “A toy kitchen set or dolls can help with imaginative play.”
B. “Video games with puzzles are great for cognitive development.”
C. “Small marbles and magnets are ideal for fine motor skills.”
D. “A bicycle with hand brakes will promote coordination.”
A. “A toy kitchen set or dolls can help with imaginative play.”
Rationale: Preschoolers (3-5 years) engage in imaginative play, making pretend kitchen sets and dolls ideal. Video games are more suitable for older children, marbles and magnets are choking hazards, and a bicycle with hand brakes is too advanced for a 3-year-old.
A nurse is preparing to teach a 5-year-old child about an upcoming procedure. Which strategy would be most effective?
A. Use medical terminology and detailed explanations.
B. Ask the child to read an informational pamphlet.
C. Give a step-by-step lecture about the procedure.
D. Provide a simple explanation and allow the child to play with medical equipment.
D. Provide a simple explanation and allow the child to play with medical equipment.
Rationale: Young children understand concepts better through hands-on experiences. Allowing them to explore medical equipment reduces fear. Using medical terminology, expecting them to read, or providing long lectures would not be effective at this age.
A nurse is assessing a 10-year-old patient. What is the best approach to ensure effective communication?
A. Speak only to the parent to obtain accurate information.
B. Use abstract language to challenge the child’s cognitive skills.
C. Provide straightforward explanations and allow the child to express concerns.
D. Use baby talk to make the child feel comfortable.
C. Provide straightforward explanations and allow the child to express concerns.
Rationale: School-age children can understand logical explanations and should be given the opportunity to ask questions. Speaking only to the parent excludes the child, abstract language is confusing, and baby talk is inappropriate.
A new mother asks the nurse how to reduce the risk of SIDS. Which statement by the mother indicates a need for further teaching?
A. “I will always place my baby on their back to sleep.”
B. “I can let my baby sleep in my bed as long as I remove blankets and pillows.”
C. “I will avoid exposing my baby to cigarette smoke.”
D. “Using a firm mattress without extra bedding is safest for my baby.”
B. “I can let my baby sleep in my bed as long as I remove blankets and pillows.”
Rationale: Bed-sharing increases the risk of SIDS, even without extra bedding. Infants should sleep in their own crib on a firm mattress. The other statements correctly describe safe sleep practices.
A nurse is educating parents on SIDS prevention. Which recommendation should the nurse include?
A. “Place your baby on their stomach for naps to prevent choking.”
B. “Swaddle your baby in multiple layers to keep them warm at night.”
C. “Offer a pacifier at bedtime, as it may help reduce the risk of SIDS.”
D. “Use a pillow to support your baby’s head while sleeping.”
C. “Offer a pacifier at bedtime, as it may help reduce the risk of SIDS.”
Rationale: Studies suggest pacifier use at bedtime may reduce SIDS risk. Babies should always sleep on their back, excessive layering can cause overheating, and pillows increase the risk of suffocation.
A nurse is assessing a 2-week-old newborn during a routine check-up. The newborn’s vital signs are: HR 170 bpm, RR 65 breaths/min, BP 85/55 mmHg, and temperature 98.2°F (36.8°C). Which finding requires immediate intervention?
A. Heart rate of 170 bpm
B. Respiratory rate of 65 breaths/min
C. Blood pressure of 85/55 mmHg
D. Temperature of 98.2°F (36.8°C)
B. Respiratory rate of 65 breaths/min
Rationale: The normal respiratory rate for a newborn is 30-60 breaths per minute. A rate above 60 may indicate respiratory distress, requiring further evaluation. The heart rate, blood pressure, and temperature are within the expected range.
A 4-year-old child is brought to the emergency department with fever and cough. The nurse notes the following vital signs: HR 145 bpm, RR 35 breaths/min, BP 82/58 mmHg, and temperature 101.2°F (38.4°C). What is the priority nursing action?
A. Administer an antipyretic for the fever
B. Obtain a blood pressure reading in the other arm
C. Encourage oral fluids to prevent dehydration
D. Assess for signs of respiratory distress
D. Assess for signs of respiratory distress
Rationale: A preschooler’s normal respiratory rate is 20-30 breaths per minute. A rate of 35 may indicate respiratory compromise. Assessing for signs of distress takes priority over fever management, BP reassessment, or fluid intake.
A nurse is assessing a 10-year-old child’s vital signs. Which finding would require further investigation?
A. HR: 85 bpm
B. BP: 98/65 mmHg
C. RR: 28 breaths/min
D. Temperature: 98.6°F (37°C)
C. RR: 28 breaths/min
Rationale: The normal respiratory rate for a school-age child (6-12 years) is 15-25 breaths per minute. A rate of 28 is elevated and may indicate respiratory distress. The other values are within normal limits.
The nurse is educating parents of a toddler about normal vital signs. Which statement by the parent indicates understanding?
A. “My child’s heart rate should be between 50-90 bpm at rest.”
B. “If my child’s blood pressure is 140/90 mmHg, that is normal for their age.”
C. “A respiratory rate of 25 breaths per minute is normal for my child.”
D. “My child’s normal temperature should be 96.8°F (36°C).”
C. “A respiratory rate of 25 breaths per minute is normal for my child.”
Rationale: Toddlers (1-3 years) normally have a respiratory rate of 20-40 breaths per minute. A heart rate of 50-90 bpm is too low, 140/90 mmHg is hypertensive, and a temperature of 96.8°F (36°C) is slightly below the normal range of 97.7-99.5°F (36.5-37.5°C).
A nurse is monitoring a sleeping 8-month-old infant’s vital signs. Which finding should the nurse report to the healthcare provider?
A. RR: 22 breaths/min
B. HR: 110 bpm
C. BP: 85/55 mmHg
D. Temperature: 98.1°F (36.7°C)
A. RR: 22 breaths/min
Rationale: The normal respiratory rate for an infant (1-12 months) is 25-50 breaths per minute. A rate of 22 is too low and may indicate hypoventilation. The other values are within normal limits.
The nurse is assessing a newborn’s vital signs. Which findings are within normal limits? (Select all that apply.)
A. HR: 120 bpm
B. RR: 45 breaths/min
C. BP: 90/60 mmHg
D. Temperature: 97.9°F (36.6°C)
E. HR: 170 bpm
A. HR: 120 bpm
B. RR: 45 breaths/min
D. Temperature: 97.9°F (36.6°C)
Rationale: A normal newborn’s vital signs include HR: 110-160 bpm, RR: 30-60 breaths/min, and temperature: 97.7-99.5°F (36.5-37.5°C). A BP of 90/60 mmHg is too high for a newborn (normal is 60-80/40-50 mmHg).
The nurse is educating new parents on when to seek medical attention for their infant. The nurse should instruct parents to report which vital sign abnormalities? (Select all that apply.)
A. HR: 100 bpm
B. RR: 65 breaths/min
C. BP: 80/55 mmHg
D. Temperature: 100.4°F (38°C)
E. HR: 180 bpm
B. RR: 65 breaths/min
D. Temperature: 100.4°F (38°C)
E. HR: 180 bpm
Rationale: A respiratory rate over 60 breaths/min in an infant is abnormal, a temperature of 100.4°F (38°C) or higher is considered a fever, and a heart rate over 160 bpm is concerning. A HR of 100 bpm and BP of 80/55 mmHg are within the expected range.
The nurse is reviewing vital signs for a 15-year-old adolescent. Which of the following would be considered abnormal? (Select all that apply.)
A. HR: 55 bpm
B. RR: 22 breaths/min
C. BP: 105/65 mmHg
D. Temperature: 99.3°F (37.4°C)
E. HR: 120 bpm
A. HR: 55 bpm
E. HR: 120 bpm
Rationale: The normal heart rate for an adolescent (13-18 years) is 60-100 bpm. A HR of 55 bpm is too low, and HR of 120 bpm is too high. The other values are within the normal range.
The nurse is caring for a 5-year-old child with suspected dehydration. The child’s HR is 138 bpm, RR is 28 breaths/min, BP is 75/40 mmHg, and temperature is 99°F (37.2°C). Which finding is most concerning?
A. HR of 138 bpm
B. RR of 28 breaths/min
C. BP of 75/40 mmHg
D. Temperature of 99°F (37.2°C)
C. BP of 75/40 mmHg
Rationale: Hypotension is a late sign of dehydration and shock. A BP of 75/40 mmHg is too low for a preschooler (normal: 80-115/55-80 mmHg). The other findings, though elevated, are within an acceptable range.
A nurse is teaching a group of student nurses about normal pediatric vital signs. Which statement requires correction?
A. “A newborn’s normal blood pressure is 60-80/40-50 mmHg.”
B. “A 3-year-old’s heart rate should be between 90-150 bpm.”
C. “A school-age child’s normal respiratory rate is 20-40 breaths per minute.”
D. “An adolescent’s heart rate should range from 60-100 bpm.”
C. “A school-age child’s normal respiratory rate is 20-40 breaths per minute.”
Rationale: The normal respiratory rate for school-age children is 15-25 breaths per minute. A rate of 20-40 is too high. The other statements are correct.
A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following vital signs would be considered abnormal for this age?
A. HR: 150 bpm
B. RR: 30 breaths/min
C. BP: 90/60 mmHg
D. Temperature: 98.6°F (37°C)
C. BP: 90/60 mmHg
Rationale: For a 6-month-old, normal blood pressure is typically between 70-90/50-65 mmHg, and a BP of 90/60 mmHg is on the high end and should be monitored. The other vital signs are within the expected range for a 6-month-old infant.
A nurse is preparing to assess a 2-year-old child. What is the most appropriate action to take when measuring this child’s vital signs?
A. Measure blood pressure in both arms
B. Use an automatic blood pressure cuff
C. Take the child’s temperature orally
D. Count the respiratory rate while the child is at rest
D. Count the respiratory rate while the child is at rest
Rationale: For toddlers, respiratory rates should be counted while the child is calm or at rest to avoid false elevations from crying. BP should be measured appropriately for age, and temperature should be taken axillary or rectally for accuracy.
A nurse is assessing a 10-year-old child who is complaining of headache and fatigue. The child’s vital signs are: HR 90 bpm, RR 20 breaths/min, BP 110/70 mmHg, and temperature 102°F (38.9°C). Which finding is most concerning?
A. HR of 90 bpm
B. RR of 20 breaths/min
C. Temperature of 102°F (38.9°C)
D. BP of 110/70 mmHg
C. Temperature of 102°F (38.9°C)
Rationale: A temperature of 102°F (38.9°C) is elevated and could indicate an infection or fever. The other vital signs are within normal limits for a 10-year-old child.
The nurse is assessing a preschooler who is being evaluated for a respiratory illness. The child’s vital signs are: HR 130 bpm, RR 40 breaths/min, BP 100/60 mmHg, and temperature 101.4°F (38.6°C). Which action should the nurse take next?
A. Administer antipyretics for fever
B. Assess for signs of respiratory distress
C. Obtain a second blood pressure measurement
D. Encourage the child to drink fluids
B. Assess for signs of respiratory distress
Rationale: A respiratory rate of 40 breaths/min is on the higher end of the normal range for a preschooler (20-30 breaths/min). The nurse should assess for signs of respiratory distress. The other actions are important but not the priority at this time.
A nurse is caring for a 3-month-old infant with a fever. Which of the following vital signs should be a cause for concern?
A. HR: 140 bpm
B. RR: 25 breaths/min
C. BP: 75/50 mmHg
D. Temperature: 101.3°F (38.5°C)
A. HR: 140 bpm
Rationale: The normal heart rate for a 3-month-old infant is between 100-160 bpm, so a heart rate of 140 bpm is on the higher end and may require monitoring if there is concern about fever-induced tachycardia. The other values are within normal limits.
A nurse is preparing to perform a physical exam on a newborn. What is the most important action to take before assessing the infant’s vital signs?
A. Take the temperature first
B. Ensure the infant is warm and calm
C. Assess the heart rate before taking the respiratory rate
D. Measure the blood pressure while the infant is awake
B. Ensure the infant is warm and calm
Rationale: It is essential to ensure that the newborn is warm and calm before assessing vital signs, as cold stress or crying can skew results, especially heart rate and respiratory rate.
A nurse is reviewing the vital signs of a 12-year-old child. Which finding requires further follow-up?
A. HR: 70 bpm
B. RR: 22 breaths/min
C. Temperature: 99°F (37.2°C)
D. BP: 130/85 mmHg
D. BP: 130/85 mmHg
Rationale: The normal blood pressure for a school-age child is typically 90-120/60-80 mmHg. A BP of 130/85 mmHg is elevated and may suggest hypertension, requiring further investigation.
The nurse is caring for an adolescent with a respiratory infection. The adolescent’s vital signs include a HR of 85 bpm, RR of 22 breaths/min, BP of 120/75 mmHg, and a temperature of 101°F (38.3°C). Which finding should the nurse address first?
A. HR of 85 bpm
B. RR of 22 breaths/min
C. BP of 120/75 mmHg
D. Temperature of 101°F (38.3°C)
D. Temperature of 101°F (38.3°C)
Rationale: While the vital signs are within normal limits, a fever of 101°F (38.3°C) could be indicative of an infection, and the nurse should address this finding first. Fever management is key in preventing further complications, such as dehydration or febrile seizures.
A nurse is evaluating the vital signs of a toddler during a routine check-up. Which finding would be considered within the normal range for this age group?
A. HR: 70 bpm
B. RR: 28 breaths/min
C. BP: 125/80 mmHg
D. Temperature: 99.8°F (37.7°C)
D. Temperature: 99.8°F (37.7°C)
Rationale: The normal temperature for a toddler is between 97.7-99.5°F (36.5-37.5°C). The heart rate, respiratory rate, and blood pressure in this question are outside the expected range for a toddler. HR should be 90-150 bpm, RR should be 20-40 breaths/min, and BP should be 80-110/50-80 mmHg.
A nurse is reviewing the vital signs of a 6-year-old child. Which of the following vital sign measurements is abnormal for this age?
A. HR: 110 bpm
B. RR: 24 breaths/min
C. BP: 95/60 mmHg
D. Temperature: 99.4°F (37.4°C)
A. HR: 110 bpm
Rationale: The normal heart rate for a school-age child (6-12 years) is 70-120 bpm. A HR of 110 bpm is at the upper limit of the normal range but should be monitored, especially if it is associated with any other abnormal findings. The other vital signs are within the normal range for this age.
Early or late signs of respiratory distress?
- Tachypnea (increased respiratory rate)
- Nasal flaring (enlargement of nostrils with breathing)
- Intercostal retractions (sinking of the skin between ribs)
early signs of respiratory distress
Early or late signs of respiratory distress?
- Use of accessory muscles (visible movement of neck or abdominal muscles when breathing)
- Mild agitation or restlessness
- Grunting (heard during exhalation as the child tries to keep alveoli open)
early signs of respiratory distress
Early or late signs of respiratory distress?
- Severe retractions (substernal, suprasternal, supraclavicular)
- Cyanosis (late sign) (bluish tint to lips, skin, or nail beds)
- Lethargy or decreased responsiveness
late signs of respiratory distress
Early or late signs of respiratory distress?
- Head bobbing (infants use their head to assist with breathing)
- Apnea (periods of no breathing)
late signs of respiratory distress
Early or late signs of respiratory distress?
- Hypoxia (low oxygen levels despite oxygen therapy)
- Bradycardia (late sign of respiratory failure, as the heart slows due to lack of oxygen)
late signs of respiratory distress
Name this disorder.
autosomal recessive disorder affecting the exocrine glands, leading to thick mucus production that primarily affects the lungs, pancreas, liver, intestines, and reproductive system
cystic fibrosis
What cures the pediatric client from cystic fibrosis?
There is no cure, but management focuses on improving lung function, nutrition, and preventing complications.
A nurse is assessing a 2-year-old child with respiratory distress. Which finding is most concerning and requires immediate intervention?
A. Nasal flaring and mild intercostal retractions
B. Respiratory rate of 50 breaths per minute
C. Head bobbing and lethargy
D. Mild expiratory wheezing
C. Head bobbing and lethargy
Rationale: Head bobbing and lethargy indicate severe respiratory distress and impending respiratory failure. Immediate intervention, such as oxygen therapy and possible intubation, is required.
The nurse is caring for an infant with worsening respiratory distress. Which assessment finding is an early sign of respiratory distress?
A. Cyanosis of the lips
B. Bradycardia
C. Nasal flaring and grunting
D. Hypotension
C. Nasal flaring and grunting
Rationale: Nasal flaring and grunting are early compensatory signs of respiratory distress. Cyanosis, bradycardia, and hypotension are late signs indicating respiratory failure.
A 4-year-old child is in respiratory distress with intercostal retractions, nasal flaring, and tachypnea. What should the nurse do first?
A. Obtain a chest X-ray
B. Administer oxygen
C. Initiate IV fluids
D. Perform chest physiotherapy
B. Administer oxygen
Rationale: Oxygen is the priority intervention to prevent hypoxia and respiratory failure. Chest X-ray and IV fluids may be needed later, but oxygen is the immediate action.
A newborn is diagnosed with cystic fibrosis. Which finding in the infant’s history supports this diagnosis?
A. Poor weight gain despite a good appetite
B. Frequent urination and high glucose levels
C. Enlarged fontanelles and hypotonia
D. Meconium ileus at birth
D. Meconium ileus at birth
Rationale: Meconium ileus is often the first sign of CF in newborns due to thickened intestinal secretions blocking the bowel.
A child with cystic fibrosis is prescribed pancreatic enzyme replacement therapy (PERT). When should the nurse instruct the parents to administer this medication?
A. Once daily in the morning
B. Before every meal and snack
C. After every meal
D. With large meals only
B. Before every meal and snack
Rationale: Pancreatic enzymes should be taken before every meal and snack to help digest food properly.
A school-aged child with cystic fibrosis is admitted for a respiratory infection. Which intervention should the nurse include in the plan of care?
A. Administer cough suppressants to decrease coughing
B. Limit fluid intake to prevent mucus production
C. Encourage physical activity to promote airway clearance
D. Administer broad-spectrum antibiotics only if a fever develops
C. Encourage physical activity to promote airway clearance
Rationale: Physical activity helps loosen mucus, promoting airway clearance. Cough suppressants should be avoided, and hydration is encouraged to thin secretions. Antibiotics are often given prophylactically.
A nurse is providing education to the parents of a child with cystic fibrosis. Which statement by the parent indicates a need for further teaching?
A. “I will ensure my child takes pancreatic enzymes before every meal.”
B. “My child will need a high-protein, high-calorie diet.”
C. “I will encourage my child to drink plenty of fluids.”
D. “My child only needs chest physiotherapy when sick.”
D. “My child only needs chest physiotherapy when sick.”
Rationale: Chest physiotherapy should be done daily, not just when sick, to prevent mucus buildup and lung infections.
A child with cystic fibrosis has a sodium level of 129 mEq/L. What should the nurse do first?
A. Encourage oral fluid intake
B. Notify the healthcare provider
C. Administer an IV sodium infusion
D. Restrict salt intake
B. Notify the healthcare provider
Rationale: A sodium level of 129 mEq/L is low and requires intervention. CF patients lose excessive salt in sweat, and sodium replacement may be needed.
Which laboratory result would the nurse expect in a child with cystic fibrosis?
A. Hyperglycemia
B. Increased sweat chloride levels
C. Low serum sodium levels
D. All of the above
D. All of the above
Rationale: CF can cause hyperglycemia (CF-related diabetes), increased sweat chloride levels (diagnostic test), and electrolyte imbalances (such as hyponatremia due to excessive salt loss in sweat).
A nurse is preparing to teach a family about airway clearance techniques for a child with cystic fibrosis. Which intervention should the nurse include?
A. Perform chest physiotherapy immediately after meals
B. Use bronchodilators after chest physiotherapy
C. Use a high-frequency chest wall oscillation vest
D. Avoid physical activity to conserve energy
C. Use a high-frequency chest wall oscillation vest
Rationale: A high-frequency chest wall oscillation vest helps loosen mucus. Bronchodilators should be used before physiotherapy, and it should be done before meals, not after to prevent vomiting.
A nurse is caring for a child with cystic fibrosis who has a respiratory infection. Which type of isolation precautions should be implemented?
A. Contact precautions
B. Droplet precautions
C. Standard precautions
D. Airborne precautions
A. Contact precautions
Rationale: Contact precautions are necessary for CF patients with respiratory infections due to the risk of cross-infection with other CF patients (e.g., Pseudomonas aeruginosa, Burkholderia cepacia).
A child with cystic fibrosis is scheduled for pulmonary function tests. What result is expected?
A. Increased lung compliance
B. Increased forced expiratory volume (FEV1)
C. Decreased residual lung volume
D. Decreased forced expiratory volume (FEV1)
D. Decreased forced expiratory volume (FEV1)
Rationale: FEV1 is decreased in CF due to mucus plugging and airway obstruction.
Which statement by a parent of a child with cystic fibrosis indicates an understanding of infection prevention?
A. “My child should avoid other children with CF.”
B. “I should limit my child’s outdoor play to prevent exposure to allergens.”
C. “My child will only need antibiotics if a fever develops.”
D. “We will avoid dairy products to reduce mucus production.”
A. “My child should avoid other children with CF.”
Rationale: CF patients should avoid other CF patients due to the risk of cross-infection with antibiotic-resistant bacteria.
A 10-year-old child with cystic fibrosis has been admitted with worsening pulmonary function. Which finding would indicate an emergency?
A. Increased work of breathing and intercostal retractions
B. Persistent dry cough
C. Increased appetite and thirst
D. Slightly decreased oxygen saturation of 94%
A. Increased work of breathing and intercostal retractions
Rationale: Increased work of breathing and intercostal retractions suggest severe respiratory distress, which can lead to respiratory failure.
A nurse is teaching a family about cystic fibrosis. Which statement should be included?
A. “CF affects multiple organ systems, including the lungs and pancreas.”
B. “Your child’s condition will improve over time.”
C. “Frequent use of cough suppressants is needed to control symptoms.”
D. “Your child should avoid foods high in fat.”
A. “CF affects multiple organ systems, including the lungs and pancreas.”
Rationale: CF is a multisystem disease affecting the lungs, pancreas, digestive system, and reproductive system.
A child with asthma is prescribed albuterol. What is the expected action of this medication?
a) Reduces inflammation in the airway
b) Prevents mast cell degranulation
c) Relaxes bronchial smooth muscle
d) Inhibits leukotriene production
c) Relaxes bronchial smooth muscle
Rationale: Albuterol is a short-acting beta2-agonist (SABA) that provides rapid bronchodilation by relaxing the smooth muscle in the airway.
A 10-year-old patient with asthma is prescribed an inhaled corticosteroid. What instruction should the nurse provide to the child and parent?
a) Use this medication during an acute asthma attack
b) Rinse the mouth after each use
c) Take the medication on an as-needed basis
d) Use a short-acting beta2-agonist afterward
b) Rinse the mouth after each use
Rationale: Inhaled corticosteroids (e.g., fluticasone) can cause oral thrush, so rinsing the mouth reduces the risk.
A child experiencing an acute asthma exacerbation is receiving nebulized albuterol. Which side effect should the nurse monitor for?
a) Bradycardia
b) Hyperglycemia
c) Tachycardia
d) Hypotension
c) Tachycardia
Rationale: Beta2-agonists like albuterol stimulate the sympathetic nervous system, leading to tachycardia as a common side effect.
A nurse is teaching a parent about montelukast (Singulair) for asthma control. Which statement by the parent indicates understanding?
a) “I will give this medication only when my child has symptoms.”
b) “This medication should be taken at the first sign of an asthma attack.”
c) “I will administer this medication via inhaler.”
d) “My child will take this medication daily to prevent asthma symptoms.”
d) “My child will take this medication daily to prevent asthma symptoms.”
Rationale: Montelukast is a leukotriene receptor antagonist used daily to prevent asthma exacerbations.
Which medication should the nurse question for a child with persistent asthma who is not using an inhaled corticosteroid?
a) Salmeterol
b) Albuterol
c) Montelukast
d) Ipratropium
a) Salmeterol
Rationale: LABAs (e.g., salmeterol) should never be used without an inhaled corticosteroid due to the risk of severe asthma attacks.
A nurse is educating a child with asthma about a peak flow meter. Which instruction should be included?
a) Perform the test before taking asthma medications
b) Blow out as slowly as possible
c) Perform three attempts and record the highest reading
d) Perform the test only when experiencing symptoms
c) Perform three attempts and record the highest reading
Rationale: The best effort is used to monitor airway function.
A child is prescribed ipratropium for asthma. Which finding would indicate a side effect of this medication?
a) Excessive salivation
b) Blurred vision and dry mouth
c) Wheezing and shortness of breath
d) Bradycardia and dizziness
b) Blurred vision and dry mouth
Rationale: Ipratropium is an anticholinergic, causing dry mouth and blurred vision.
The nurse is preparing to administer albuterol and budesonide to a child with asthma. Which should be given first?
a) Budesonide
b) Albuterol
c) Either can be given first
d) Give both simultaneously
b) Albuterol
Rationale: Albuterol (SABA) opens the airways first, allowing better absorption of the corticosteroid.
A parent asks why their child needs a spacer for an inhaler. The nurse explains that a spacer helps by:
a) Reducing the medication’s effect
b) Slowing down inhalation
c) Decreasing medication delivery to the lungs
d) Preventing medication buildup in the mouth
d) Preventing medication buildup in the mouth
Rationale: Spacers improve medication delivery to the lungs, reducing the risk of oropharyngeal deposition and thrush.
A nurse is assessing a child with croup. Which symptom requires immediate intervention?
a) Barking cough
b) Stridor at rest
c) Hoarseness
d) Low-grade fever
b) Stridor at rest
Rationale: Stridor at rest indicates severe airway obstruction requiring urgent intervention.
A child with epiglottitis presents to the ER. Which action should the nurse avoid?
a) Keep the child upright
b) Administer humidified oxygen
c) Prepare for intubation
d) Examine the throat with a tongue depressor
d) Examine the throat with a tongue depressor
Rationale: Examining the throat can trigger complete airway obstruction.
Which assessment finding in a child with bacterial tracheitis is most concerning?
a) Stridor that worsens despite treatment
b) Hoarseness
c) Mild fever
d) Barking cough
a) Stridor that worsens despite treatment
Rationale: Bacterial tracheitis can cause progressive airway obstruction, requiring intubation.
A nurse is preparing to administer racemic epinephrine for a child with croup. What is the expected effect?
a) Decrease airway inflammation
b) Thin mucus secretions
c) Improve oxygen saturation
d) Provide long-term symptom relief
a) Decrease airway inflammation
Rationale: Racemic epinephrine reduces swelling in the airway.
Which vaccine has significantly reduced cases of epiglottitis?
a) DTaP
b) Hib
c) MMR
d) PCV13
b) Hib
Rationale: The Haemophilus influenzae type B (Hib) vaccine prevents epiglottitis.
The nurse suspects tonsillitis in a child. What is the priority assessment?
a) Assess for dehydration
b) Obtain a throat culture
c) Assess airway patency
d) Assess for rash
c) Assess airway patency
Rationale: Severe tonsillar swelling can obstruct the airway.
Which symptom differentiates bacterial pharyngitis from viral pharyngitis?
a) Low-grade fever
b) Barking cough
c) White exudate on tonsils
d) Runny nose
c) White exudate on tonsils
Rationale: Group A Strep causes white exudate, requiring antibiotics.
A child is diagnosed with bacterial tracheitis. What is the priority intervention?
a) Administer IV antibiotics
b) Suction secretions
c) Obtain a throat culture
d) Administer nebulized albuterol
a) Administer IV antibiotics
Rationale: Bacterial tracheitis requires IV antibiotics to treat the infection.
The nurse is monitoring a child post-tonsillectomy. Which finding is concerning?
a) Mild sore throat
b) Frequent swallowing
c) Decreased appetite
d) Hoarseness
b) Frequent swallowing
Rationale: Frequent swallowing may indicate bleeding, requiring immediate intervention.
Name this disease.
A genetic disorder characterized by the production of abnormal hemoglobin (HbS), leading to sickle-shaped red blood cells. These cells cause vaso-occlusion, hemolysis, and organ damage.
sickle cell anemia
A 6-year-old child with sickle cell anemia is admitted to the emergency department with complaints of severe leg pain, fever, and swelling in the hands and feet. The nurse notes a heart rate of 132 bpm, respiratory rate of 28 breaths/min, and oxygen saturation of 92% on room air. What is the nurse’s priority action?
A. Administer IV morphine as prescribed.
B. Start oxygen therapy at 2 L/min via nasal cannula.
C. Begin IV hydration with normal saline.
D. Draw blood cultures and administer antibiotics.
B. Start oxygen therapy at 2 L/min via nasal cannula.
Rationale: Oxygen is the priority to prevent further sickling. Pain management and hydration are also essential but should follow oxygenation.
Which clinical manifestation is most concerning in a child with sickle cell anemia?
A. Fatigue and pallor
B. Hand-foot syndrome (dactylitis)
C. Hematuria
D. Sudden onset of unilateral weakness
D. Sudden onset of unilateral weakness
Rationale: This indicates a stroke, a severe complication of sickle cell disease requiring immediate intervention.
A child with sickle cell disease is experiencing a vaso-occlusive crisis. What is the most appropriate intervention?
A. Apply cold compresses to affected areas.
B. Encourage the child to ambulate frequently.
C. Administer IV fluids and opioid analgesics as prescribed.
D. Restrict fluids to prevent overhydration.
C. Administer IV fluids and opioid analgesics as prescribed.
Rationale: IV fluids reduce blood viscosity and opioid analgesics (e.g., morphine) manage severe pain. Cold therapy and fluid restriction can worsen sickling.
Which factor most increases a child’s risk for a sickle cell crisis?
A. Drinking plenty of fluids
B. Living in a warm climate
C. Swimming in a cold pool
D. Eating a high-protein diet
C. Swimming in a cold pool
Rationale: Cold temperatures cause vasoconstriction, increasing the risk of sickling and vaso-occlusive crisis.
The nurse is educating parents about sickle cell disease. Which statements should be included? (Select all that apply.)
A. “Encourage your child to drink plenty of fluids.”
B. “Administer penicillin daily until at least 5 years old.”
C. “Apply cold packs for pain relief during crises.”
D. “Ensure your child receives routine vaccines, including pneumococcal and meningococcal.”
E. “Hydroxyurea may help reduce the frequency of crises.”
A. “Encourage your child to drink plenty of fluids.”
B. “Administer penicillin daily until at least 5 years old.”
D. “Ensure your child receives routine vaccines, including pneumococcal and meningococcal.”
E. “Hydroxyurea may help reduce the frequency of crises.”
Rationale: Hydration prevents sickling, prophylactic penicillin prevents infections, and vaccinations are crucial. Cold packs should not be used, as they cause vasoconstriction.
A school nurse is providing education on sickle cell anemia to teachers. Which factors can trigger a sickle cell crisis? (Select all that apply.)
A. Dehydration
B. Infection
C. Exposure to high altitudes
D. Fever
E. Warm environments
A. Dehydration
B. Infection
C. Exposure to high altitudes
D. Fever
Rationale: Dehydration, infection, high altitude, and fever increase sickling. Warm environments do not contribute to sickling.
A nurse is preparing to administer hydroxyurea to a child with sickle cell disease. What should the nurse monitor for? (Select all that apply.)
A. Increased hemoglobin F (HbF) levels
B. Decreased white blood cell count
C. Signs of infection
D. Increased platelet count
E. Severe pain relief within 15 minutes
A. Increased hemoglobin F (HbF) levels
B. Decreased white blood cell count
C. Signs of infection
Rationale: Hydroxyurea increases fetal hemoglobin (HbF), reducing sickling, but can cause bone marrow suppression, leading to low WBCs and increased infection risk. It does not work immediately for pain relief.
A nurse is teaching parents of a child with sickle cell anemia about signs of splenic sequestration. Which symptom should prompt immediate medical attention?
A. Jaundice and icterus
B. Increasing fatigue and lethargy
C. Sudden severe abdominal pain with a rapidly enlarging spleen
D. Pain in the joints and extremities
C. Sudden severe abdominal pain with a rapidly enlarging spleen
Rationale: Splenic sequestration crisis is life-threatening and causes hypovolemic shock.
What is the main reason why children with sickle cell anemia need prophylactic penicillin?
A. To reduce the frequency of pain crises
B. To prevent bacterial infections such as pneumonia
C. To increase fetal hemoglobin levels
D. To help maintain normal red blood cell production
B. To prevent bacterial infections such as pneumonia
Rationale: Children with sickle cell disease have functional asplenia, increasing the risk of infections.
A child with sickle cell anemia presents with chest pain, dyspnea, and fever. The nurse suspects acute chest syndrome. What is the priority intervention?
A. Administer albuterol nebulizer treatment.
B. Encourage deep breathing and coughing.
C. Begin IV antibiotics and oxygen therapy.
D. Position the child in a prone position.
C. Begin IV antibiotics and oxygen therapy.
Rationale: Acute chest syndrome is a life-threatening emergency requiring oxygen and antibiotics to prevent respiratory failure.
A nurse is reviewing a child’s laboratory results. Which finding is consistent with sickle cell anemia?
A. Increased hemoglobin A (HbA)
B. Increased fetal hemoglobin (HbF)
C. Decreased reticulocyte count
D. Increased bilirubin levels
D. Increased bilirubin levels
Rationale: Chronic hemolysis leads to increased bilirubin, causing jaundice.
A nurse is evaluating discharge teaching for parents of a child with sickle cell disease. Which statement by the parent indicates a need for further teaching?
A. “Cold packs are the best way to relieve pain during a crisis.”
B. “I will encourage my child to drink plenty of fluids.”
C. “My child should avoid extreme temperatures.”
D. “We will ensure our child gets their routine vaccines.”
A. “Cold packs are the best way to relieve pain during a crisis.”
Rationale: Warm packs should be used for pain relief, as cold temperatures can worsen sickling.
A genetic bleeding disorder caused by a deficiency or dysfunction of von Willebrand factor (vWF), which is essential for platelet adhesion and stabilization of Factor VIII.
Von Willebrand Disease (VWD)
A genetic X-linked recessive disorder causing deficiency of clotting factors, leading to prolonged bleeding.
Hemophilia
A nurse is assessing a child with suspected von Willebrand disease. Which of the following findings would be most indicative of this condition?
A. Petechiae and ecchymosis
B. Prolonged bleeding after minor cuts
C. Joint hemorrhages and deep muscle bleeds
D. Spontaneous hemarthrosis
B. Prolonged bleeding after minor cuts
Rationale: VWD causes prolonged bleeding due to defective platelet adhesion. Petechiae are rare, and joint/muscle bleeds are more common in hemophilia.
Which laboratory value is expected in a child with von Willebrand disease?
A. Increased platelet count
B. Prolonged PT and normal PTT
C. Decreased von Willebrand factor and prolonged bleeding time
D. Decreased Factor IX levels
C. Decreased von Willebrand factor and prolonged bleeding time
Rationale: VWD results in decreased vWF and prolonged bleeding time due to impaired platelet function. Factor IX deficiency is seen in Hemophilia B.
A child with VWD is scheduled for a minor dental procedure. Which pre-procedure intervention should the nurse anticipate?
A. Administration of Desmopressin (DDAVP)
B. Administration of fresh frozen plasma
C. Administration of Factor IX concentrate
D. Administration of heparin
A. Administration of Desmopressin (DDAVP)
Rationale: DDAVP increases the release of stored vWF and Factor VIII, making it the first-line treatment for mild to moderate VWD.
A nurse is teaching the parents of a child with VWD about management. Which statement by the parent indicates a need for further education?
A. “We should avoid giving our child ibuprofen for pain.”
B. “My child should wear a medical alert bracelet.”
C. “My child may need vWF replacement before surgery.”
D. “Aspirin is a safe pain reliever for my child.”
D. “Aspirin is a safe pain reliever for my child.”
Rationale: Aspirin and NSAIDs should be avoided as they impair platelet function and worsen bleeding.
A nurse is reviewing discharge instructions for a child with VWD. Which instruction is most important to include?
A. “Use a soft toothbrush and avoid rough play.”
B. “Encourage contact sports to improve endurance.”
C. “Administer desmopressin every day to prevent bleeding.”
D. “Report mild nosebleeds immediately to the emergency department.”
A. “Use a soft toothbrush and avoid rough play.”
Rationale: Soft toothbrushes and avoiding rough play help prevent bleeding episodes. Desmopressin is used only as needed, and mild nosebleeds can often be managed at home.
Which of the following medications should be avoided in a child with von Willebrand disease?
A. Acetaminophen
B. Naproxen
C. Tranexamic acid
D. Desmopressin
B. Naproxen
Rationale: NSAIDs like naproxen impair platelet function and increase bleeding risk in VWD.
A nurse is caring for a child with VWD who has an active nosebleed. What is the most appropriate action?
A. Tilt the child’s head back and pinch the nostrils.
B. Apply pressure to the bridge of the nose and administer DDAVP.
C. Encourage the child to blow their nose to clear clots.
D. Position the child supine and elevate their legs.
B. Apply pressure to the bridge of the nose and administer DDAVP.
Rationale: Applying pressure and using DDAVP (if prescribed) can help control bleeding. The head should not be tilted back to prevent aspiration.
Which factor is deficient or dysfunctional in von Willebrand disease?
A. Factor VIII
B. Factor IX
C. Factor XI
D. von Willebrand Factor
D. von Willebrand Factor
Rationale: von Willebrand factor is deficient or dysfunctional, leading to impaired platelet adhesion and clot formation.
A child with hemophilia A is admitted for spontaneous joint bleeding. Which nursing intervention is most appropriate?
A. Apply heat packs to the affected joint.
B. Encourage passive range-of-motion exercises.
C. Administer Factor VIII replacement therapy.
D. Massage the joint to improve circulation.
C. Administer Factor VIII replacement therapy.
Rationale: Factor VIII replacement is the primary treatment for hemophilia A. Heat and massage increase bleeding, and ROM exercises should be delayed until bleeding resolves.
Which laboratory value is expected in a child with hemophilia A?
A. Normal PTT and prolonged PT
B. Prolonged PTT and normal PT
C. Increased platelet count
D. Decreased bleeding time
B. Prolonged PTT and normal PT
Rationale: Hemophilia affects the intrinsic clotting pathway, leading to prolonged PTT while PT remains normal.
A child with hemophilia falls and sustains a minor cut. What is the priority nursing intervention?
A. Apply direct pressure and administer Factor VIII or IX.
B. Apply ice and elevate the affected limb.
C. Administer desmopressin.
D. Observe for spontaneous clotting before intervening.
A. Apply direct pressure and administer Factor VIII or IX.
Rationale: Direct pressure helps control bleeding, and factor replacement is needed to support clot formation.
A parent of a child with hemophilia A asks why desmopressin (DDAVP) is prescribed. What is the nurse’s best response?
A. “It helps release stored Factor VIII from endothelial cells.”
B. “It stimulates bone marrow to produce more platelets.”
C. “It prevents platelet destruction.”
D. “It helps dissolve existing blood clots.”
A. “It helps release stored Factor VIII from endothelial cells.”
Rationale: DDAVP stimulates the release of Factor VIII from endothelial cells, improving clotting in mild cases.
What is a common early sign of a spontaneous joint bleed in a child with hemophilia?
A. Bruising around the affected joint
B. Tingling or warmth in the joint
C. Weak pulses in the extremity
D. Cool, pale skin around the joint
B. Tingling or warmth in the joint
Rationale: Tingling and warmth are early signs of joint bleeding, which can progress to swelling and pain if untreated.
A nurse is teaching the parents of a child with hemophilia about home care. Which statement indicates correct understanding?
A. “We should avoid administering vaccinations.”
B. “We will encourage contact sports for socialization.”
C. “Ibuprofen is the best pain reliever for joint pain.”
D. “We should apply ice and pressure if bleeding occurs.”
D. “We should apply ice and pressure if bleeding occurs.”
Rationale: Ice and pressure help control bleeding. Vaccinations are safe but should be given subcutaneously with pressure applied.
A child with hemophilia is receiving Factor VIII prophylactically. When should the parents administer the factor?
A. Only when bleeding occurs
B. Daily, at the same time each day
C. Before physical activity or sports
D. Only if the child has a fever
C. Before physical activity or sports
Rationale: Prophylactic Factor VIII is often given before activities that increase bleeding risk, such as sports.
What is the priority teaching for a school nurse caring for a child with hemophilia?
A. Keep Factor VIII/IX on hand for immediate administration.
B. Encourage the child to participate in all physical activities.
C. Allow the child to self-administer aspirin for pain.
D. Monitor the child closely for excessive bruising and joint pain.
D. Monitor the child closely for excessive bruising and joint pain.
Rationale: Early recognition of bleeding signs is crucial for prompt treatment. Factor administration requires a healthcare provider.
A rare but serious condition in which the bone marrow fails to produce sufficient amounts of all blood cell types—red blood cells (RBCs), white blood cells (WBCs), and platelets—leading to pancytopenia. This condition results from bone marrow suppression or failure, which can be caused by autoimmune disorders, infections, certain medications, radiation, toxins, or genetic disorders (e.g., Fanconi anemia).
aplastic anemia
A 10-year-old child is diagnosed with aplastic anemia. The nurse expects which of the following findings on the child’s complete blood count (CBC)?
A. Increased white blood cell count, decreased hemoglobin
B. Decreased red blood cell count, white blood cells, and platelets
C. Normal red blood cell count, increased platelets
D. Increased hematocrit, decreased platelet count
B. Decreased red blood cell count, white blood cells, and platelets
Rationale: Aplastic anemia causes pancytopenia, which means decreased red blood cells, white blood cells, and platelets. This is a key diagnostic feature.
A patient with suspected aplastic anemia undergoes a bone marrow biopsy. What would be the most likely finding in the biopsy?
A. Hypercellular bone marrow with increased hematopoietic cells
B. Hypocellular bone marrow with a predominance of fat cells
C. Increased number of immature white blood cells
D. Dense bone marrow with abnormal red blood cells
B. Hypocellular bone marrow with a predominance of fat cells
Rationale: In aplastic anemia, the bone marrow is typically hypocellular, meaning it contains fewer hematopoietic (blood-forming) cells and may have a higher proportion of fat cells.
A nurse is providing education to a patient diagnosed with aplastic anemia. Which statement by the patient indicates a need for further teaching?
A. “I will avoid exposure to infections by practicing good hygiene.”
B. “I should be careful when taking medications like acetaminophen to avoid liver damage.”
C. “I should expect to feel fatigued and weak since my bone marrow isn’t making enough blood cells.”
D. “I can continue with my normal physical activity and exercise regimen without limitations.”
D. “I can continue with my normal physical activity and exercise regimen without limitations.”
Rationale: Patients with aplastic anemia often experience fatigue, weakness, and a higher risk of bleeding or infection, so activity should be restricted to prevent complications.
A patient with aplastic anemia is undergoing treatment with immunosuppressive therapy. What is the primary goal of this therapy?
A. To decrease the destruction of bone marrow by the immune system
B. To stimulate bone marrow production of red blood cells
C. To increase platelet production in the bone marrow
D. To reduce the risk of genetic mutations
A. To decrease the destruction of bone marrow by the immune system
Rationale: Immunosuppressive therapy is used in aplastic anemia to suppress the immune system’s attack on the bone marrow, which is often the cause of the condition in acquired cases.
A patient is admitted with aplastic anemia. Which laboratory test would the nurse expect to confirm the diagnosis?
A. Low hemoglobin and high reticulocyte count
B. High white blood cell count and low platelets
C. Hypocellular bone marrow with reduced hematopoietic cells
D. Elevated iron levels and normal white blood cell count
C. Hypocellular bone marrow with reduced hematopoietic cells
Rationale: A bone marrow biopsy showing hypocellular marrow with reduced hematopoietic cells is a key diagnostic test for aplastic anemia.
A child with aplastic anemia has a reticulocyte count that is abnormally low. What does this indicate?
A. The bone marrow is producing insufficient red blood cells
B. The child’s bone marrow is producing an excess of white blood cells
C. The bone marrow is functioning normally but cannot release enough platelets
D. The child is producing excessive immature red blood cells
A. The bone marrow is producing insufficient red blood cells
Rationale: A low reticulocyte count indicates that the bone marrow is not producing enough red blood cells, which is a hallmark of aplastic anemia.
A patient with aplastic anemia presents with signs of infection and bleeding. What is the nurse’s priority action?
A. Administer broad-spectrum antibiotics and initiate transfusions.
B. Provide fluids to address dehydration and manage fever.
C. Apply pressure to the bleeding site and monitor vital signs.
D. Administer immunosuppressive therapy and monitor for side effects.
A. Administer broad-spectrum antibiotics and initiate transfusions.
Rationale: The patient’s signs of infection and bleeding are critical complications of aplastic anemia. Broad-spectrum antibiotics are needed to treat infection, and transfusions may be necessary to manage bleeding and anemia.
Occurs when the body doesn’t have enough iron to produce adequate hemoglobin, leading to reduced oxygen-carrying capacity in the blood. Preventing this type of anemia involves ensuring adequate iron intake and addressing factors that may increase the body’s iron requirements or impair absorption.
iron-deficiency anemia
A pregnant woman is diagnosed with iron-deficiency anemia. What recommendation should the nurse provide to enhance the absorption of non-heme iron from plant-based foods?
A. Avoid consuming dairy products with iron-rich meals.
B. Take a calcium supplement with meals to increase iron absorption.
C. Drink tea or coffee with meals to enhance iron absorption.
D. Eat foods high in vitamin C with iron-rich plant foods.
D. Eat foods high in vitamin C with iron-rich plant foods.
Rationale: Vitamin C enhances the absorption of non-heme iron from plant-based foods, so the nurse should recommend eating foods rich in vitamin C (e.g., citrus fruits, tomatoes) alongside iron-rich meals.
A nurse is educating a vegetarian adolescent on how to prevent iron-deficiency anemia. Which food item should the nurse recommend to increase iron intake?
A. White bread
B. Spinach and lentils
C. Cow’s milk
D. Fresh fruit juices
B. Spinach and lentils
Rationale: Spinach and lentils are excellent sources of non-heme iron, which can help prevent iron-deficiency anemia in a vegetarian diet. While fruits and vegetables are important, they do not provide significant iron.
A 2-year-old child is at risk for iron-deficiency anemia. What intervention should the nurse prioritize to prevent this condition in the child?
A. Introduce iron-fortified cereals and formula.
B. Encourage the child to eat large portions of vegetables.
C. Limit the child’s intake of milk to 16-24 ounces per day.
D. Provide the child with a daily multivitamin with iron.
C. Limit the child’s intake of milk to 16-24 ounces per day.
Rationale: Excessive milk intake (over 24 ounces per day) can reduce the absorption of iron in young children and lead to iron-deficiency anemia. The nurse should limit milk intake and ensure the child consumes iron-rich foods.
A nurse is educating a postpartum woman about preventing iron-deficiency anemia. Which statement by the patient indicates the need for further teaching?
A. “I will eat iron-rich foods like red meat and leafy vegetables.”
B. “I should take my prenatal vitamins for the first few months after delivery.”
C. “I should drink coffee and tea with meals to help with iron absorption.”
D. “I will include vitamin C-rich foods with my iron-containing meals.”
C. “I should drink coffee and tea with meals to help with iron absorption.”
Rationale: Coffee and tea can inhibit the absorption of iron, so the patient should avoid drinking these beverages with iron-rich meals. The nurse should encourage the patient to focus on vitamin C-rich foods to enhance absorption.
A nurse is providing discharge instructions to a patient who is at risk for iron-deficiency anemia. What should the nurse include in the teaching plan to prevent this condition?
A. “You should avoid all dairy products while increasing your iron intake.”
B. “Iron supplements should be taken with a glass of milk to prevent stomach upset.”
C. “Limit your intake of fruits and vegetables to prevent interference with iron absorption.”
D. “Include foods high in iron, such as lean meats, beans, and fortified cereals.”
D. “Include foods high in iron, such as lean meats, beans, and fortified cereals.”
Rationale: The patient should be instructed to include iron-rich foods like lean meats, beans, and fortified cereals to prevent iron-deficiency anemia. Dairy and certain fruits/vegetables can interfere with iron absorption, so the nurse should not recommend limiting iron-rich foods.
A congenital heart defect where there is a hole in the wall (septum) that divides the two upper chambers of the heart (the atria). This causes abnormal blood flow between the atria.
Atrial Septal Defect (ASD)
A narrowing of the aorta, which is the main artery that carries oxygen-rich blood from the heart to the body. The narrowing leads to increased pressure in the upper body and decreased blood flow to the lower body.
Coarctation of the Aorta
combination of four heart defects
Tetralogy of Fallot
Which heart defects are associated with Tetralogy of Fallot?
- Ventricular Septal Defect (VSD) - A hole between the two ventricles.
- Pulmonary Stenosis - Narrowing of the pulmonary valve or artery, restricting blood flow to the lungs.
- Overriding Aorta - The aorta is positioned directly over the ventricular septal defect, allowing oxygen-poor blood to flow into the aorta.
- Right Ventricular Hypertrophy - Thickening of the right ventricle due to the increased workload.
A nurse is assessing a child with a suspected atrial septal defect (ASD). Which of the following findings would the nurse most likely expect to observe?
A. Severe cyanosis with difficulty feeding
B. Systolic murmur and fatigue during physical activities
C. Weak pulses in the lower extremities
D. Increased blood pressure in the upper extremities
B. Systolic murmur and fatigue during physical activities
Rationale: A systolic murmur and fatigue during physical activities are common signs of ASD due to abnormal blood flow between the atria.
An infant with a suspected atrial septal defect (ASD) is being assessed. The nurse should expect which of the following findings?
A. Strong pulses in the lower extremities
B. Shortness of breath during activities
C. Cyanosis and clubbing of the fingers
D. Increased respiratory rate without other symptoms
B. Shortness of breath during activities
Rationale: Shortness of breath during activities is a common sign of ASD, as the heart is working harder to pump oxygenated blood to the body.
A nurse is teaching a parent about atrial septal defect (ASD) and its common symptoms. Which statement by the parent indicates a need for further teaching?
A. “My child may have a heart murmur.”
B. “My child may experience fatigue during play.”
C. “My child will likely have a significant amount of cyanosis.”
D. “My child may have frequent respiratory infections.”
C. “My child will likely have a significant amount of cyanosis.”
Rationale: Significant cyanosis is not a typical sign of ASD unless the defect is very large. Mild cyanosis might occur in severe cases but is not as prominent as in other defects like tetralogy of Fallot.
A 5-year-old child is diagnosed with an atrial septal defect (ASD). The nurse hears a murmur upon auscultation. Which action should the nurse take next?
A. Document the finding and continue monitoring.
B. Administer a diuretic as prescribed.
C. Prepare the child for surgery immediately.
D. Notify the healthcare provider for immediate intervention.
A. Document the finding and continue monitoring.
Rationale: A murmur is common in ASD and typically does not require immediate intervention unless other severe symptoms are present. The nurse should monitor and document the finding.
A nurse is assessing a child with suspected coarctation of the aorta. Which of the following findings would the nurse expect to observe?
A. Weak or absent pulses in the upper extremities
B. Blood pressure higher in the arms than in the legs
C. Cyanosis that worsens with crying
D. Systolic murmur at the left sternal border
B. Blood pressure higher in the arms than in the legs
Rationale: In coarctation of the aorta, the blood pressure is higher in the upper body (arms) due to the narrowing of the aorta.
Which of the following is a common sign of coarctation of the aorta in a pediatric patient?
A. Weak or absent pulses in the lower extremities
B. Increased blood pressure in the lower extremities
C. Cyanosis at rest
D. Increased oxygen saturation levels
A. Weak or absent pulses in the lower extremities
Rationale: Coarctation of the aorta causes decreased blood flow to the lower body, leading to weak or absent pulses in the lower extremities.
A nurse is educating the parents of a child diagnosed with coarctation of the aorta. Which of the following should the nurse include in the teaching?
A. “The pulse in the legs will be stronger than the pulse in the arms.”
B. “The condition will resolve on its own without treatment.”
C. “Leg pain will decrease as blood flow improves with activity.”
D. “The heart murmur may be heard due to blood flow across the narrowed aorta.”
D. “The heart murmur may be heard due to blood flow across the narrowed aorta.”
Rationale: A murmur is often heard due to the turbulence of blood flow across the narrowed aorta in coarctation.
A child with coarctation of the aorta is undergoing treatment. Which of the following would the nurse expect as a part of the management plan?
A. Administration of intravenous fluids to increase blood volume
B. Increased salt intake to help normalize blood pressure
C. No intervention is necessary as the condition resolves with age
D. Surgical repair or balloon angioplasty to widen the narrowed aorta
D. Surgical repair or balloon angioplasty to widen the narrowed aorta
Rationale: Coarctation of the aorta often requires surgical repair or balloon angioplasty to widen the narrowed aorta and restore normal blood flow.
A child with tetralogy of Fallot (TOF) is experiencing a “tet spell” after crying. Which of the following interventions should the nurse prioritize?
A. Administer a bronchodilator to relieve airway constriction.
B. Have the child squat to increase blood flow to the lungs.
C. Provide supplemental oxygen to increase oxygen saturation.
D. Give a dose of aspirin to prevent blood clots.
B. Have the child squat to increase blood flow to the lungs.
Rationale: Squatting helps increase blood flow to the lungs and improve oxygenation during a tet spell, as it increases systemic vascular resistance.
A nurse is assessing a child with tetralogy of Fallot (TOF). Which of the following findings is most characteristic of this condition?
A. Severe cyanosis, particularly during crying or feeding
B. Weak pulses in the lower extremities
C. Systolic murmur at the left sternal border
D. Bounding pulses in the neck and arms
A. Severe cyanosis, particularly during crying or feeding
Rationale: Cyanosis, especially during crying or feeding, is a hallmark sign of TOF due to decreased oxygenation in the blood.
A nurse is teaching the parents of a child diagnosed with tetralogy of Fallot (TOF) about the condition. Which statement by the parent indicates a need for further teaching?
A. “My child may have a heart murmur that is loudest during systole.”
B. “I should monitor my child for episodes of severe cyanosis, especially during crying.”
C. “My child will need surgery soon to correct the defects.”
D. “My child should avoid physical activity and exercise until treatment is completed.”
D. “My child should avoid physical activity and exercise until treatment is completed.”
Rationale: Physical activity may increase the risk of tet spells. However, after surgical repair, physical activity can typically be resumed.
A child diagnosed with tetralogy of Fallot (TOF) is undergoing surgery. Which defect is most responsible for the child’s cyanosis and hypoxia?
A. Pulmonary stenosis
B. Ventricular septal defect (VSD)
C. Overriding aorta
D. Right ventricular hypertrophy
A. Pulmonary stenosis
Rationale: Pulmonary stenosis is the most significant cause of cyanosis and hypoxia in TOF because it obstructs blood flow to the lungs, leading to decreased oxygenation.
A nurse is assessing a pediatric patient with a suspected heart condition. Which of the following would be a key sign of poor perfusion during a cardiovascular assessment?
A. Jugular venous distention (JVD)
B. Warm extremities with brisk capillary refill
C. Absence of peripheral pulses
D. Normal heart rhythm on auscultation
A. Jugular venous distention (JVD)
Rationale: JVD is a key sign of poor cardiac output or heart failure, indicating that the right side of the heart is not pumping efficiently.
A patient is admitted with heart failure. The nurse notices the patient is exhibiting confusion and lethargy. Which of the following is the most likely cause?
A. Electrolyte imbalance due to diuretic therapy
B. Decreased cerebral perfusion from heart failure
C. Hypoxia due to pulmonary congestion
D. Blood clot formation due to immobility
B. Decreased cerebral perfusion from heart failure
Rationale: Confusion and lethargy are signs of poor cerebral perfusion due to inadequate cardiac output in heart failure, which may impair oxygen delivery to the brain.
A patient with a history of myocardial infarction (MI) is being assessed for chest pain. The nurse should consider the possibility of a new ischemic event if the pain is:
A. Short-lived, relieved with rest
B. Sharp and localized to the left shoulder
C. Crushing or tight, radiating to the arm or jaw
D. Dull and aching, relieved with nitroglycerin
C. Crushing or tight, radiating to the arm or jaw
Rationale: A crushing or tight pain that radiates to the arm or jaw is characteristic of myocardial ischemia and should be evaluated as a possible acute MI.
The nurse is auscultating a heart murmur in a pediatric patient. Which of the following would be the next appropriate step in the nursing process?
A. Notify the healthcare provider for further assessment
B. Document the findings and continue monitoring
C. Administer oxygen to improve circulation
D. Prepare the patient for immediate surgery
A. Notify the healthcare provider for further assessment
Rationale: A heart murmur requires further evaluation to determine its cause, which may be indicative of structural heart disease.
The nurse is performing a cardiovascular assessment on a pediatric patient and notes the presence of pitting edema in the lower extremities. What should the nurse do next?
A. Assess the patient for signs of dehydration
B. Review the patient’s medication list for diuretics
C. Reassess the edema after 1 hour of rest
D. Notify the healthcare provider for further evaluation
D. Notify the healthcare provider for further evaluation
Rationale: Pitting edema in the lower extremities may indicate fluid retention, possibly related to heart failure, and should be reported to the healthcare provider immediately.
A nurse is caring for a patient with suspected heart failure and notices jugular venous distention (JVD). The nurse should interpret this as:
A. A sign of hypovolemia
B. An indication of increased cardiac output
C. A possible indication of right-sided heart failure
D. A normal finding in elderly patients
C. A possible indication of right-sided heart failure
Rationale: JVD is commonly associated with right-sided heart failure, where the heart is unable to effectively pump blood, leading to blood backup into the jugular veins.
A nurse is assessing a patient’s capillary refill time. What is the expected normal finding?
A. More than 5 seconds
B. Less than 2 seconds
C. 4-5 seconds
D. 3 seconds
B. Less than 2 seconds
Rationale: Capillary refill time of less than 2 seconds is considered normal and indicates good peripheral circulation.
The nurse is preparing to auscultate a patient’s heart sounds. Which of the following heart sounds would the nurse identify as a potential sign of heart failure?
A. S1 and S2 sounds with a clear rhythm
B. A third heart sound (S3) or gallop rhythm
C. A high-pitched murmur at the apex
D. A split S2 during expiration
B. A third heart sound (S3) or gallop rhythm
Rationale: An S3 heart sound (gallop rhythm) is often indicative of heart failure, especially in cases where there is fluid overload.
The nurse is reviewing laboratory results for a patient with a suspected heart failure diagnosis. Which of the following results would be most consistent with heart failure?
A. Low B-type natriuretic peptide (BNP)
B. Normal troponin levels
C. Elevated B-type natriuretic peptide (BNP)
D. Normal complete blood count (CBC)
C. Elevated B-type natriuretic peptide (BNP)
Rationale: Elevated BNP levels are a key diagnostic marker for heart failure, indicating increased myocardial stress and fluid overload.
A ________ patient is one who experiences an acute episode of severe cyanosis (bluish discoloration of the skin and mucous membranes) due to insufficient oxygenation. This can be seen in conditions like Tetralogy of Fallot (TOF) or other congenital heart defects that involve mixing of oxygenated and deoxygenated blood, such as transposition of the great arteries.
hypercyanotic
A pediatric patient with Tetralogy of Fallot is experiencing a “Tet spell” and becomes acutely cyanotic. Which of the following interventions should the nurse implement first to manage this crisis?
A. Administer 100% oxygen via non-rebreather mask
B. Place the child in a supine position
C. Encourage the child to walk around to increase circulation
D. Administer morphine to calm the child
A. Administer 100% oxygen via non-rebreather mask
Rationale: Administering 100% oxygen is the first priority to increase oxygen levels in the blood and help improve the cyanosis in a child with a Tet spell. Oxygen is crucial in managing this emergency situation.
A child with a history of Tetralogy of Fallot experiences a hypercyanotic episode. The nurse should immediately place the child in which of the following positions to help alleviate the symptoms?
A. Supine with the head elevated
B. Knee-chest position
C. Left lateral recumbent position
D. Trendelenburg position
B. Knee-chest position
Rationale: The knee-chest position increases systemic vascular resistance, which helps decrease the right-to-left shunting of blood and improves oxygenation during a hypercyanotic episode in children with Tetralogy of Fallot.
A nurse is caring for a 2-year-old child with Tetralogy of Fallot. The child becomes acutely cyanotic and is experiencing difficulty breathing. The nurse should prepare to administer which of the following medications to help reduce the severity of the “Tet spell”?
A. Acetaminophen
B. Propranolol
C. Ibuprofen
D. Atropine
B. Propranolol
Rationale: Propranolol is a beta-blocker that may be used to reduce the frequency and severity of Tet spells in children with Tetralogy of Fallot by decreasing the heart’s workload and improving blood flow. It is not indicated for pain relief (acetaminophen, ibuprofen) or bradycardia (atropine).
An acute, systemic vasculitis that primarily affects children, especially those under the age of 5. It causes inflammation in the blood vessels, particularly the coronary arteries.
Kawasaki disease
A 3-year-old child presents to the clinic with a 5-day history of high fever, red eyes, and a bright red, swollen tongue. The nurse notes the child has a polymorphous rash on the trunk and peeling of the fingers and toes. The child also has swollen lymph nodes on the right side of the neck. The nurse suspects Kawasaki disease. Which of the following is the priority intervention for this patient?
A. Administer aspirin as prescribed
B. Initiate a high-dose intravenous immunoglobulin (IVIG) infusion
C. Prepare the child for cardiac catheterization
D. Administer acetaminophen for fever reduction
B. Initiate a high-dose intravenous immunoglobulin (IVIG) infusion
Rationale: Early administration of intravenous immunoglobulin (IVIG) is a key treatment for Kawasaki disease and helps reduce the risk of coronary artery aneurysms. It is more effective when given within 10 days of the onset of fever.
A nurse is assessing a 2-year-old child who is suspected to have Kawasaki disease. Which of the following findings would support this diagnosis?
A. Bilateral conjunctivitis, peeling skin on the palms of the hands, and strawberry tongue
B. Persistent cough, wheezing, and shortness of breath
C. Fever, swollen lymph nodes, and a red rash with central clearing
D. Jaundice, hepatomegaly, and pale stools
A. Bilateral conjunctivitis, peeling skin on the palms of the hands, and strawberry tongue
Rationale: Key clinical manifestations of Kawasaki disease include bilateral conjunctival injection (red eyes), strawberry tongue, and peeling skin (desquamation), particularly on the palms and soles. These symptoms are consistent with Kawasaki disease.
A 4-year-old child with Kawasaki disease is receiving intravenous immunoglobulin (IVIG) therapy. Which of the following is the most important nursing consideration during this treatment?
A. Monitor for signs of an allergic reaction, such as fever and rash
B. Monitor for signs of fluid overload, including edema and dyspnea
C. Administer aspirin as prescribed to reduce the risk of bleeding
D. Keep the child on a low-sodium diet to prevent hypertension
B. Monitor for signs of fluid overload, including edema and dyspnea
Rationale: IVIG therapy can cause fluid overload, especially in patients with Kawasaki disease who may already have cardiovascular involvement. Monitoring for signs of fluid overload, such as edema and dyspnea, is critical during treatment.
A 5-year-old child is diagnosed with Kawasaki disease and is admitted to the hospital. The nurse educates the parents about the potential complications of this condition. Which of the following is the most serious complication associated with Kawasaki disease?
A. Coronary artery aneurysms
B. Seizures
C. Respiratory distress
D. Developmental delay
A. Coronary artery aneurysms
Rationale: The most serious complication of Kawasaki disease is coronary artery aneurysms, which can lead to long-term heart problems. Early diagnosis and treatment with IVIG are essential to prevent coronary artery damage.
A nurse is educating the parents of a child with Kawasaki disease about the importance of follow-up care. Which of the following should the nurse emphasize to the parents regarding the child’s cardiovascular health?
A. The child will likely need regular cardiac monitoring to assess for coronary artery abnormalities
B. The child will have a normal life expectancy without any restrictions
C. The child should be placed on long-term antihypertensive medication
D. The child will be monitored for signs of kidney disease due to the effects of Kawasaki disease
A. The child will likely need regular cardiac monitoring to assess for coronary artery abnormalities
Occurs when the body loses more fluids than it takes in, leading to an imbalance. The signs can vary depending on the severity of dehydration (mild, moderate, or severe).
dehydration
A 4-year-old child presents to the emergency department with a 2-day history of vomiting, diarrhea, and decreased urination. On examination, the child is lethargic, has sunken eyes, and dry mucous membranes. The nurse notes the child’s skin is slow to return to normal after being pinched. What is the most likely diagnosis and appropriate management for this child?
A. Mild dehydration; provide oral rehydration with an electrolyte solution
B. Moderate dehydration; initiate IV fluid therapy with normal saline
C. Severe dehydration; administer isotonic IV fluids and monitor for shock
D. Severe dehydration; administer oral fluids and monitor for improvement
B. Moderate dehydration; initiate IV fluid therapy with normal saline
Rationale: The child is showing signs of moderate dehydration, such as lethargy, sunken eyes, and poor skin turgor. IV fluid therapy with normal saline is needed to correct fluid deficits.
A nurse is assessing a 3-year-old child with suspected dehydration. The child has been refusing fluids for the past 12 hours, has dark urine, and appears irritable. The nurse notices the child has a dry mouth and slightly sunken eyes. What is the priority intervention for this child?
A. Administer a dose of oral rehydration solution (ORS)
B. Administer normal saline IV bolus
C. Encourage increased fluid intake of water and juice
D. Monitor the child’s vital signs for 2 hours and reassess
A. Administer a dose of oral rehydration solution (ORS)
Rationale: This child has mild dehydration, which can be managed with oral rehydration solution (ORS). ORS helps replace fluids and electrolytes lost and should be given before considering IV fluids.
An infant with moderate dehydration presents with sunken fontanels, dry mucous membranes, and a decreased number of wet diapers. Which of the following interventions should the nurse implement first?
A. Administer a prescribed dose of acetaminophen
B. Start an IV line and infuse 20 mL/kg of isotonic IV fluid
C. Encourage the infant to drink water and clear liquids
D. Offer the infant 2-3 oz of oral rehydration solution (ORS) every 10 minutes
B. Start an IV line and infuse 20 mL/kg of isotonic IV fluid
Rationale: In moderate dehydration, especially with an infant, IV fluid administration is typically required for rapid rehydration, particularly when the child is unable to tolerate oral rehydration or fluids.
A 5-year-old child is being treated for severe dehydration with IV fluids. The nurse monitors the child for signs of complications during rehydration. Which of the following findings would indicate that the child is developing fluid overload?
A. Increased heart rate and blood pressure
B. Decreased respiratory rate and increased urine output
C. Edema, dyspnea, and jugular vein distension
D. Sunken eyes and dry skin
C. Edema, dyspnea, and jugular vein distension
Rationale: Signs of fluid overload include edema, dyspnea (difficulty breathing), and jugular vein distension, which are indications that the child is receiving too much fluid too quickly.
A 2-year-old child is admitted with severe dehydration and a history of diarrhea and vomiting. The nurse is preparing to administer IV fluids. Which of the following types of IV fluids is most appropriate for this child’s dehydration?
A. Hypertonic saline
B. Dextrose 5% in water (D5W)
C. 0.45% sodium chloride solution
D. Ringer’s lactate or normal saline
D. Ringer’s lactate or normal saline
Rationale: Isotonic fluids, such as Ringer’s lactate or normal saline, are used for initial rehydration in severe dehydration as they help restore both fluid and electrolyte balance without causing further imbalances.
A nurse is teaching the parents of a toddler how to manage mild dehydration at home. Which of the following instructions should the nurse provide?
A. “Offer the child small sips of oral rehydration solution (ORS) every 5-10 minutes.”
B. “Encourage the child to drink large amounts of water at once to replace lost fluids.”
C. “Avoid giving the child any juice or sugary drinks until they are fully rehydrated.”
D. “Give the child a dose of over-the-counter anti-diarrheal medication.”
A. “Offer the child small sips of oral rehydration solution (ORS) every 5-10 minutes.”
Rationale: Oral rehydration solution (ORS) is the most effective treatment for mild dehydration. Offering small sips frequently is key to preventing further fluid loss, whereas large volumes of fluids may not be tolerated.
T/F
Both ulcerative colitis (UC) and Crohn’s disease (CD) are types of inflammatory bowel disease (IBD) that cause inflammation in the digestive tract, but they differ in the areas affected, the nature of the inflammation, and their clinical manifestations.
true
A 25-year-old female with a history of Crohn’s disease presents to the clinic with complaints of worsening abdominal pain and diarrhea. Which of the following findings would most likely be associated with Crohn’s disease?
A) Continuous inflammation of the colon
B) Pseudopolyps seen on colonoscopy
C) Fistulas and abscesses
D) Rectal bleeding as the primary symptom
C) Fistulas and abscesses
Rationale: Fistulas and abscesses are common complications of Crohn’s disease due to inflammation affecting all layers of the bowel wall. Continuous inflammation and pseudopolyps are more characteristic of ulcerative colitis.
A nurse is educating a patient diagnosed with ulcerative colitis about the risk of colorectal cancer. Which of the following statements by the nurse is most accurate?
A) “You should have a colonoscopy every 1-2 years after 8 years of diagnosis.”
B) “Colorectal cancer is only a concern during flare-ups of ulcerative colitis.”
C) “The risk of colorectal cancer decreases with treatment of ulcerative colitis.”
D) “You will not need a colonoscopy until after 10 years of diagnosis.”
A) “You should have a colonoscopy every 1-2 years after 8 years of diagnosis.”
Rationale: Long-term ulcerative colitis increases the risk of colorectal cancer, especially after 8 years of disease. Regular screenings are necessary for early detection.
A 19-year-old male with a history of Crohn’s disease is experiencing frequent diarrhea and weight loss. Which of the following complications should the nurse monitor for in this patient?
A) Toxic megacolon
B) Fistulas and strictures
C) Colon cancer
D) Perianal abscesses
B) Fistulas and strictures
Rationale: Crohn’s disease can lead to fistulas, strictures, and malabsorption. Toxic megacolon and colon cancer are more commonly associated with ulcerative colitis.
A nurse is performing an abdominal assessment on a patient with Crohn’s disease. Which of the following findings would be most suggestive of a complication related to this condition?
A) Abdominal distension with hyperactive bowel sounds
B) Pain relieved by defecation
C) Firm, non-tender abdomen with a palpable mass in the right lower quadrant
D) Dark brown, non-bloody stool
C) Firm, non-tender abdomen with a palpable mass in the right lower quadrant
Rationale: A palpable mass in the right lower quadrant could indicate a complication such as a fistula or abscess in a patient with Crohn’s disease.
A nurse is caring for a patient with ulcerative colitis who is experiencing a flare-up. Which of the following interventions would be most appropriate during this time?
A) Encourage high-fiber foods to promote bowel regularity
B) Provide a high-calorie, low-protein diet
C) Administer corticosteroids as prescribed to reduce inflammation
D) Administer antibiotics to prevent infection
C) Administer corticosteroids as prescribed to reduce inflammation
Rationale: During a flare-up of ulcerative colitis, corticosteroids are commonly used to reduce inflammation and control symptoms. High-fiber foods are not recommended during flare-ups.
A nurse is providing discharge instructions to a patient with Crohn’s disease. Which of the following dietary recommendations is appropriate for this patient?
A) Encourage high-fat, high-fiber foods to aid in digestion.
B) Recommend a diet rich in dairy products to enhance calcium intake.
C) Suggest a low-residue diet to reduce bowel irritation.
D) Recommend increasing intake of raw vegetables to promote bowel regularity.
C) Suggest a low-residue diet to reduce bowel irritation.
Rationale: A low-residue diet is often recommended for Crohn’s disease to reduce irritation and minimize symptoms. High-fat and high-fiber foods may exacerbate symptoms.
A patient with ulcerative colitis is admitted to the hospital with severe abdominal pain, fever, and vomiting. The nurse should monitor for which of the following complications?
A) Fistulas and abscesses
B) Toxic megacolon
C) Nutritional deficiencies
D) Small bowel obstruction
B) Toxic megacolon
Rationale: Toxic megacolon is a life-threatening complication associated with severe ulcerative colitis, presenting with fever, abdominal pain, and distension.
A nurse is assessing a 30-year-old female patient with Crohn’s disease. The nurse notes that the patient is malnourished and has a decreased albumin level. Which of the following should the nurse include in the plan of care?
A) Encourage increased fiber intake to improve digestion
B) Administer corticosteroids to reduce bowel inflammation
C) Encourage the patient to drink caffeinated beverages to stimulate appetite
D) Collaborate with a dietitian to provide a high-protein, high-calorie diet
D) Collaborate with a dietitian to provide a high-protein, high-calorie diet
Rationale: Patients with Crohn’s disease may experience malabsorption and malnutrition, and a high-protein, high-calorie diet is necessary to help with healing and nutrient absorption.
A condition that affects infants, where the muscle at the end of the stomach (the pylorus) thickens and narrows, making it difficult for food to pass from the stomach into the small intestine. This narrowing leads to a blockage, causing vomiting, dehydration, and weight loss.
pyloric stenosis
A nurse is assessing an infant who is suspected to have pyloric stenosis. Which of the following clinical manifestations should the nurse expect to find?
A) Severe diarrhea after feeding
B) Projectile vomiting after feedings
C) Increased abdominal distension
D) Constipation and abdominal bloating
B) Projectile vomiting after feedings
Rationale: Projectile vomiting is a classic sign of pyloric stenosis. This occurs because the thickened pyloric muscle causes a blockage, leading to forceful vomiting shortly after feeding. The other options are not typical signs of pyloric stenosis.
A 2-week-old infant is diagnosed with pyloric stenosis. After pyloromyotomy surgery, the nurse should prioritize which of the following actions?
A) Monitor for signs of infection at the surgical site
B) Begin oral feedings immediately postoperatively
C) Ensure the infant is kept NPO for 48 hours
D) Assess for signs of dehydration due to vomiting
A) Monitor for signs of infection at the surgical site
Rationale: After pyloromyotomy surgery, it is important to monitor for infection at the surgical site. Postoperatively, oral feedings can typically be introduced shortly after the procedure.
A nurse is educating the parents of a newborn about pyloric stenosis. Which statement by the parents indicates a need for further teaching?
A) “My baby might need surgery to correct the blockage.”
B) “My baby’s vomiting is a sign that the condition is worsening.”
C) “Pyloric stenosis is a condition that can be managed with medication.”
D) “Surgical treatment is usually very effective, and my baby will likely recover quickly.”
C) “Pyloric stenosis is a condition that can be managed with medication.”
Rationale: Pyloric stenosis is typically treated with surgery (pyloromyotomy), not medication. If parents suggest that medication is the primary treatment, this indicates a misunderstanding and requires further teaching. The other statements are accurate about the condition and its treatment.
A 6-month-old infant with a cleft lip is scheduled for surgery. Which of the following factors is most important to consider before proceeding with the surgical repair?
A) The infant’s ability to walk
B) The infant’s ability to breastfeed
C) The infant’s weight and overall health
D) The infant’s ability to sit up independently
C) The infant’s weight and overall health
Rationale: Surgery for cleft lip repair is typically performed when the infant is around 10 weeks old and weighs about 10 pounds. The child’s overall health is important to ensure they are ready for surgery. The other factors listed are not primary considerations for the surgery.
A nurse is educating the parents of a child with a cleft palate. At what age is it typical for cleft palate repair surgery to be performed?
A) 2-3 months old
B) 4-6 months old
C) 9-12 months old
D) 2-3 years old
C) 9-12 months old
Rationale: Cleft palate repair surgery is typically performed when the child is between 9 and 12 months old. This timing allows for optimal healing and speech development. The other age ranges are not typical for this surgery.
Which of the following is an essential part of the post-operative care for a child who has undergone cleft lip repair surgery?
A) Administering pain medication as ordered
B) Allowing the child to feed immediately after surgery
C) Placing the child on their stomach to sleep
D) Limiting follow-up care to one visit after surgery
A) Administering pain medication as ordered
Rationale: Administering pain medication as ordered is essential to manage discomfort after surgery. The child should not feed immediately after surgery to allow for healing, and the child should be placed on their back to sleep to avoid pressure on the repaired lip. Follow-up care is important and should not be limited to just one visit.
A nurse is counseling the parents of a child who has undergone cleft palate repair surgery. Which statement indicates the need for further teaching?
A) “My child will likely need speech therapy after the surgery.”
B) “We should expect dental care and orthodontic treatment in the future.”
C) “We will follow up with the healthcare provider regularly to monitor my child’s development.”
D) “My child will be able to eat solid foods immediately after surgery.”
D) “My child will be able to eat solid foods immediately after surgery.”
Rationale: After cleft palate surgery, the child typically cannot eat solid foods immediately. A soft or liquid diet is usually recommended initially, and solid foods are reintroduced gradually as healing progresses. The other statements are accurate and reflect appropriate care and expectations.
A 1-year-old child who had cleft lip and palate surgery is showing signs of speech delay. Which of the following actions is the nurse most likely to recommend?
A) Referral to a speech therapist for evaluation and intervention
B) Delaying speech therapy until the child is 2 years old
C) Encouraging the child to speak only simple words
D) Limiting communication to non-verbal methods
A) Referral to a speech therapist for evaluation and intervention
Rationale: Speech therapy is often needed after cleft lip and palate repairs to address any speech delays. Early intervention with a speech therapist helps improve language development. The other actions are not appropriate for managing speech delays in a child who has had cleft lip and palate surgery.
A a congenital condition that affects the large intestine (colon) and causes problems with passing stool. It is characterized by the absence of nerve cells (ganglion cells) in a portion of the colon, which leads to difficulty in moving stool through the intestines. The affected portion of the colon becomes narrow and inflamed because the muscles in that area cannot contract properly to push stool forward.
Hirschsprung disease
A 2-day-old infant is diagnosed with Hirschsprung disease. The nurse expects which of the following findings in this infant?
A) Severe dehydration and low blood pressure
B) Failure to pass meconium within the first 48 hours of life
C) Cyanosis and rapid breathing
D) Yellow-green vomit and abdominal pain
B) Failure to pass meconium within the first 48 hours of life
Rationale: One of the classic signs of Hirschsprung disease in a newborn is the failure to pass meconium within the first 24-48 hours of life due to the lack of ganglion cells in the colon. This leads to a functional obstruction of the intestines. The other options do not specifically relate to Hirschsprung disease.
A nurse is preparing a 3-month-old infant for surgery to correct Hirschsprung disease. Which of the following is an important preoperative nursing intervention?
A) Encourage breastfeeding immediately before surgery
B) Assess the infant’s hydration status and provide IV fluids if needed
C) Teach the parents how to perform colostomy care
D) Administer pain medication prior to surgery without a doctor’s order
B) Assess the infant’s hydration status and provide IV fluids if needed
Rationale: Since infants with Hirschsprung disease often present with symptoms like vomiting, abdominal distention, and constipation, they may be dehydrated. Ensuring adequate hydration before surgery is crucial for the infant’s stability. The other options are not appropriate as preoperative interventions for this condition.
A patient with Inflammatory Bowel Disease (IBD) is experiencing an acute flare-up. Which of the following treatments is most likely to be prescribed to control the inflammation during this flare-up?
A) Antibiotics
B) Antacids
C) Corticosteroids
D) Diuretics
C) Corticosteroids
Rationale: Corticosteroids are commonly used to control inflammation during an acute flare-up of IBD. They help reduce symptoms such as pain and diarrhea. Antibiotics, antacids, and diuretics are not appropriate treatments for IBD flare-ups.
A nurse is educating a patient with Inflammatory Bowel Disease (IBD) about medications. Which of the following statements by the patient indicates the need for further teaching about immunosuppressive drugs used in IBD treatment?
A) “I will take these medications as prescribed to reduce inflammation.”
B) “I should report any signs of infection to my healthcare provider while on this medication.”
C) “Immunosuppressive drugs will prevent flare-ups from occurring.”
D) “These medications will help me fight infections.”
D) “These medications will help me fight infections.”
Rationale: Immunosuppressive drugs are used to reduce inflammation in IBD, but they do not help fight infections. In fact, these medications suppress the immune system, making the patient more vulnerable to infections, and any signs of infection should be promptly reported to the healthcare provider.
A patient with Inflammatory Bowel Disease (IBD) is being started on biologic therapy. Which of the following is a common side effect that the nurse should monitor for during treatment?
A) Hyperglycemia
B) Weight loss
C) Increased risk of infections
D) Hypertension
C) Increased risk of infections
Rationale: Biologic therapies used to treat IBD work by suppressing the immune system, which increases the risk of infections. Hyperglycemia, weight loss, and hypertension are not common side effects of biologic therapies.
A patient with IBD is being discharged after a hospitalization for severe flare-ups. The nurse provides dietary instructions. Which of the following dietary recommendations is most appropriate for this patient during remission?
A) Consume a high-fiber diet to promote regular bowel movements
B) Avoid all dairy products to prevent exacerbating symptoms
C) Eat small, frequent meals that are low in fat and easy to digest
D) Drink high-sugar beverages to maintain energy levels
C) Eat small, frequent meals that are low in fat and easy to digest
Rationale: During remission, patients with IBD should focus on eating small, frequent meals that are easy to digest and low in fat to prevent triggering symptoms. A high-fiber diet may irritate the bowel, and high-sugar beverages are not recommended for optimal nutrition.
A patient with IBD is being prepared for surgery due to complications. Which of the following interventions should the nurse prioritize before the surgery?
A) Promote fluid intake to prevent dehydration
B) Encourage a high-protein diet
C) Teach the patient how to perform post-surgical wound care
D) Monitor for signs of gastrointestinal bleeding
A) Promote fluid intake to prevent dehydration
Rationale: Promoting fluid intake is essential to prevent dehydration, which is a common concern for patients with IBD, especially during flare-ups or before surgery. While a high-protein diet, wound care education, and monitoring for bleeding are also important, maintaining hydration is a priority for the patient’s overall health and surgical outcome.
A patient presents with right lower quadrant abdominal pain, nausea, and a fever of 101°F. Which of the following is the most likely clinical manifestation of appendicitis?
A) Severe, diffuse abdominal pain that is relieved by vomiting
B) Pain initially in the upper abdomen that moves to the lower left quadrant
C) Sudden onset of sharp, upper right quadrant pain after eating
D) Right lower quadrant pain with rebound tenderness and guarding
D) Right lower quadrant pain with rebound tenderness and guarding
Rationale: Appendicitis typically presents with right lower quadrant pain, often associated with rebound tenderness (pain upon release of pressure) and muscle guarding. The other options do not accurately describe the common clinical manifestations of appendicitis.
A nurse is assessing a patient with suspected appendicitis. The patient complains of pain when the nurse palpates the lower left abdomen. This finding is known as:
A) Murphy’s sign
B) Rovsing’s sign
C) Cullen’s sign
D) McBurney’s point tenderness
B) Rovsing’s sign
Rationale: Rovsing’s sign refers to pain in the right lower quadrant when pressure is applied to the left lower quadrant, indicating appendicitis. Murphy’s sign is related to gallbladder disease, Cullen’s sign indicates internal bleeding, and McBurney’s point tenderness is specific to appendicitis but directly over the right lower quadrant.
A 10-year-old child presents with fever, nausea, and right lower quadrant abdominal pain. Upon physical exam, the nurse notes positive rebound tenderness and muscle guarding. What is the nurse’s priority intervention?
A) Administering antacids to relieve abdominal discomfort
B) Encouraging the child to drink clear fluids
C) Preparing the child for immediate surgery or imaging studies
D) Instructing the child to rest and avoid movement
C) Preparing the child for immediate surgery or imaging studies
Rationale: The clinical manifestations of appendicitis (fever, nausea, right lower quadrant pain, rebound tenderness, and guarding) suggest an emergency situation that requires further imaging studies and potentially surgery to prevent rupture. The other interventions are not appropriate for suspected appendicitis.
A patient with appendicitis reports worsening abdominal pain that started as a dull ache near the belly button. Which of the following best describes the progression of this pain in appendicitis?
A) The pain begins as sharp and localized in the right lower quadrant.
B) The pain starts as generalized abdominal pain and localizes to the right lower quadrant.
C) The pain is constant and unrelieved by movement.
D) The pain starts in the left lower quadrant and radiates to the upper abdomen.
B) The pain starts as generalized abdominal pain and localizes to the right lower quadrant.
Rationale: In appendicitis, the pain typically starts as a dull, generalized ache near the belly button and then localizes to the right lower quadrant as the inflammation worsens. The other descriptions do not accurately reflect the typical progression of appendicitis pain.
A patient presents with dysuria, frequency, and urgency. On examination, the nurse notes mild suprapubic tenderness. These symptoms are most indicative of which of the following conditions?
A) Acute glomerulonephritis
B) Pyelonephritis
C) Renal calculi
D) Cystitis
D) Cystitis
Rationale: Cystitis, or bladder infection, is characterized by dysuria (painful urination), frequency, urgency, and suprapubic tenderness. These are common clinical manifestations of a lower urinary tract infection (UTI), typically involving the bladder.
A patient with a urinary tract infection (UTI) presents with fever, chills, nausea, vomiting, and flank pain. Based on these symptoms, the nurse suspects which of the following?
A) Acute cystitis
B) Prostatitis
C) Pyelonephritis
D) Urethritis
C) Pyelonephritis
Rationale: Pyelonephritis is characterized by fever, chills, nausea, vomiting, and flank pain, which suggest an upper urinary tract infection affecting the kidneys. Cystitis, prostatitis, and urethritis primarily involve the lower urinary tract.
A patient is diagnosed with pyelonephritis. Which of the following clinical manifestations should the nurse expect to observe in this patient?
A) Suprapubic tenderness and dysuria
B) Hematuria and flank pain
C) Clear, non-cloudy urine and no fever
D) Urinary retention with a weak stream
B) Hematuria and flank pain
Rationale: Pyelonephritis typically presents with symptoms such as hematuria (blood in the urine), flank pain (due to kidney inflammation), fever, and chills. Suprapubic tenderness and dysuria are more typical of cystitis.
A nurse is educating a patient on the differences between a urinary tract infection (UTI) and pyelonephritis. Which of the following statements by the patient indicates a need for further education?
A) “I should expect fever and chills with pyelonephritis.”
B) “I can manage cystitis with antibiotics and rest.”
C) “Pyelonephritis affects only the bladder and urethra.”
D) “Flank pain is a common symptom of pyelonephritis.”
C) “Pyelonephritis affects only the bladder and urethra.”
Rationale: This statement is incorrect because pyelonephritis affects the kidneys, not just the bladder and urethra. Cystitis affects the bladder, while pyelonephritis involves an upper urinary tract infection, including the kidneys.
A patient with a urinary tract infection (UTI) reports feeling fatigued and having cloudy, foul-smelling urine. The nurse understands that these symptoms may indicate a UTI involving which part of the urinary tract?
A) Lower urinary tract
B) Upper urinary tract
C) Urethra only
D) Prostate gland
A) Lower urinary tract (bladder)
Rationale: Fatigue, cloudy, and foul-smelling urine are common symptoms of a UTI in the lower urinary tract (bladder). Pyelonephritis (an upper urinary tract infection) would typically present with more systemic symptoms such as fever and flank pain.
A patient with nephrotic syndrome presents with edema, proteinuria, and hypoalbuminemia. Which of the following laboratory findings is most commonly associated with nephrotic syndrome?
A) Elevated blood urea nitrogen (BUN)
B) Decreased serum albumin levels
C) Elevated serum potassium levels
D) Increased white blood cell count (WBC)
B) Decreased serum albumin levels
Rationale: Nephrotic syndrome is characterized by proteinuria, hypoalbuminemia, hyperlipidemia, and edema. The most prominent lab finding in nephrotic syndrome is decreased serum albumin levels, which results from the loss of proteins in the urine.
A nurse is reviewing the lab results of a patient with nephrotic syndrome. Which of the following would be expected in the urinalysis of this patient?
A) Presence of proteinuria greater than 3.5 g/day
B) Low specific gravity
C) Presence of casts without protein
D) Negative for glucose and protein
A) Presence of proteinuria greater than 3.5 g/day
Rationale: Proteinuria greater than 3.5 g/day is a hallmark of nephrotic syndrome, as the kidneys lose large amounts of protein due to glomerular damage. The other options do not align with the typical presentation of nephrotic syndrome.
A patient with nephrotic syndrome has elevated cholesterol levels. Which of the following lab findings is most likely to be seen in this patient?
A) Hyperlipidemia
B) Hypokalemia
C) Hypercalcemia
D) Hypoglycemia
A) Hyperlipidemia
Rationale: Hyperlipidemia (elevated cholesterol and triglyceride levels) is commonly associated with nephrotic syndrome due to the liver’s increased production of lipoproteins in response to protein loss.
A nurse is reviewing the lab results of a patient with nephrotic syndrome and notices an elevated blood urea nitrogen (BUN) and creatinine level. What do these elevated values indicate?
A) Dehydration and impaired kidney function
B) Decreased glomerular filtration rate (GFR)
C) Hyperkalemia due to renal insufficiency
D) Liver dysfunction leading to impaired protein synthesis
B) Decreased glomerular filtration rate (GFR)
Rationale: Elevated BUN and creatinine levels typically indicate renal dysfunction or a decreased GFR, which can occur in nephrotic syndrome as the kidneys are damaged and unable to efficiently filter waste products.
A patient with nephrotic syndrome has an albumin level of 2.0 g/dL and proteinuria of 4.5 g/day. Which of the following lab findings should the nurse monitor closely in this patient?
A) Calcium levels for signs of hypercalcemia
B) Potassium levels for possible hypokalemia
C) Sodium levels for signs of hypernatremia
D) Lipid profile for elevated cholesterol and triglycerides
D) Lipid profile for elevated cholesterol and triglycerides
Rationale: Nephrotic syndrome often results in elevated lipid levels, including increased cholesterol and triglycerides, due to the liver’s increased production of lipoproteins in response to the loss of albumin and other proteins in the urine. Monitoring the lipid profile is crucial.
A patient is diagnosed with glomerulonephritis. Which of the following clinical manifestations would the nurse expect to observe in this patient?
A) Decreased blood pressure and peripheral edema
B) Hypertension, hematuria, and proteinuria
C) Increased urine output and hypokalemia
D) Hypercalcemia and polyuria
B) Hypertension, hematuria, and proteinuria
Rationale: Glomerulonephritis typically presents with hypertension due to fluid retention, hematuria (blood in the urine), and proteinuria (protein in the urine), which are classic signs of glomerular damage.
A nurse is reviewing the lab results of a patient with glomerulonephritis. Which of the following findings is most likely to be present?
A) Increased serum albumin levels
B) Decreased uric acid levels
C) Elevated serum creatinine and BUN
D) Increased hemoglobin and hematocrit levels
C) Elevated serum creatinine and BUN
Rationale: In glomerulonephritis, the glomeruli are damaged, leading to impaired kidney function and a decreased glomerular filtration rate (GFR). This results in elevated serum creatinine and blood urea nitrogen (BUN) levels, which are indicative of renal dysfunction.
A nurse is providing education to a patient with glomerulonephritis. What is the most important dietary modification for the patient to manage their condition?
A) Low-sodium diet to manage fluid retention and hypertension
B) High-protein diet to prevent malnutrition
C) Low-calcium diet to prevent kidney stones
D) High-potassium diet to support kidney function
A) Low-sodium diet to manage fluid retention and hypertension
Rationale: A low-sodium diet is essential for patients with glomerulonephritis to help manage fluid retention and hypertension, which are common complications of the condition. Excess sodium can worsen edema and high blood pressure.
A nurse is assessing a patient with glomerulonephritis who reports recent upper respiratory infection. Which of the following would the nurse be most concerned about in relation to the development of glomerulonephritis?
A) Recent group A streptococcal infection
B) High-fat diet consumption
C) Family history of hypertension
D) Recent history of urinary tract infection (UTI)
A) Recent group A streptococcal infection
Rationale: Glomerulonephritis can develop after a group A streptococcal infection, such as strep throat or skin infections. The immune response to this infection can trigger inflammation in the glomeruli, leading to glomerulonephritis.
A nurse is assessing a pediatric patient who was recently rescued from a near-drowning incident in a swimming pool. What is the nurse’s priority action?
A) Administering prophylactic antibiotics
B) Assessing respiratory status and oxygen saturation
C) Encouraging oral fluid intake
D) Checking for signs of hypoglycemia
B) Assessing respiratory status and oxygen saturation
Rationale: The priority for a patient with a submersion injury is assessing airway, breathing, and circulation. Even if the child appears stable, delayed respiratory complications such as pulmonary edema and respiratory distress syndrome can occur.
A 5-year-old child was submerged underwater for approximately two minutes but was quickly revived and is now awake and alert in the emergency department. The parents ask why the child needs to stay for observation. What is the nurse’s best response?
A) “We need to ensure your child does not develop an infection.”
B) “Even though your child seems fine now, complications like lung injury can develop hours later.”
C) “We need to observe your child for signs of dehydration.”
D) “Since your child is awake and breathing well, discharge will be soon.”
B) “Even though your child seems fine now, complications like lung injury can develop hours later.”
Rationale: Secondary complications, such as delayed pulmonary edema and acute respiratory distress syndrome (ARDS), can develop within 24 hours, requiring extended monitoring.
A child experiencing a submersion injury is at risk for which of the following life-threatening complications?
A) Pulmonary edema
B) Hyperthermia
C) Hypertension
D) Hypoglycemia
A) Pulmonary edema
Rationale: Pulmonary complications, including pulmonary edema and ARDS, can develop hours after the incident due to lung injury from water aspiration.
A nurse is caring for a pediatric patient who was submerged in cold water for an extended period. What condition should the nurse anticipate?
A) Hyperthermia
B) Metabolic alkalosis
C) Hypothermia
D) Hypertension
C) Hypothermia
Rationale: Prolonged submersion in cold water can lead to hypothermia, which may contribute to bradycardia, decreased cardiac output, and altered mental status.
A 6-year-old child is admitted after a near-drowning incident. Which assessment finding would indicate worsening respiratory distress?
A) Pink, moist mucous membranes
B) Clear breath sounds
C) Capillary refill of less than 2 seconds
D) Intercostal retractions and grunting
D) Intercostal retractions and grunting
Rationale: Retractions and grunting are signs of increased work of breathing, which may indicate impending respiratory failure, a common delayed complication of submersion injuries.
A nurse is providing discharge instructions to parents of a child recovering from a near-drowning incident. What symptom should the parents immediately report?
A) Increased thirst
B) Mild fatigue
C) Coughing or difficulty breathing
D) Increased appetite
C) Coughing or difficulty breathing
Rationale: Signs of respiratory distress, such as coughing or difficulty breathing, may indicate delayed pulmonary complications, requiring immediate medical attention.
A child is admitted following a near-drowning incident in freshwater. The nurse understands that aspiration of freshwater can cause which of the following complications?
A) Fluid overload and hypervolemia
B) Surfactant washout leading to atelectasis
C) Severe dehydration
D) Hypertension and tachycardia
B) Surfactant washout leading to atelectasis
Rationale: Freshwater aspiration can dilute and wash out surfactant, leading to alveolar collapse (atelectasis) and impaired gas exchange.
Which pediatric patient is at the highest risk for a submersion injury?
A) A 10-year-old child who swims with a life jacket
B) A 7-year-old who takes swim lessons and is supervised
C) A 3-year-old who has unsupervised access to a backyard pool
D) A 15-year-old who swims competitively
C) A 3-year-old who has unsupervised access to a backyard pool
Rationale: Toddlers and young children are at the highest risk for submersion injuries, especially when left unsupervised near water sources.
A nurse is developing a care plan for a 2-year-old child with cerebral palsy (CP). Which of the following interventions is most appropriate for promoting mobility in this age group?
A) Encouraging the child to use a walker
B) Teaching the child to use a wheelchair
C) Implementing passive range-of-motion exercises
D) Recommending total bed rest to prevent fatigue
C) Implementing passive range-of-motion exercises
Rationale: Passive range-of-motion exercises help prevent contractures and maintain joint flexibility in young children with CP who may have limited voluntary movement. Mobility aids like walkers are typically introduced later as the child grows.
A school nurse is developing an individualized education plan (IEP) for a child with cerebral palsy who has difficulty with fine motor skills. Which accommodation is most appropriate?
A) Encouraging the child to write out all assignments
B) Providing large-print books
C) Limiting the child’s participation in classroom activities
D) Allowing the use of assistive technology, such as speech-to-text software
D) Allowing the use of assistive technology, such as speech-to-text software
Rationale: Children with CP often have fine motor impairments that make writing difficult. Assistive technology like speech-to-text software supports communication and academic participation.
A nurse is teaching the parents of a 4-year-old child with cerebral palsy about appropriate play activities to support development. Which of the following activities should the nurse recommend?
A) Video games that require rapid hand movements
B) Structured physical therapy sessions only
C) Adaptive tricycles and modified puzzles
D) Competitive sports requiring high coordination
C) Adaptive tricycles and modified puzzles
Rationale: Adaptive tricycles help strengthen muscles and promote movement, while modified puzzles improve fine motor skills. Play should be developmentally appropriate and focus on enhancing motor function.
A nurse is educating the parents of an 8-year-old child with cerebral palsy about nutritional management. Which recommendation is most appropriate?
A) Offer large, solid meals to improve oral muscle strength
B) Encourage self-feeding without assistance
C) Avoid using adaptive utensils to promote normal eating habits
D) Provide small, frequent meals with soft or pureed textures
D) Provide small, frequent meals with soft or pureed textures
Rationale: Children with CP often have difficulty swallowing and controlling oral muscles. Soft or pureed foods in small portions help prevent choking and ensure adequate nutrition.
A nurse is preparing to administer medication to a 10-year-old child with cerebral palsy who experiences spasticity. Which medication should the nurse anticipate administering?
A) Albuterol
B) Baclofen
C) Phenytoin
D) Prednisone
B) Baclofen
Rationale: Baclofen is a muscle relaxant commonly used to reduce spasticity in patients with CP, improving mobility and comfort.
A nurse is caring for a 12-year-old with cerebral palsy who has difficulty with verbal communication. What is the best strategy to enhance communication?
A) Using an augmentative and alternative communication (AAC) device
B) Speaking louder to help the child understand
C) Discouraging communication attempts to prevent frustration
D) Asking yes/no questions only
A) Using an augmentative and alternative communication (AAC) device
Rationale: AAC devices, such as communication boards or speech-generating devices, help children with CP express their needs and interact effectively.
A nurse is providing discharge teaching to the parents of a 15-year-old with cerebral palsy. What should the nurse emphasize regarding the adolescent’s transition to adulthood?
A) Encouraging vocational training and independent living skills
B) Limiting social interactions to prevent stress
C) Expecting complete dependence on caregivers
D) Avoiding discussion of future goals to prevent anxiety
A) Encouraging vocational training and independent living skills
Rationale: As children with CP grow, they should be encouraged to develop skills for independent living, education, and employment, based on their abilities and needs.
A nurse is caring for a pediatric patient who is experiencing an active tonic-clonic seizure. What is the nurse’s priority action?
A) Restrain the child to prevent injury
B) Place a padded tongue blade in the child’s mouth
C) Turn the child onto their side and maintain a patent airway
D) Administer a bolus of IV fluids
C) Turn the child onto their side and maintain a patent airway
Rationale: Turning the child onto their side helps prevent aspiration and keeps the airway open. Restraining the child or placing objects in the mouth can cause further injury.
A child in the emergency department is actively seizing and has been for five minutes. Which medication should the nurse anticipate administering first?
A) IV lorazepam
B) IV phenytoin
C) IV valproic acid
D) IV levetiracetam
A) IV lorazepam
Rationale: Benzodiazepines, such as lorazepam or diazepam, are the first-line treatment for an acute seizure due to their rapid action in stopping seizure activity.
A school nurse witnesses a student experiencing a generalized seizure in the classroom. Which action should the nurse avoid?
A) Placing a folded jacket under the student’s head
B) Loosening restrictive clothing
C) Attempting to insert an oral airway during the seizure
D) Moving objects away from the student
C) Attempting to insert an oral airway during the seizure
Rationale: Inserting anything into the mouth during a seizure can cause injury, aspiration, or airway obstruction. The focus should be on safety and positioning.
A nurse is caring for a child who had a seizure and is now postictal. Which intervention is the most appropriate?
A) Suction the child’s airway aggressively
B) Reorient the child and allow for rest
C) Offer food and fluids immediately
D) Ambulate the child to assess coordination
B) Reorient the child and allow for rest
Rationale: After a seizure, children often experience postictal confusion, fatigue, and drowsiness. They should be allowed to rest and reorient gradually.
A parent of a child with epilepsy asks how they should respond if their child has a seizure at home. Which statement by the nurse requires further teaching?
A) “I should time the seizure and call 911 if it lasts more than five minutes.”
B) “I should turn my child on their side and clear the area of harmful objects.”
C) “I should stay with my child and monitor their breathing.”
D) “I should hold my child down to prevent injury during the seizure.”
D) “I should hold my child down to prevent injury during the seizure.”
Rationale: Restraining a child during a seizure can cause injury. Instead, caregivers should focus on ensuring a safe environment and positioning the child on their side.
A nurse is assessing a child with suspected Duchenne Muscular Dystrophy (DMD). Which early sign is most characteristic of this condition?
A) Loss of bowel and bladder control
B) Persistent Moro reflex beyond infancy
C) Difficulty rising from the floor and using hands to push on thighs
D) Increased deep tendon reflexes
C) Difficulty rising from the floor and using hands to push on thighs
Rationale: This describes Gower’s sign, a hallmark of DMD. Children with DMD experience progressive muscle weakness, starting in the lower extremities, leading to difficulty standing up.
The nurse is performing an assessment on a 5-year-old child with Duchenne Muscular Dystrophy. Which additional finding should the nurse expect?
A) Hypertonic muscles with spastic movements
B) Enlarged calf muscles with muscle weakness
C) Tremors and uncoordinated fine motor movements
D) Hyporeflexia with increased sensation
B) Enlarged calf muscles with muscle weakness
Rationale: Pseudohypertrophy of the calves (enlarged calf muscles due to fatty and fibrotic tissue replacement) is a classic finding in DMD, along with progressive muscle weakness.
A parent of a child newly diagnosed with Duchenne Muscular Dystrophy asks what symptoms to expect as the disease progresses. What is the nurse’s best response?
A) “You will notice muscle weakness that starts in the legs and spreads upward.”
B) “Your child will experience frequent seizures as the disease progresses.”
C) “Your child will lose the ability to speak before losing the ability to walk.”
D) “Your child will experience numbness and tingling in the extremities.”
A) “You will notice muscle weakness that starts in the legs and spreads upward.”
Rationale: DMD follows a progressive pattern of muscle weakness beginning in the lower extremities and moving upward, leading to loss of ambulation and respiratory complications.
The nurse is assessing a child with Duchenne Muscular Dystrophy. Which finding indicates a late-stage complication of the disease?
A) Decreased respiratory effort and frequent lung infections
B) Increased strength in upper extremities
C) Involuntary muscle contractions and spasticity
D) Decreased pain perception in lower extremities
A) Decreased respiratory effort and frequent lung infections
Rationale: As DMD progresses, respiratory muscles weaken, leading to ineffective breathing, decreased lung function, and a high risk of respiratory infections.
The nurse is evaluating a school-age child diagnosed with Duchenne Muscular Dystrophy. Which statement by the parents requires further teaching?
A) “We encourage him to remain as active as possible to slow muscle weakness.”
B) “We perform passive range-of-motion exercises to maintain flexibility.”
C) “We expect his symptoms to improve as he gets older.”
D) “We are monitoring for breathing difficulties as the disease progresses.”
C) “We expect his symptoms to improve as he gets older.”
Rationale: DMD is a progressive disease that worsens over time. The nurse should provide education about its degenerative nature and available supportive treatments.
A nurse is assessing a child with a suspected head injury after falling from a bicycle. Which finding is most concerning and requires immediate intervention?
A) Headache and mild dizziness
B) Brief episode of vomiting after the fall
C) Small bruise on the forehead with no loss of consciousness
D) Unequal pupil size and decreased responsiveness
D) Unequal pupil size and decreased responsiveness
Rationale: Unequal pupils and decreased responsiveness indicate increased intracranial pressure (ICP) or possible brain herniation, requiring immediate medical intervention.
The nurse is monitoring a child admitted with a head injury. Which sign would indicate increasing intracranial pressure?
A) Bradycardia and widened pulse pressure
B) Tachycardia and hypotension
C) Hyperactive reflexes and muscle spasms
D) Decreased urine output and peripheral edema
A) Bradycardia and widened pulse pressure
Rationale: Cushing’s triad, which includes bradycardia, hypertension with widened pulse pressure, and irregular respirations, is a late sign of increased ICP and requires immediate intervention.
A nurse is assessing the level of consciousness in a child with a head injury. Which method is most appropriate?
A) Checking deep tendon reflexes
B) Monitoring pupillary response to light
C) Using the Glasgow Coma Scale
D) Observing for signs of seizure activity
C) Using the Glasgow Coma Scale
Rationale: The Glasgow Coma Scale (GCS) is the standard tool for assessing consciousness in head injury patients by evaluating eye opening, verbal response, and motor response.
A child with a recent head injury is being monitored for potential complications. The nurse notes a sudden clear fluid drainage from the child’s nose. What is the nurse’s next best action?
A) Have the child blow their nose to clear the drainage
B) Test the fluid for glucose and notify the provider
C) Apply pressure to the nose and position the child supine
D) Administer an antihistamine to prevent further drainage
B) Test the fluid for glucose and notify the provider
Rationale: Clear drainage from the nose could indicate cerebrospinal fluid (CSF) leakage, which suggests a skull fracture. Testing the fluid for glucose helps confirm the presence of CSF.
A nurse is developing a care plan for a child with autism spectrum disorder (ASD). Which intervention is the most appropriate to include?
A) Encourage frequent eye contact and social interaction
B) Use structured routines and visual schedules
C) Introduce new activities spontaneously to promote flexibility
D) Speak in a loud and animated voice to maintain attention
B) Use structured routines and visual schedules
Rationale: Children with ASD thrive on routine and predictability. Structured routines and visual schedules help reduce anxiety and improve understanding of daily activities.
A child with autism spectrum disorder (ASD) is hospitalized. The parents express concern about their child’s difficulty coping with changes. What is the nurse’s best action?
A) Minimize environmental stimuli and maintain a consistent routine
B) Encourage interaction with multiple staff members to promote adaptability
C) Provide unstructured free time to encourage independence
D) Offer choices frequently to help the child feel in control
A) Minimize environmental stimuli and maintain a consistent routine
Rationale: Children with ASD often have sensory sensitivities and difficulty with change. A consistent routine and a calm environment help them feel secure and reduce distress.
The nurse is assessing a child with autism spectrum disorder (ASD) who is experiencing sensory overload. Which behavior would indicate this?
A) Rocking back and forth and covering ears
B) Engaging in prolonged eye contact and smiling
C) Sitting quietly and responding promptly to questions
D) Pointing to objects and making verbal requests
A) Rocking back and forth and covering ears
Rationale: Sensory overload in children with ASD may manifest as repetitive behaviors, self-soothing actions like rocking, or covering ears in response to overwhelming stimuli.
A parent asks the nurse for strategies to help their child with autism spectrum disorder (ASD) improve communication skills. Which response by the nurse is most appropriate?
A) “Encourage long conversations to improve social skills.”
B) “Force your child to make eye contact during conversations.”
C) “Allow your child to avoid verbal communication altogether.”
D) “Sign language or picture communication systems may be helpful.”
D) “Sign language or picture communication systems may be helpful.”
Rationale: Many children with ASD benefit from alternative communication methods such as sign language or picture exchange communication systems (PECS) to enhance their ability to express needs and emotions.
A nurse is working with a child with autism spectrum disorder (ASD) who becomes distressed in the hospital setting. What is the nurse’s priority action?
A) Redirect the child to a quiet, low-stimulation area
B) Encourage interaction with other children to promote socialization
C) Restrict comforting objects to encourage independence
D) Increase the frequency of verbal instructions to gain compliance
A) Redirect the child to a quiet, low-stimulation area
Rationale: Children with ASD can become overwhelmed by excessive noise or activity. A quiet, controlled environment can help them regain a sense of calm.
Which nursing intervention is most effective when administering care to a hospitalized child with autism spectrum disorder (ASD)?
A) Assign different nurses daily to promote adaptability
B) Maintain a calm, structured approach with minimal changes
C) Encourage participation in group activities to build social skills
D) Frequently touch the child to provide comfort and reassurance
B) Maintain a calm, structured approach with minimal changes
Rationale: Children with ASD function best in structured environments with consistent caregivers. Sudden changes can cause distress and increased anxiety.
The parents of a 5-year-old child with autism spectrum disorder (ASD) ask about behavioral therapies. What should the nurse recommend?
A) Applied behavior analysis (ABA) therapy to reinforce positive behaviors
B) Long periods of free play to promote self-expression
C) Punishment-based strategies to discourage repetitive behaviors
D) Avoiding any form of structured intervention to reduce stress
A) Applied behavior analysis (ABA) therapy to reinforce positive behaviors
Rationale: ABA therapy is an evidence-based approach used to help children with ASD develop communication, social, and behavioral skills through positive reinforcement.
A school nurse is developing a plan of care for a child diagnosed with attention-deficit/hyperactivity disorder (ADHD). Which intervention should the nurse include to help the child succeed academically?
A) Seat the child in the back of the classroom to avoid distractions
B) Allow the child to complete assignments at their own pace without deadlines
C) Provide a structured schedule with clear expectations and minimal distractions
D) Encourage the child to engage in multiple tasks simultaneously to improve focus
C) Provide a structured schedule with clear expectations and minimal distractions
Rationale: Children with ADHD benefit from a structured environment that minimizes distractions and includes clear expectations. Predictability helps them focus and complete tasks more effectively. Seating arrangements should be in the front of the classroom to reduce external distractions, and breaking tasks into manageable steps with frequent breaks can improve performance.
A nurse is providing parent education on managing a child with ADHD at home. Which statement by the parent indicates a need for further teaching?
A) “I will create a daily routine with set meal and bedtime schedules.”
B) “I will allow my child to watch television and play video games as a reward for completing homework.”
C) “I will give my child one instruction at a time instead of multiple directions at once.”
D) “I will use positive reinforcement and praise for good behavior.”
B) “I will allow my child to watch television and play video games as a reward for completing homework.”
Rationale: While rewards can be an effective behavioral management strategy, excessive screen time can worsen ADHD symptoms by increasing hyperactivity and reducing attention span. Instead, parents should use non-screen-based rewards such as outdoor play, stickers, or extra reading time.
A nurse is educating a parent on the medication management of their child with ADHD. Which statement by the parent indicates understanding?
A) “I should give my child the stimulant medication right before bedtime to improve sleep.”
B) “My child’s appetite may decrease, so I will encourage meals before taking the medication.”
C) “If my child skips a dose, I should double the next dose to make up for it.”
D) “I can stop giving my child the medication on weekends to allow for a break.”
B) “My child’s appetite may decrease, so I will encourage meals before taking the medication.”
Rationale: Stimulant medications, such as methylphenidate and amphetamines, commonly cause appetite suppression. Administering the medication after breakfast helps ensure adequate nutrition. Medications should be taken as prescribed without doubling missed doses, and drug holidays should only be done under a healthcare provider’s guidance.
A nurse is assisting a teacher in managing a child with ADHD in the classroom. Which strategy is most appropriate?
A) Increase homework assignments to reinforce learning
B) Use open-ended questions to encourage critical thinking
C) Seat the child next to a highly talkative student to improve socialization
D) Implement frequent breaks and allow short bursts of physical activity
D) Implement frequent breaks and allow short bursts of physical activity
Rationale: Children with ADHD often struggle with sitting still for long periods. Incorporating short, scheduled breaks and allowing movement can help them release energy and improve focus when they return to tasks. Additionally, tasks should be broken into smaller steps with immediate feedback.
A nurse is reviewing discharge instructions with the parents of a child newly diagnosed with ADHD. Which recommendation should the nurse prioritize?
A) “Maintain a highly structured routine and clear expectations at home.”
B) “Allow the child to engage in activities without rules to foster creativity.”
C) “Use strict punishment for impulsive behaviors to teach self-control.”
D) “Limit all forms of stimulation, including outdoor activities, to avoid overstimulation.”
A) “Maintain a highly structured routine and clear expectations at home.”
Rationale: Children with ADHD thrive in environments with structure, consistency, and clear expectations. Providing predictable routines reduces anxiety and improves self-regulation. Strict punishment is ineffective in managing ADHD behaviors, and outdoor activities are beneficial for releasing excess energy and improving concentration.
A nurse is assessing a 3-year-old child for signs of a developmental delay. Which finding is most concerning and warrants further evaluation?
A) The child speaks in two-word phrases
B) The child has difficulty dressing independently
C) The child does not make eye contact or respond to their name
D) The child is unable to hop on one foot
C) The child does not make eye contact or respond to their name
Rationale: Lack of eye contact and failure to respond to their name can be early indicators of autism spectrum disorder (ASD) or an intellectual disability. While two-word phrases at 3 years may be slightly delayed, it is not as concerning as the absence of social engagement. Difficulty dressing independently and inability to hop on one foot are not expected milestones at this age.
A nurse is evaluating a preschool-aged child for possible learning disabilities. Which assessment finding would be most indicative of a developmental delay?
A) Difficulty recognizing colors and shapes
B) Occasional temper tantrums when frustrated
C) Speaking in unclear sentences that are difficult to understand
D) Preferring to play alone rather than with peers
C) Speaking in unclear sentences that are difficult to understand
Rationale: By age 4, a child’s speech should be mostly intelligible to strangers. Persistent speech difficulties may indicate a language or developmental delay. Occasional temper tantrums and difficulty recognizing colors and shapes can be typical for the age group, while a preference for solitary play may require further assessment but is not a definitive sign of a learning disability.
A nurse is educating the parents of a child with an intellectual disability on how to enhance their child’s learning at home. Which strategy is most appropriate?
A) Providing repetitive, structured activities to reinforce learning
B) Encouraging the child to learn independently with minimal assistance
C) Introducing multiple new concepts at once to improve cognitive skills
D) Discouraging the use of visual aids or hands-on learning tools
A) Providing repetitive, structured activities to reinforce learning
Rationale: Children with intellectual disabilities benefit from repetition, structure, and clear, simple instructions. Breaking tasks into smaller steps and using hands-on activities can enhance understanding and retention. Learning independently without guidance may lead to frustration, and introducing multiple new concepts at once can be overwhelming.
A nurse is planning care for a toddler with a suspected developmental delay. Which intervention would be most beneficial in promoting learning and skill development?
A) Encouraging interaction with peers in a structured environment
B) Limiting exposure to new experiences to avoid sensory overload
C) Using a passive learning approach with minimal interaction
D) Waiting until the child reaches school age before implementing interventions
A) Encouraging interaction with peers in a structured environment
Rationale: Social interaction in a structured environment helps toddlers develop communication, cognitive, and motor skills. Early intervention is crucial for children with developmental delays, and waiting until school age can result in missed opportunities for growth. Active learning with engagement is more effective than passive approaches.
The nurse is developing a plan of care for a preschooler with a learning disability. Which strategy would best support the child’s cognitive development?
A) Offering multisensory learning experiences such as music, visuals, and hands-on activities
B) Providing lengthy verbal instructions to enhance comprehension
C) Avoiding the use of rewards or praise to encourage internal motivation
D) Encouraging self-directed learning without adult supervision
A) Offering multisensory learning experiences such as music, visuals, and hands-on activities
Rationale: Children with learning disabilities benefit from multisensory approaches that reinforce concepts through visual, auditory, and kinesthetic learning. Short, simple instructions are more effective than lengthy explanations, and positive reinforcement encourages engagement and motivation.
A nurse is counseling a parent concerned about their toddler’s delayed speech. Which response by the nurse is most appropriate?
A) “Your child will likely catch up on their own, so there’s no need to worry.”
B) “Speech delays are always a sign of an intellectual disability and require immediate intervention.”
C) “You should wait until your child is school-aged before seeking speech therapy services.”
D) “It is normal for some children to develop speech later, but an evaluation can help determine if therapy is needed.”
D) “It is normal for some children to develop speech later, but an evaluation can help determine if therapy is needed.”
Rationale: While some children develop speech later, early intervention is key for those with significant delays. An evaluation by a speech-language pathologist can help determine if therapy is necessary. Delayed speech is not always indicative of an intellectual disability, but it should not be ignored.
A nurse is assessing a 14-year-old patient diagnosed with major depressive disorder. Which finding would be most concerning and require immediate intervention?
A) Reports of feeling sad and withdrawn for the past two weeks
B) Increased sleep and decreased appetite
C) Expresses feelings of worthlessness and has a plan to harm themselves
D) Declining academic performance and social withdrawal
C) Expresses feelings of worthlessness and has a plan to harm themselves
Rationale: A patient expressing suicidal ideation with a plan requires immediate intervention to ensure their safety. While sadness, changes in sleep and appetite, and social withdrawal are symptoms of depression, they do not pose an immediate life-threatening risk like suicidal intent does.
A nurse is caring for a 10-year-old patient diagnosed with PTSD following a traumatic event. Which intervention would be most appropriate to help the child process their emotions?
A) Encourage the child to talk about the trauma in detail daily
B) Provide a structured, predictable environment with emotional support
C) Have the child discuss their trauma in a group setting with peers
D) Discourage discussion about the trauma to prevent distress
B) Provide a structured, predictable environment with emotional support
Rationale: Children with PTSD benefit from a structured and predictable environment that fosters a sense of safety. Forcing the child to discuss their trauma too soon may retraumatize them, and avoiding the topic entirely does not help them process their emotions effectively.
A nurse is developing a care plan for an adolescent with depression. Which intervention should be prioritized?
A) Encourage the patient to participate in social activities even if they refuse
B) Monitor for signs of self-harm and suicidal ideation
C) Allow the patient to sleep throughout the day to help with fatigue
D) Minimize interactions to avoid overwhelming the patient
B) Monitor for signs of self-harm and suicidal ideation
Rationale: Suicide risk is a major concern in depressed adolescents, making frequent assessment for self-harm and suicidal ideation a priority. Encouraging social interaction should be done gradually and not forced. Allowing excessive sleep can worsen symptoms, and minimizing interactions can increase feelings of isolation.
A nurse is caring for a child with PTSD who experiences frequent flashbacks. What is the most appropriate nursing intervention during a flashback episode?
A) Remind the child they are safe and reorient them to the present moment
B) Encourage the child to discuss the details of their trauma immediately
C) Leave the child alone to work through their emotions
D) Restrain the child to prevent injury
A) Remind the child they are safe and reorient them to the present moment
Rationale: During a flashback, grounding techniques such as reassurance and reorientation to the present moment help reduce distress. Forcing discussion about the trauma can worsen anxiety, and leaving the child alone may make them feel unsafe. Restraints should only be used as a last resort if the child is at risk of harming themselves or others.
A nurse is caring for a 4-year-old child with Down syndrome and intellectual disabilities. Which of the following should be the nurse’s primary concern when planning care for this child?
A) Ensuring the child receives appropriate immunizations
B) Promoting communication and social interaction
C) Addressing safety concerns related to potential developmental delays
D) Managing the child’s dietary preferences and feeding habits
C) Addressing safety concerns related to potential developmental delays
Rationale: Children with Down syndrome and intellectual disabilities are at higher risk for developmental delays, including motor and cognitive skills. This increases the potential for injury or accidents. Prioritizing safety concerns, such as falls and accidental ingestion, is essential in planning care. While immunizations, communication, and dietary habits are important, safety is the primary concern in this scenario.
A nurse is assessing a 5-year-old child with Down syndrome. The child has difficulty with balance and coordination. Which action should the nurse take to help improve the child’s mobility?
A) Recommend that the child participate in swimming to improve muscle strength
B) Encourage the child to engage in solitary play to minimize injury risk
C) Teach the child to use assistive devices such as a walker for better support
D) Refer the child to physical therapy to address coordination and balance issues
D) Refer the child to physical therapy to address coordination and balance issues
Rationale: Children with Down syndrome often have delays in motor development, including difficulties with coordination and balance. Referral to physical therapy is essential for developing skills to improve mobility and reduce the risk of falls or other injuries. Swimming can be a beneficial activity, but physical therapy should be prioritized to address these specific issues.
A nurse is educating the parents of a child with Down syndrome and intellectual disabilities about developmental milestones. Which statement should the nurse include in the teaching?
A) “Your child will likely meet all developmental milestones on time.”
B) “Your child may meet milestones at a later age, but with support, they will improve.”
C) “You should avoid interventions that could delay your child’s development.”
D) “It’s best to let your child develop independently without support from others.”
B) “Your child may meet milestones at a later age, but with support, they will improve.”
Rationale: Children with Down syndrome often experience delays in meeting developmental milestones, but with appropriate interventions, such as speech therapy, occupational therapy, and physical therapy, they can improve. Encouraging support and realistic expectations helps parents manage their child’s development effectively. It is not recommended to avoid interventions or let the child develop independently without support.
What would asymmetric gluteal folds be indicative of?
hip dysplasia
A 7-year-old child presents with a limp and complains of hip pain, particularly after physical activity. The physician suspects Legg-Calvé-Perthes disease. Which of the following findings would be most consistent with this condition?
A) Joint stiffness and swelling
B) Limited range of motion in the hip joint
C) Swollen knees with warmth and redness
D) Painful and swollen wrists
B) Limited range of motion in the hip joint
Rationale: Legg-Calvé-Perthes disease typically presents with hip pain, limping, and limited range of motion due to disruption of blood flow to the femoral head, leading to avascular necrosis. Joint stiffness and swelling are more commonly seen in conditions like Juvenile Idiopathic Arthritis (JIA).
A child diagnosed with Juvenile Idiopathic Arthritis (JIA) complains of pain and swelling in both knees. Which of the following is the most likely clinical manifestation of JIA?
A) Pain and swelling of large joints, especially the knees and wrists
B) Limping and limited range of motion of the hip joint
C) Morning stiffness that improves throughout the day
D) Cold and swollen fingers with a blue hue
A) Pain and swelling of large joints, especially the knees and wrists
Rationale: JIA typically affects large joints such as the knees, wrists, and ankles, and it is often associated with morning stiffness. Legg-Calvé-Perthes disease, on the other hand, involves the hip joint, not the knees or wrists.
A nurse is assessing a child with Legg-Calvé-Perthes disease. Which of the following findings would be expected during the physical examination?
A) Swollen and warm wrists and ankles
B) Asymmetrical gluteal folds
C) Decreased range of motion in the hip
D) Red, inflamed joints of the hands
C) Decreased range of motion in the hip
Rationale: Children with Legg-Calvé-Perthes disease commonly exhibit limited range of motion in the affected hip joint due to avascular necrosis of the femoral head. This condition typically does not cause swelling or warmth in other joints like wrists and ankles.
When managing a child diagnosed with Juvenile Idiopathic Arthritis (JIA), which of the following treatments would be a priority to help manage inflammation and pain?
A) Nonsteroidal anti-inflammatory drugs (NSAIDs)
B) Corticosteroid injections into affected joints
C) Use of a joint replacement surgery
D) Complete bed rest for 6 weeks
A) Nonsteroidal anti-inflammatory drugs (NSAIDs)
Rationale: The first-line treatment for JIA is typically NSAIDs to reduce inflammation and pain. Corticosteroid injections are used for more severe cases, but they are not typically the first treatment. Joint replacement is not a standard treatment for JIA in children, and complete bed rest is not recommended for long-term management.
A nurse is educating the parents of a child with Legg-Calvé-Perthes disease. Which of the following statements should the nurse include in the teaching?
A) “Your child will need to avoid weight-bearing activities to reduce pressure on the hip.”
B) “Surgery is required in all cases of Legg-Calvé-Perthes disease.”
C) “There is no need for physical therapy in the management of this disease.”
D) “Children with Legg-Calvé-Perthes disease often experience complete resolution without treatment.”
A) “Your child will need to avoid weight-bearing activities to reduce pressure on the hip.”
Rationale: Treatment for Legg-Calvé-Perthes disease includes avoiding weight-bearing activities to reduce stress on the femoral head and promote healing. Surgery is not required for all cases; physical therapy is often part of the treatment plan, and complete resolution without treatment is not common.
Which of the following clinical manifestations would differentiate Juvenile Idiopathic Arthritis (JIA) from Legg-Calvé-Perthes disease in a pediatric patient?
A) Joint deformities and growth disturbances
B) Pain in the hip joint with limping
C) Pain with movement and limited range of motion in the hip
D) Swollen, warm, and tender joints in the hands and wrists
D) Swollen, warm, and tender joints in the hands and wrists
Rationale: Swelling, warmth, and tenderness in the joints of the hands and wrists are characteristic of JIA. Legg-Calvé-Perthes disease primarily affects the hip joint, causing pain and limited range of motion but not swelling or warmth in other joints.
Which diagnostic test would be most helpful in confirming a diagnosis of Legg-Calvé-Perthes disease?
A) X-ray of the affected hip
B) Complete blood count (CBC)
C) Magnetic resonance imaging (MRI) of the joints
D) Ultrasound of the affected joint
A) X-ray of the affected hip
Rationale: An X-ray of the hip is the most commonly used diagnostic tool for confirming Legg-Calvé-Perthes disease. It will show the characteristic changes in the femoral head. While MRI and ultrasound can also provide useful information, an X-ray is typically the first diagnostic step.
Which of the following is the main goal in managing a child with Legg-Calvé-Perthes disease?
A) To perform joint replacement surgery to restore hip function
B) To reduce pain and prevent further damage to the femoral head
C) To promote weight-bearing activities to speed up recovery
D) To provide a range of motion exercises to increase joint flexibility
B) To reduce pain and prevent further damage to the femoral head
Rationale: The main goal in managing Legg-Calvé-Perthes disease is to reduce pain, protect the femoral head from further damage, and promote healing. Weight-bearing activities are generally avoided, and joint replacement is not typically needed in children with this condition.
A nurse is caring for a child with Juvenile Idiopathic Arthritis (JIA). Which of the following is the most important goal when developing a care plan for this patient?
A) Limiting the child’s physical activity to prevent joint pain
B) Encouraging the child to avoid all social interactions
C) Teaching the child to rely on others for daily activities
D) Preventing joint deformities and preserving joint function
D) Preventing joint deformities and preserving joint function
Rationale: The primary goal in managing JIA is to prevent joint deformities and preserve joint function. Limiting physical activity may not be necessary, and encouraging social interaction is important for emotional well-being. Encouraging independence in daily activities is key in promoting development.
A 12-year-old child is diagnosed with scoliosis. The curve is measured at 15 degrees. Which of the following would be the most appropriate treatment at this stage?
A) Surgery
B) Observation with regular follow-up
C) Spinal bracing
D) Physical therapy
B) Observation with regular follow-up
Rationale: A curve of 15 degrees is considered mild and typically requires observation with regular follow-up to monitor for progression. Surgery or bracing is not indicated for mild curves.
A 14-year-old patient with scoliosis has a curve of 45 degrees. What is the most appropriate intervention at this stage?
A) Observation and no intervention
B) Surgery to correct the deformity
C) Physical therapy for strengthening the muscles
D) Spinal bracing to prevent further curvature
D) Spinal bracing to prevent further curvature
Rationale: Moderate scoliosis (usually 25-45 degrees) is often managed with spinal bracing to prevent further progression. Surgery is not typically performed unless the curve exceeds 45 degrees or causes significant complications.
A 16-year-old with scoliosis has a curve of 60 degrees. What would be the most appropriate treatment?
A) Physical therapy to improve posture
B) Observation with follow-up every 6 months
C) Spinal bracing to reduce curve progression
D) Surgical intervention to correct the deformity
D) Surgical intervention to correct the deformity
Rationale: Severe scoliosis (greater than 45 degrees) is often treated with surgery to correct the deformity and prevent further complications such as respiratory or cardiovascular issues. Bracing is no longer effective at this stage.
A 13-year-old patient with scoliosis presents with a curve of 30 degrees. The healthcare provider decides to implement a treatment plan. Which of the following interventions would be the most appropriate?
A) Physical therapy alone
B) Spinal bracing to prevent further progression
C) Immediate surgery
D) Observation and regular follow-up every 3-6 months
B) Spinal bracing to prevent further progression
Rationale: Moderate scoliosis (typically between 25-45 degrees) is generally managed with spinal bracing to prevent the curve from worsening. Surgery is not indicated unless the curve progresses beyond 45 degrees.
Which of the following is the most important factor to assess in a patient with scoliosis to determine the need for bracing or surgery?
A) The patient’s age and remaining growth potential
B) The presence of back pain
C) The degree of joint flexibility
D) The patient’s level of physical activity
A) The patient’s age and remaining growth potential
Rationale: The need for bracing or surgery is largely determined by the patient’s age, skeletal maturity, and remaining growth potential. If a child is still growing, bracing may be more effective. Surgery is typically considered in severe cases or if the curve progresses despite bracing.
A nurse is preparing a care plan for a child with scoliosis and a curve of 35 degrees. What would be the most important aspect of care for this child?
A) Encouraging the child to perform physical activities to improve posture
B) Ensuring the child wears the spinal brace as prescribed
C) Recommending immediate surgery to correct the curve
D) Monitoring for respiratory symptoms and limitation of physical activity
B) Ensuring the child wears the spinal brace as prescribed
Rationale: For moderate scoliosis (25-45 degrees), spinal bracing is often the primary intervention to prevent further progression of the curve. Encouraging adherence to wearing the brace as prescribed is crucial to the success of this treatment.
A 6-year-old child presents to the emergency room with a suspected fractured radius after falling off a bicycle. Which of the following would be the priority assessment for this patient?
A) Assessing for signs of infection
B) Measuring the length of the limb
C) Checking for neurovascular compromise (e.g., pulse, capillary refill, sensation)
D) Assessing for psychological distress
C) Checking for neurovascular compromise (e.g., pulse, capillary refill, sensation)
Rationale: The priority assessment in pediatric fractures includes evaluating for neurovascular compromise to ensure adequate blood flow and nerve function distal to the injury. This helps identify potential complications such as compartment syndrome or nerve damage.
A child with a fracture of the tibia is being treated with a cast. Which of the following instructions should the nurse provide to the parent regarding care at home?
A) “Keep the cast dry at all times, and avoid using lotion on the skin underneath.”
B) “Allow your child to put weight on the cast immediately after the injury.”
C) “You should remove the cast if it gets itchy.”
D) “Monitor for signs of infection, such as fever, redness, or drainage from the cast.”
D) “Monitor for signs of infection, such as fever, redness, or drainage from the cast.”
Rationale: Monitoring for signs of infection is crucial, especially when the child has a cast. Signs like fever, redness, or drainage from the cast may indicate infection, and timely intervention is needed to prevent complications such as osteomyelitis.
A pediatric patient with a femur fracture is in traction. Which of the following would be a primary consideration for the nurse in managing this patient’s care?
A) Ensuring the child remains in the same position to avoid traction displacement
B) Regularly checking for signs of impaired circulation and skin integrity
C) Allowing the child to walk around with support to speed up healing
D) Removing the traction weight if the child complains of pain
B) Regularly checking for signs of impaired circulation and skin integrity
Rationale: The nurse must regularly assess for impaired circulation and monitor skin integrity in patients in traction to prevent complications such as skin breakdown, compartment syndrome, or nerve damage. These are crucial to prevent further damage and promote healing.
A child is diagnosed with a fracture and is being treated with a fiberglass cast. What is the most important action for the nurse when monitoring the casted limb?
A) Measuring the circumference of the limb before and after casting
B) Assessing for neurovascular status, including pulse, capillary refill, and sensation
C) Repositioning the limb every 4 hours to prevent muscle atrophy
D) Keeping the limb elevated at heart level at all times
B) Assessing for neurovascular status, including pulse, capillary refill, and sensation
Rationale: Neurovascular assessment is essential to monitor for possible complications like compartment syndrome, which can occur with a fracture and cast. Ensuring blood flow and sensation remain intact is key for proper healing and early detection of problems.
A child presents with a spiral fracture of the humerus. Which of the following would be a potential complication of this injury?
A) Traction
B) Infection
C) Fat embolism
D) Hemorrhagic shock
C) Fat embolism
Rationale: A spiral fracture, often seen in long bones like the humerus, carries a risk of fat embolism, where fat from the bone marrow enters the bloodstream. This can lead to respiratory distress, confusion, and other serious complications.
A 10-year-old child with a tibial fracture is being treated in a cast. After 48 hours, the child complains of increasing pain in the leg. What should the nurse do first?
A) Administer pain medication as ordered
B) Perform a neurovascular assessment
C) Remove the cast
D) Reassure the child that pain is normal
B) Perform a neurovascular assessment
Rationale: Increasing pain in the leg could be a sign of complications such as compartment syndrome or impaired circulation. A neurovascular assessment (checking for pulse, capillary refill, and sensation) is necessary to rule out these issues and prevent further injury.
A nurse is caring for a 4-year-old child with a displaced fracture of the radius. The child is being treated with a cast. What complication should the nurse closely monitor for in this patient?
A) Osteoporosis
B) Neurovascular compromise
C) Contractures
D) DVT (deep vein thrombosis)
B) Neurovascular compromise
Rationale: Displaced fractures can lead to neurovascular compromise, where circulation or nerve function is impaired. This can result in further damage and complications, so it is crucial for the nurse to regularly assess for neurovascular changes, such as decreased pulse, capillary refill, or sensation.
A 3-year-old child is recovering from a femur fracture treated with a hip spica cast. What is a key priority in the child’s post-cast care?
A) Teaching the child to walk as soon as possible
B) Ensuring proper hydration and nutrition
C) Monitoring for signs of respiratory distress
D) Checking for signs of constipation or urinary retention
D) Checking for signs of constipation or urinary retention
Rationale: A hip spica cast can restrict the child’s movement and bowel/bladder function, making constipation and urinary retention common complications. Ensuring proper hydration and monitoring for these symptoms are important aspects of care to prevent further complications.
A nurse is caring for a pediatric patient who has sustained a femoral fracture. Which of the following complications should the nurse be most concerned about after the child is placed in traction?
A) Hip dislocation
B) Compartment syndrome
C) Infection at the fracture site
D) Delayed bone healing
B) Compartment syndrome
Rationale: Compartment syndrome is a serious complication of fractures, especially in limbs that are placed in traction. It occurs when pressure builds up in a muscle compartment, restricting blood flow. Early recognition is essential to prevent permanent damage to muscles and nerves.
A child with a fractured femur is being treated with a cast. The nurse should provide education to the family about all of the following EXCEPT:
A) “You should not attempt to remove or adjust the cast yourself.”
B) “If the cast gets wet, it may weaken and should be replaced.”
C) “Check the cast for any cracks or breaks as this could indicate a complication.”
D) “You should elevate the leg to decrease swelling, especially for the first 24-48 hours.”
C) “Check the cast for any cracks or breaks as this could indicate a complication.”
Rationale: While it is important to monitor the cast for signs of damage or complications, it is not typically appropriate for the family to attempt to assess cracks or breaks themselves. The healthcare provider should inspect the cast regularly for signs of damage or complications, such as infection or skin irritation.
What is compartment syndrome?
Occurs when swelling or bleeding within a muscle compartment increases pressure, compromising blood flow and leading to tissue damage. It often results from trauma, such as fractures, and requires prompt recognition and intervention, typically through surgery (fasciotomy) to relieve the pressure and prevent permanent damage to muscles and nerves.
A 5-year-old child presents with difficulty walking, frequent falls, and an inability to rise from a sitting position. The nurse suspects muscular dystrophy. Which of the following is the most likely clinical manifestation of this condition?
A. Progressive muscle weakness
B. Hyperreflexia
C. Joint stiffness
D. Hypotension
A. Progressive muscle weakness
Rationale: Muscular dystrophy is characterized by progressive muscle weakness, particularly affecting the proximal muscles, leading to difficulty walking and rising from a sitting position.
A nurse is assessing a child with suspected muscular dystrophy. The nurse notes that the child uses their hands to push off their legs in order to stand up. What is this maneuver known as?
A. Gower’s sign
B. Babinski sign
C. Hoffman’s sign
D. Trousseau’s sign
A. Gower’s sign
Rationale: Gower’s sign is a classic clinical manifestation of muscular dystrophy, where the child uses their hands to push off their legs to help stand due to proximal muscle weakness.
A 6-year-old child with muscular dystrophy is admitted to the hospital with progressive difficulty in walking. The nurse is educating the parents on expected clinical manifestations of the condition. Which of the following should the nurse include in the education?
A. Loss of motor skills, including difficulty with balance and coordination
B. Chronic muscle spasms
C. Sudden loss of vision
D. Severe gastrointestinal distress
A. Loss of motor skills, including difficulty with balance and coordination
Rationale: Muscular dystrophy leads to the progressive loss of motor skills, affecting balance and coordination as muscles weaken over time.
A nurse is evaluating the clinical manifestations of a child with muscular dystrophy. Which of the following is an expected finding on physical examination?
A. Increased deep tendon reflexes
B. Calf muscle hypertrophy
C. Widespread rash
D. Absence of muscle tone
B. Calf muscle hypertrophy
Rationale: Calf muscle hypertrophy is a common finding in muscular dystrophy due to muscle degeneration and replacement by connective tissue, a phenomenon often seen early in the disease.
A nurse is assessing a newborn for signs of developmental dysplasia of the hip (DDH). Which of the following findings would suggest DDH in the infant?
A. Hyperextension of the knee
B. Excessive movement of the leg
C. Normal asymmetric skin folds
D. Limited abduction of the hip
D. Limited abduction of the hip
Rationale: Limited abduction of the hip is a classic sign of developmental dysplasia of the hip in infants, indicating a potential dislocation or instability of the hip joint.
A 3-month-old infant is brought to the clinic with concerns of a possible hip dislocation. The nurse performs the Barlow test. What is the purpose of this test?
A. To check for hip flexion contracture
B. To evaluate the infant’s gait
C. To assess for hip joint stability and detect dislocation
D. To test for neurological abnormalities
C. To assess for hip joint stability and detect dislocation
Rationale: The Barlow test is used to assess for hip joint instability and detect dislocation by gently pushing the thigh backward, which can dislocate a hip that is already at risk.
A nurse is performing a physical exam on an infant and notices asymmetric gluteal and thigh folds. What condition could this finding suggest?
A. Hip arthritis
C. Developmental dysplasia of the hip (DDH)
B. Scoliosis
D. Muscular dystrophy
C. Developmental dysplasia of the hip (DDH)
Rationale: Asymmetric gluteal and thigh folds are a sign of developmental dysplasia of the hip, indicating potential hip dislocation or subluxation.
A 6-month-old infant is suspected of having developmental dysplasia of the hip. The nurse performs the Ortolani test. Which of the following is the purpose of this maneuver?
A. To check for hip joint dislocation and reduction
B. To assess for knee instability
C. To evaluate for skin abnormalities
D. To assess for tibial torsion
A. To check for hip joint dislocation and reduction
Rationale: The Ortolani test is used to check for hip joint dislocation and reduction by gently abducting the infant’s hips to check for a “clunk” that indicates a reducible hip dislocation.
A nurse is educating the parents of an infant diagnosed with developmental dysplasia of the hip. Which of the following symptoms should the nurse explain as a common sign of DDH in infants?
A. Excessive crying
B. Increased muscle tone in the legs
C. Loss of sensation in the lower extremities
D. Difference in leg length
D. Difference in leg length
Rationale: A difference in leg length is a common sign of developmental dysplasia of the hip, often due to a hip dislocation or subluxation that affects the symmetry of the lower extremities.
What is a Pavlik harness?
A medical device used to treat developmental dysplasia of the hip (DDH) in infants. It is designed to hold the baby’s hips in a flexed and abducted position, which helps to keep the femoral head within the hip socket and encourages proper hip development. The harness is worn full-time for several months, depending on the severity of the condition, and it helps to gradually stabilize the hip joint to prevent or correct dislocation.
A nurse is assessing a 3-month-old infant with suspected torticollis. Which of the following findings would be most characteristic of the condition?
A. Limited range of motion in the neck and head tilted to one side
B. Inability to focus eyes on a single object
C. Unilateral weakness of the facial muscles
D. Unilateral swelling in the neck with fever
A. Limited range of motion in the neck and head tilted to one side
Rationale: Torticollis, or “twisted neck,” is characterized by the head being tilted to one side due to tightness or spasm in the neck muscles, often the sternocleidomastoid. This results in limited range of motion and asymmetry of head position.
A nurse is caring for a 6-month-old infant diagnosed with congenital torticollis. Which of the following should the nurse educate the parents to observe for in the child?
A. Difficulty feeding due to poor suck reflex
B. Favoring one side of the head when lying down or sleeping
C. Increased muscle tone in the arms
D. Difficulty walking or crawling
B. Favoring one side of the head when lying down or sleeping
Rationale: Infants with torticollis often favor one side of the head when lying down or sleeping, leading to positional flat head syndrome (plagiocephaly). It is important for parents to monitor and alternate the baby’s sleeping position to help prevent this.
When a nurse observes an infant with suspected torticollis, which of the following actions is most important for the nurse to take?
A. Encourage the parents to begin physical therapy as soon as possible
B. Recommend the use of a soft neck collar for comfort
C. Assess for other signs of neurological deficits
D. Encourage the child to sit upright as much as possible to strengthen neck muscles
C. Assess for other signs of neurological deficits
Rationale: While torticollis is often a muscular issue, it can sometimes be associated with underlying neurological conditions. Therefore, it’s important to assess for other neurological signs to rule out any serious causes of the symptoms.
A nurse is teaching the parents of a child recently diagnosed with osteogenesis imperfecta (OI) about the condition. Which of the following statements should the nurse include in the teaching?
A. “Your child will need to avoid any physical activity to prevent fractures.”
B. “You should support your child’s bones by providing appropriate safety measures and encouraging gentle activities.”
C. “Your child will likely experience significant developmental delays due to bone fractures.”
D. “The condition will improve over time as your child’s bones strengthen with age.”
B. “You should support your child’s bones by providing appropriate safety measures and encouraging gentle activities.”
Rationale: Osteogenesis imperfecta is a genetic disorder characterized by fragile bones, leading to frequent fractures. While it’s important to avoid high-risk activities, gentle exercise and safety measures can promote bone strength and development without causing harm.
When discussing the management of osteogenesis imperfecta (OI) with a parent, the nurse explains the importance of vitamin D and calcium. Which statement by the parent indicates a need for further teaching?
A. “Vitamin D and calcium will help strengthen my child’s bones and prevent fractures.”
B. “I will give my child calcium-rich foods to support their bone health.”
C. “I should avoid giving my child supplements, as they are not helpful for bone health.”
D. “We may need to consult a dietitian to ensure the correct balance of nutrients.”
C. “I should avoid giving my child supplements, as they are not helpful for bone health.”
Rationale: Vitamin D and calcium are important for bone health and can help reduce the frequency of fractures in children with osteogenesis imperfecta. The parent should be educated on the role of supplements in addition to a balanced diet.
The nurse is teaching the parents of a child with osteogenesis imperfecta (OI) about safe handling techniques. Which action should the nurse advise the parents to avoid when caring for their child?
A. Gently lifting the child under the arms
B. Supporting the child’s head and neck when lifting
C. Using soft, padded surfaces for the child’s activities
D. Encouraging the child to play independently on a soft mattress
A. Gently lifting the child under the arms
Rationale: Lifting a child with osteogenesis imperfecta under the arms can place excessive stress on the bones, potentially causing fractures. Proper lifting techniques should include supporting the head, neck, and body, avoiding lifting by the arms.
A parent asks the nurse how they can promote their child’s social development with osteogenesis imperfecta (OI). Which suggestion should the nurse provide to the parent?
A. “Limit your child’s interaction with other children to avoid risk of injury.”
B. “Focus on individual play, as group play may be too risky for your child.”
C. “Avoid enrolling your child in any physical activities until they are older.”
D. “Encourage your child to play with others in a safe, controlled environment.”
D. “Encourage your child to play with others in a safe, controlled environment.”
Rationale: While safety is important, promoting socialization and play is critical for a child’s emotional and social development. Parents should be encouraged to create a safe environment where their child can interact with peers without excessive risk of injury.
The nurse is discussing medication options for a child with osteogenesis imperfecta (OI) with the parents. Which of the following medications may be prescribed to help improve bone density?
A. Corticosteroids
B. Bisphosphonates
C. Calcium carbonate
D. Vitamin C
B. Bisphosphonates
Rationale: Bisphosphonates, such as pamidronate, are used to help increase bone density and reduce the risk of fractures in children with osteogenesis imperfecta. These medications work by inhibiting the activity of osteoclasts, the cells responsible for bone resorption.
A nurse is assessing a patient with Type 1 diabetes. Which of the following clinical manifestations would the nurse most likely observe in this patient?
A. Polyuria, polydipsia, and weight gain
B. Polyphagia, rapid weight loss, and ketoacidosis
C. Hypoglycemia, blurred vision, and fatigue
D. Hyperglycemia, sluggishness, and abdominal cramping
B. Polyphagia, rapid weight loss, and ketoacidosis
Rationale: Type 1 diabetes is typically characterized by polyphagia (increased hunger), rapid weight loss due to inability to use glucose, and the potential for developing diabetic ketoacidosis (DKA), which is more common in Type 1 than Type 2 diabetes.
A nurse is caring for a child newly diagnosed with Type 1 diabetes. Which of the following signs and symptoms would be most concerning and require immediate intervention?
A. Blood glucose of 120 mg/dL
B. Blood glucose of 250 mg/dL with fruity-smelling breath
C. A weight loss of 5 lbs in one week
D. Frequent urination and increased thirst
B. Blood glucose of 250 mg/dL with fruity-smelling breath
Rationale: A blood glucose level of 250 mg/dL with fruity-smelling breath is indicative of diabetic ketoacidosis (DKA), a life-threatening condition that requires immediate medical intervention.
A patient with Type 2 diabetes presents with complaints of increased thirst, frequent urination, and blurred vision. What is the most likely cause of these symptoms?
A. Hyperglycemia
B. Hypoglycemia
C. Diabetic ketoacidosis (DKA)
D. Insulin resistance
A. Hyperglycemia
Rationale: Hyperglycemia (high blood glucose) can lead to symptoms such as increased thirst (polydipsia), frequent urination (polyuria), and blurred vision. These are common manifestations in both Type 1 and Type 2 diabetes.
A nurse is educating a patient with Type 1 diabetes about diabetic ketoacidosis (DKA). Which of the following signs would the nurse explain as most commonly associated with DKA?
A. Increased hunger and irritability
B. Nausea, vomiting, and constipation
C. Weight gain and fatigue
D. Acetone breath and confusion
D. Acetone breath and confusion
Rationale: Diabetic ketoacidosis (DKA) is characterized by acetone (fruity-smelling) breath and confusion. Other signs include dehydration, nausea, and vomiting. It is caused by an acute insulin deficiency leading to ketone production.
A patient with Type 2 diabetes is found to have a blood glucose level of 350 mg/dL. What is the priority nursing action?
A. Administer insulin as ordered and monitor blood glucose
B. Encourage the patient to drink water and monitor for dehydration
C. Administer a dose of oral glucose and reassess in 30 minutes
D. Recheck the blood glucose in 1 hour to assess for a trend
A. Administer insulin as ordered and monitor blood glucose
Rationale: A blood glucose level of 350 mg/dL is significantly elevated and requires insulin administration for correction. Hyperglycemia at this level can lead to dehydration, and insulin is necessary to reduce blood glucose.
A nurse is assessing a patient in the emergency department with suspected diabetic ketoacidosis (DKA). Which of the following would be expected in the physical examination?
A. Decreased respiratory rate and slow heart rate
B. Elevated blood pressure and bradycardia
C. Deep, rapid breathing (Kussmaul respirations)
D. Cyanosis and cold extremities
C. Deep, rapid breathing (Kussmaul respirations)
Rationale: Kussmaul respirations, characterized by deep and rapid breathing, are a common compensatory mechanism in DKA. They occur as the body tries to reduce acidosis by expelling carbon dioxide.
A patient with Type 2 diabetes is experiencing increased thirst, increased urination, and weight loss despite adequate caloric intake. What complication should the nurse be most concerned about?
A. Hypoglycemia
B. Diabetic neuropathy
C. Hyperosmolar hyperglycemic state (HHS)
D. Diabetic ketoacidosis (DKA)
C. Hyperosmolar hyperglycemic state (HHS)
Rationale: Hyperosmolar hyperglycemic state (HHS) is a serious complication of Type 2 diabetes, characterized by extremely high blood glucose levels, dehydration, and altered mental status. Unlike DKA, HHS is not typically associated with ketone production.
A patient is admitted to the hospital in diabetic ketoacidosis (DKA). Which of the following findings would indicate improvement of the patient’s condition?
A. Blood glucose remains above 300 mg/dL
B. Acetone breath odor persists
C. Blood pH returns to normal range
D. Patient experiences nausea and vomiting
C. Blood pH returns to normal range
Rationale: In DKA, blood pH is typically acidic due to the accumulation of ketones. Improvement is indicated by a return to a normal pH level (7.35-7.45), which reflects correction of acidosis.
A patient with Type 1 diabetes is admitted with diabetic ketoacidosis (DKA). What is the primary goal of treatment in the initial phase?
A. Decrease blood glucose to normal levels
B. Correct dehydration and electrolyte imbalances
C. Increase insulin levels rapidly
D. Provide oral glucose for stabilization
B. Correct dehydration and electrolyte imbalances
Rationale: In the initial phase of DKA treatment, the priority is to correct dehydration and electrolyte imbalances, particularly potassium, which may be low. Insulin therapy and blood glucose reduction occur after these priorities are addressed.
A nurse is educating a newly diagnosed patient with Type 1 diabetes on signs of diabetic ketoacidosis (DKA). Which of the following symptoms should the nurse emphasize as requiring immediate attention?
A. Sudden weight gain
B. Blurry vision
C. Frequent hunger
D. Nausea and vomiting
D. Nausea and vomiting
Rationale: Nausea and vomiting are common signs of diabetic ketoacidosis (DKA) and may indicate a worsening condition. Immediate medical attention is needed to prevent further complications.
A patient with Type 2 diabetes is experiencing fatigue, dry skin, and fruity-smelling breath. The nurse suspects diabetic ketoacidosis (DKA). Which of the following laboratory results would the nurse expect to see?
A. Low blood glucose
B. Normal electrolyte levels
C. Increased insulin levels
D. Decreased blood pH
D. Decreased blood pH
Rationale: In DKA, the blood pH decreases due to the accumulation of ketones. This leads to metabolic acidosis, which is a key diagnostic indicator of DKA.
A nurse is caring for a patient with Type 1 diabetes who is at risk for diabetic ketoacidosis (DKA). Which of the following nursing interventions is most important to prevent DKA?
A. Ensuring the patient takes insulin as prescribed
B. Encouraging the patient to eat high-carbohydrate meals
C. Restricting fluid intake to prevent dehydration
D. Educating the patient to avoid exercise at all times
A. Ensuring the patient takes insulin as prescribed
Rationale: Consistent insulin administration is essential for preventing diabetic ketoacidosis (DKA) in patients with Type 1 diabetes. Insulin helps control blood glucose levels and prevents ketone production that can lead to DKA.
A patient with diabetic ketoacidosis (DKA) is admitted to the emergency department with a blood glucose of 600 mg/dL and a blood pH of 7.2. What is the priority treatment for this patient?
A. Administer oral glucose to normalize blood sugar levels
B. Administer intravenous insulin and fluids to correct dehydration and acidosis
C. Administer potassium supplements to correct hypokalemia
D. Encourage the patient to drink water to reduce blood sugar levels
B. Administer intravenous insulin and fluids to correct dehydration and acidosis
Rationale: The priority treatment for DKA is to administer intravenous insulin to lower blood glucose levels and IV fluids to correct dehydration and acidosis. Potassium levels also need to be monitored and corrected, but fluid and insulin administration is the priority.
A nurse is caring for a patient with mild hypoglycemia who is alert and able to swallow. Which of the following interventions should the nurse implement?
A. Administer 25 grams of glucose orally
B. Administer 1 mg of glucagon intramuscularly
C. Administer 50 mL of normal saline intravenously
D. Give the patient a snack of crackers with peanut butter
A. Administer 25 grams of glucose orally
Rationale: For mild hypoglycemia in an alert patient who can swallow, the nurse should administer 15-20 grams of glucose or carbohydrate, which is equivalent to 25 grams of glucose. This helps rapidly raise blood glucose levels.
A patient with severe hypoglycemia is unresponsive and unable to swallow. Which of the following actions is most appropriate for the nurse to take?
A. Administer 25 grams of glucose orally
B. Provide the patient with an oral snack of juice and crackers
C. Administer 1 mg of glucagon intramuscularly or subcutaneously
D. Recheck the blood glucose level after 30 minutes
C. Administer 1 mg of glucagon intramuscularly or subcutaneously
Rationale: In severe hypoglycemia with an unresponsive patient, glucagon should be administered intramuscularly or subcutaneously. Glucagon stimulates the liver to release glucose and raise blood glucose levels.
A nurse is assessing a patient with DKA. Which of the following is an expected outcome of treatment for DKA after 24 hours of therapy?
A. Blood glucose of 250 mg/dL
B. Blood pH of 7.35-7.45
C. Decreased urine output
D. Increased acetone breath odor
B. Blood pH of 7.35-7.45
Rationale: A blood pH of 7.35-7.45 is within the normal range and would indicate that the acidosis associated with DKA is improving. Blood glucose should also decrease, but the normalization of pH is a critical sign of recovery from DKA.
A nurse is caring for a patient with DKA who is receiving insulin therapy. Which laboratory value should be closely monitored during treatment?
A. Sodium levels
B. Calcium levels
C. Hemoglobin levels
D. Blood glucose levels
D. Blood glucose levels
Rationale: Blood glucose levels must be closely monitored during insulin therapy in DKA to ensure they are decreasing appropriately. Additionally, potassium and other electrolytes should also be monitored, but blood glucose is the primary concern.
A patient with severe hypoglycemia has become unresponsive. The nurse has administered 1 mg of glucagon intramuscularly. What is the next appropriate action?
A. Wait 15 minutes and then reassess blood glucose levels
B. Reassess the patient’s blood glucose level immediately
C. Administer 25 grams of oral glucose
D. Administer 1 more dose of glucagon
A. Wait 15 minutes and then reassess blood glucose levels
Rationale: After administering glucagon, the nurse should wait approximately 15 minutes and reassess the patient’s blood glucose level. If the patient remains unresponsive or the blood glucose level is still low, additional measures, such as IV glucose, may be required.
A patient with DKA is receiving intravenous insulin and fluids. Which of the following is the most important nursing action during the first hour of treatment?
A. Assess vital signs and urine output every hour
B. Check blood glucose every 15 minutes
C. Provide a high-carbohydrate snack to prevent hypoglycemia
D. Monitor for signs of fluid overload, such as crackles in the lungs
A. Assess vital signs and urine output every hour
Rationale: During the initial phase of DKA treatment, monitoring vital signs and urine output is critical to assess the patient’s response to fluid resuscitation and ensure that kidney function is adequate. Close observation for signs of fluid overload is important.
A nurse is providing education on the management of mild hypoglycemia to a patient with Type 1 diabetes. Which of the following teaching points should the nurse include?
A. “You can eat a chocolate bar to treat mild hypoglycemia.”
B. “If you experience symptoms of hypoglycemia, wait for them to resolve without treatment.”
C. “Consume 15-20 grams of carbohydrate, such as glucose tablets or fruit juice.”
D. “You should drink a large amount of water to flush out the sugar.”
C. “Consume 15-20 grams of carbohydrate, such as glucose tablets or fruit juice.”
Rationale: For mild hypoglycemia, the appropriate treatment is to consume 15-20 grams of a fast-acting carbohydrate, such as glucose tablets or fruit juice, to raise blood glucose levels quickly.
A nurse is caring for a patient in diabetic ketoacidosis (DKA). Which of the following is a key priority in the initial treatment phase?
A. Administering potassium replacement
B. Providing insulin to reduce blood glucose levels
C. Treating dehydration with IV fluids
D. Monitoring for signs of hypoglycemia
C. Treating dehydration with IV fluids
Rationale: The first priority in treating DKA is fluid resuscitation to correct dehydration. This helps to improve circulation and kidney function. Insulin therapy and potassium replacement follow once the fluid status is corrected.
A nurse is educating a patient with Type 2 diabetes about proper diabetes management. Which of the following statements by the patient indicates the need for further teaching?
A. “I should monitor my blood glucose levels regularly and keep a log.”
B. “I can skip my exercise routine if I feel like my blood sugar is stable.”
C. “I should follow a healthy diet plan to manage my blood glucose.”
D. “I need to take my medication as prescribed by my healthcare provider.”
B. “I can skip my exercise routine if I feel like my blood sugar is stable.”
Rationale: Exercise is an important part of diabetes management, even when blood sugar levels seem stable. Regular exercise helps control blood glucose, improve insulin sensitivity, and reduce cardiovascular risks associated with diabetes.
A nurse is teaching a patient with Type 1 diabetes about insulin administration. What is the most important instruction to provide regarding insulin storage?
A. “Store your insulin at room temperature to avoid pain during injection.”
B. “Insulin should be kept in the refrigerator and never be frozen.”
C. “Keep your insulin exposed to sunlight to ensure it remains effective.”
D. “Store insulin in a hot environment to ensure quick absorption.”
B. “Insulin should be kept in the refrigerator and never be frozen.”
Rationale: Insulin should be stored in a cool, dry place such as the refrigerator. Freezing insulin reduces its effectiveness, and exposure to extreme heat or sunlight can degrade it.
A nurse is caring for a patient with diabetes who has been prescribed an insulin regimen. The patient is unsure when to check blood glucose levels. What is the best response by the nurse?
A. “You should check your blood glucose levels only if you feel symptoms of hypoglycemia.”
B. “You should only check your blood glucose once a day to monitor trends.”
C. “You need to check blood glucose levels immediately after meals only.”
D. “You should check your blood glucose levels before meals and at bedtime.”
D. “You should check your blood glucose levels before meals and at bedtime.”
Rationale: Checking blood glucose before meals and at bedtime is recommended to monitor the patient’s blood glucose levels, adjust insulin doses, and prevent hypoglycemia or hyperglycemia.
A nurse is reviewing a diabetes care plan for a patient with Type 2 diabetes. The nurse notices that the patient’s A1C level is higher than the target range. What is the priority intervention to help the patient achieve better glycemic control?
A. Increase the frequency of insulin injections
B. Assess the patient’s adherence to diet, exercise, and medication plan
C. Provide additional education on the signs and symptoms of hypoglycemia
D. Schedule more frequent blood glucose checks throughout the day
B. Assess the patient’s adherence to diet, exercise, and medication plan
Rationale: The priority is to assess the patient’s adherence to their treatment plan, including diet, exercise, and medications. If there are gaps in adherence, addressing them can improve glycemic control and help the patient achieve a better A1C level.
A nurse is caring for a patient with diabetes and is discussing the role of physical activity in blood glucose control. Which of the following is the most appropriate recommendation?
A. “Exercise can lower blood glucose levels, so it’s important to monitor blood glucose before, during, and after exercise.”
B. “You should limit physical activity to avoid fluctuations in blood glucose levels.”
C. “Only high-intensity exercise can help manage blood glucose, so walking should be avoided.”
D. “Physical activity should be avoided if blood glucose levels are high to prevent complications.”
A. “Exercise can lower blood glucose levels, so it’s important to monitor blood glucose before, during, and after exercise.”
Rationale: Physical activity can lower blood glucose levels, so it is essential to monitor blood glucose before, during, and after exercise to prevent hypoglycemia. Mild to moderate exercise is encouraged as part of diabetes management.
A nurse is educating a patient with diabetes on how to recognize and manage symptoms of hypoglycemia. Which of the following is an early sign of hypoglycemia that the nurse should include in the teaching?
A. Nausea and vomiting
B. Blurred vision
C. Sweating and shaking
D. Slow heart rate
C. Sweating and shaking
Rationale: Early signs of hypoglycemia include sweating, shaking, and feelings of nervousness or anxiety. Recognizing these symptoms early allows for prompt treatment, such as consuming carbohydrates to raise blood glucose levels.
A patient with diabetes is being discharged from the hospital and needs instructions on the proper use of a continuous glucose monitor (CGM). Which of the following is the most important teaching point for the patient?
A. “You will need to calibrate the CGM before each meal.”
B. “You must check your blood glucose levels with a fingerstick every time the CGM reading is abnormal.”
C. “The CGM can replace all blood glucose checks completely.”
D. “The CGM provides real-time glucose trends, but you should still check your blood glucose regularly as needed.”
D. “The CGM provides real-time glucose trends, but you should still check your blood glucose regularly as needed.”
Rationale: A continuous glucose monitor provides real-time glucose trends but should not replace traditional blood glucose checks, especially when readings are abnormal. Fingerstick tests may still be necessary to confirm the CGM readings.
A nurse is caring for a patient with hypothyroidism. Which of the following clinical manifestations would the nurse expect to observe in this patient?
A. Weight loss, palpitations, and heat intolerance
B. Weight gain, cold intolerance, and fatigue
C. Diarrhea, excessive thirst, and increased appetite
D. Hypertension, tremors, and tachycardia
B. Weight gain, cold intolerance, and fatigue
Rationale: Hypothyroidism typically presents with symptoms such as weight gain, cold intolerance, fatigue, and depression due to reduced metabolic rate. These clinical manifestations are common as the thyroid hormone levels are insufficient.
A nurse is assessing a patient with hyperthyroidism. Which of the following findings would be most indicative of this condition?
A. Decreased heart rate, constipation, and cold intolerance
B. Weight loss, heat intolerance, and tachycardia
C. Swelling in the extremities, fatigue, and depression
D. Increased appetite, brittle nails, and weight gain
B. Weight loss, heat intolerance, and tachycardia
Rationale: Hyperthyroidism is characterized by increased metabolic rate, leading to weight loss, heat intolerance, tachycardia, and sometimes palpitations. These symptoms occur due to excess thyroid hormones.
A nurse is reviewing lab results for a patient suspected of having hypothyroidism. Which of the following lab findings would most likely be elevated in this patient?
A. Serum calcium
B. Serum glucose
C. Blood urea nitrogen (BUN)
D. Thyroid-stimulating hormone (TSH)
D. Thyroid-stimulating hormone (TSH)
Rationale: In hypothyroidism, the thyroid gland does not produce enough thyroid hormones, so the pituitary gland compensates by increasing the production of TSH. Elevated TSH levels are commonly seen in hypothyroidism.
A nurse is caring for a patient with hyperthyroidism and an elevated thyroid-stimulating hormone (TSH) level. Which of the following conditions should the nurse suspect?
A. Primary hyperthyroidism
B. Secondary hyperthyroidism
C. Hypothyroidism
D. Tertiary hypothyroidism
C. Hypothyroidism
Rationale: In primary hyperthyroidism, TSH levels are usually low due to negative feedback from elevated thyroid hormones. However, in hypothyroidism, the TSH level is elevated as the pituitary gland tries to stimulate the thyroid to produce more hormones.
A nurse is caring for a patient with hyperthyroidism who presents with a goiter. What is the most likely cause of the goiter in this patient?
A. Autoimmune destruction of thyroid tissue
B. Excessive iodine intake
C. Decreased blood flow to the thyroid gland
D. Increased thyroid hormone production
D. Increased thyroid hormone production
Rationale: A goiter is often caused by the enlargement of the thyroid gland due to overstimulation, as seen in hyperthyroidism. This can occur with conditions such as Graves’ disease, where there is excessive thyroid hormone production.
A nurse is assessing a patient with hypothyroidism. Which of the following signs and symptoms would the nurse expect to see in the patient’s physical exam?
A. Thin, brittle hair and exophthalmos
B. Puffy face, dry skin, and slow reflexes
C. Tremors, tachycardia, and fine hair
D. Warm, moist skin and sweating
B. Puffy face, dry skin, and slow reflexes
Rationale: Hypothyroidism slows the metabolism, resulting in physical findings such as a puffy face, dry skin, and delayed reflexes. These are common characteristics of the condition due to reduced thyroid hormone levels.
A nurse is reviewing lab results for a patient with suspected hyperthyroidism. Which of the following lab findings would most likely be decreased in this patient?
A. Serum TSH
B. Serum calcium
C. Serum potassium
D. Serum sodium
A. Serum TSH
Rationale: In hyperthyroidism, the high levels of thyroid hormones inhibit the release of TSH from the pituitary gland, leading to decreased levels of serum TSH as part of the negative feedback mechanism.
A nurse is educating a patient with hyperthyroidism about their medication regimen. Which statement by the patient indicates the need for further teaching?
A. “I will take my antithyroid medication every day as prescribed.”
B. “I need to monitor my heart rate regularly, as my medication can cause tachycardia.”
C. “I should continue my antithyroid medication even if I start feeling better.”
D. “I will stop taking my antithyroid medication if I feel any discomfort.”
D. “I will stop taking my antithyroid medication if I feel any discomfort.”
Rationale: Antithyroid medications should not be stopped abruptly. Discontinuing the medication can cause a resurgence of symptoms. The patient should take the medication as prescribed and notify the healthcare provider if any issues arise.
A nurse is caring for a patient with hypothyroidism. What is the most appropriate treatment for this condition?
A. Beta-blockers to decrease heart rate
B. Levothyroxine to replace thyroid hormones
C. Antithyroid medications to decrease thyroid function
D. Calcium supplements to improve bone density
B. Levothyroxine to replace thyroid hormones
Rationale: Levothyroxine is a synthetic form of thyroid hormone that is used to replace the thyroid hormones in patients with hypothyroidism, thereby normalizing metabolic function and reducing symptoms.
A nurse is caring for a patient with hypothyroidism. The patient is experiencing constipation, fatigue, and weight gain. Which of the following interventions would be most appropriate to help the patient manage these symptoms?
A. Encourage the patient to increase fluid intake and fiber to relieve constipation
B. Recommend a low-calorie, low-protein diet to address weight gain
C. Limit the patient’s physical activity to reduce fatigue
D. Administer a diuretic to reduce weight
A. Encourage the patient to increase fluid intake and fiber to relieve constipation
Rationale: Constipation is a common symptom of hypothyroidism due to slowed metabolism. Increasing fiber and fluid intake, along with other lifestyle changes, can help relieve constipation and improve the patient’s overall comfort.
A nurse is assessing a patient with hyperthyroidism. Which of the following physical signs would the nurse expect to find during the examination?
A. Bradycardia and weight gain
B. Cold intolerance and dry skin
C. Tachycardia and tremors
D. Diarrhea and poor appetite
C. Tachycardia and tremors
Rationale: Hyperthyroidism increases metabolic rate, leading to symptoms such as tachycardia, tremors, weight loss, and heat intolerance. These are common signs of excessive thyroid hormone production.
A nurse is educating a patient with hypothyroidism about their treatment. Which of the following instructions would be most important for the nurse to include in the teaching?
A. “You can skip a dose of levothyroxine if you forget to take it.”
B. “Take levothyroxine at the same time every day, preferably on an empty stomach.”
C. “You can stop taking levothyroxine if you experience side effects.”
D. “Take levothyroxine with food to improve absorption.”
B. “Take levothyroxine at the same time every day, preferably on an empty stomach.”
Rationale: Levothyroxine should be taken at the same time each day to maintain consistent levels of thyroid hormone in the body. Taking it on an empty stomach improves absorption. Patients should not stop taking it without consulting a healthcare provider.
A nurse is caring for a patient with hyperthyroidism who has recently been started on antithyroid medication. Which of the following side effects should the nurse monitor for?
A. Weight gain and lethargy
B. Cold intolerance and dry skin
C. Rash and fever
D. Hyperreflexia and tremors
C. Rash and fever
Rationale: Antithyroid medications can cause allergic reactions, including rash and fever. The nurse should monitor for these side effects and notify the healthcare provider if they occur.
Why would you give growth hormone deficiency?
Growth hormone deficiency is treated with recombinant human growth hormone (rhGH) to promote normal growth and development in children. It is typically prescribed when a child has a confirmed deficiency in growth hormone, which leads to growth failure and short stature. The treatment helps stimulate growth, increase height, and improve overall development. In adults, rhGH may be used to treat symptoms of growth hormone deficiency such as decreased muscle mass, increased fat, and low energy levels. The goal is to restore normal growth patterns and enhance quality of life.
A nurse is caring for a child diagnosed with Diabetes Insipidus (DI). What clinical manifestation would the nurse most likely observe in this patient?
A) Increased urine output with low specific gravity
B) Decreased urine output with high specific gravity
C) Weight gain and fluid retention
D) Hypoglycemia and bradycardia
A) Increased urine output with low specific gravity
Rationale: Diabetes Insipidus is characterized by large amounts of dilute urine due to a deficiency of antidiuretic hormone (ADH), which leads to decreased water reabsorption in the kidneys. This results in increased urine output and a low specific gravity.
A child with Syndrome of Inappropriate Antidiuretic Hormone (SIADH) is admitted to the hospital. What finding would the nurse expect to observe in this patient?
A) Increased urine output with low specific gravity
B) Weight loss and dehydration
C) Hypertension and edema
D) Increased thirst and dry mucous membranes
C) Hypertension and edema
Rationale: SIADH results in excessive release of ADH, causing the kidneys to retain water. This leads to fluid retention, hypertension, and edema.
A nurse is assessing a patient with Diabetes Insipidus. Which of the following is the priority assessment for this patient?
A) Monitoring for signs of fluid overload
B) Monitoring urine output and specific gravity
C) Assessing for symptoms of hyponatremia
D) Monitoring blood glucose levels
B) Monitoring urine output and specific gravity
Rationale: The priority assessment for a patient with DI is to monitor urine output and specific gravity. The patient will produce large amounts of dilute urine, so monitoring helps assess the severity of the condition and ensure hydration status.
A nurse is caring for a patient with SIADH. What is the most important laboratory value to monitor in this patient?
A) Serum sodium levels
B) Blood glucose levels
C) Hemoglobin and hematocrit
D) Serum potassium levels
A) Serum sodium levels
Rationale: SIADH causes water retention and dilution of sodium in the body, leading to hyponatremia. Monitoring serum sodium levels is crucial to prevent complications like seizures or coma due to severe hyponatremia.
A nurse is teaching a patient diagnosed with Diabetes Insipidus about managing the condition. Which of the following would be most important to include in the teaching?
A) Increase fluid intake to prevent dehydration
B) Restrict sodium intake to prevent water retention
C) Avoid physical activity to prevent excessive fluid loss
D) Monitor for swelling in the lower extremities
A) Increase fluid intake to prevent dehydration
Rationale: Since patients with DI lose large amounts of water in the urine, increasing fluid intake is essential to prevent dehydration and maintain fluid balance.
Which of the following findings would indicate a potential complication in a patient with SIADH?
A) Dry mucous membranes
B) Increased urine output
C) Weight gain and a decrease in serum sodium
D) Dehydration and increased thirst
C) Weight gain and a decrease in serum sodium
Rationale: In SIADH, fluid retention can lead to weight gain and dilution of serum sodium levels, resulting in hyponatremia. This is a serious complication and requires prompt intervention.
A patient with SIADH is at risk for developing which of the following?
A) Hypertension and fluid overload
B) Hypernatremia and dehydration
C) Hyperglycemia and ketosis
D) Hypokalemia and muscle cramps
A) Hypertension and fluid overload
Rationale: SIADH leads to excessive water retention, which can result in fluid overload, increasing the risk for hypertension and edema.
A nurse is caring for a child with Diabetes Insipidus and notices a urine output of 4 liters per day with a specific gravity of 1.002. Which of the following interventions would the nurse prioritize?
A) Administering IV fluids and monitoring electrolytes
B) Limiting the child’s water intake to prevent water intoxication
C) Administering vasopressin and monitoring urine output
D) Encouraging the child to drink fluids to replace lost water
D) Encouraging the child to drink fluids to replace lost water
Rationale: The primary intervention for Diabetes Insipidus is to encourage fluid intake to replace the water lost through excessive urine output. Monitoring for dehydration is key to maintaining fluid balance.
A 4-year-old child presents with a circular, red, itchy rash with raised borders on the scalp. The child’s parents report that the rash has been gradually spreading. Which of the following is the most likely diagnosis?
A) Impetigo
B) Tinea corporis
C) Tinea capitis
D) Contact dermatitis
C) Tinea capitis
Rationale: Tinea capitis is a fungal infection of the scalp, presenting as a circular, scaly, itchy rash with raised borders. It commonly affects children and can spread if untreated.
A child is diagnosed with tinea corporis. Which of the following is the primary treatment for this condition?
A) Oral antibiotics
B) Topical antifungal cream
C) Oral antifungal medication
D) Topical corticosteroids
B) Topical antifungal cream
Rationale: Tinea corporis is a superficial fungal infection treated with topical antifungal agents like clotrimazole or terbinafine. Oral antifungals may be necessary for more severe or extensive cases.
A nurse is caring for a child with tinea pedis. Which of the following interventions would be most important for preventing the spread of the infection?
A) Encouraging the child to wear closed-toed shoes
B) Applying a topical steroid to the affected area
C) Using an antibacterial soap to wash the feet
D) Ensuring the child’s feet are kept clean and dry
D) Ensuring the child’s feet are kept clean and dry
Rationale: Tinea pedis (athlete’s foot) thrives in warm, moist environments. Keeping the feet clean and dry, along with avoiding sharing footwear, can help prevent the spread of the infection.
A 6-year-old child presents with a pruritic, ring-shaped lesion on the inner thigh, with clear skin in the center and a raised border. Which of the following diagnoses is most likely?
A) Tinea cruris
B) Tinea versicolor
C) Eczema
D) Psoriasis
A) Tinea cruris
Rationale: Tinea cruris (jock itch) is a fungal infection that commonly affects the groin area, characterized by a ring-shaped lesion with a raised border and clear skin in the center.
A 3-year-old child presents with a persistent rash on the scalp that has resulted in some hair loss. The pediatrician diagnoses tinea capitis. Which of the following treatment options is the most appropriate for this condition?
A) Topical antifungal cream
B) Oral antifungal medication
C) Topical corticosteroids
D) Oral antibiotics
B) Oral antifungal medication
Rationale: Tinea capitis, a fungal infection of the scalp, requires oral antifungal treatment such as griseofulvin or terbinafine due to its deep tissue involvement and resistance to topical therapy.
A child has been diagnosed with tinea corporis, and the nurse is providing discharge teaching. Which of the following instructions is most important to include in the teaching?
A) “You should apply the antifungal cream only until the rash is gone.”
B) “Make sure to wash the affected area with antibacterial soap daily.”
C) “Avoid sharing towels, clothing, or hats until the infection is cleared.”
D) “Topical corticosteroids will speed up the healing process.”
C) “Avoid sharing towels, clothing, or hats until the infection is cleared.”
Rationale: Tinea corporis is contagious, and sharing personal items like towels, clothing, or hats can lead to the spread of the infection. It’s important to avoid close contact with others until the infection resolves.
A nurse is caring for a child with tinea versicolor. The parent asks how to prevent future infections. Which of the following responses is most appropriate?
A) “Avoid sweating and keep the skin dry.”
B) “Ensure your child uses an antifungal shampoo every day.”
C) “Dress your child in loose-fitting cotton clothing.”
D) “Limit exposure to direct sunlight.”
A) “Avoid sweating and keep the skin dry.”
Rationale: Tinea versicolor is caused by a yeast that thrives in warm, moist environments. Reducing sweating and keeping the skin dry can help prevent recurrence.
A nurse is teaching a parent how to apply topical antifungal cream to a child with tinea corporis. Which of the following instructions should the nurse include?
A) “Apply the cream to the affected area once a day, even if the rash goes away.”
B) “Apply the cream only to the edges of the rash to avoid spreading it.”
C) “Wash the affected area with soap and water, dry it thoroughly, then apply the cream.”
D) “Stop using the cream if the rash improves in 2 days.”
C) “Wash the affected area with soap and water, dry it thoroughly, then apply the cream.”
Rationale: The area should be cleaned and dried before applying the antifungal cream to maximize its effectiveness. It is important to follow the full course of treatment, even if symptoms improve.
A 5-year-old child presents with a circular, scaly patch on the scalp, along with hair loss in the affected area. What is the nurse’s priority action in managing this condition?
A) Apply a topical corticosteroid to the lesion
B) Administer oral antifungal therapy as prescribed
C) Recommend over-the-counter antifungal shampoo
D) Instruct the parent to trim the child’s hair to allow for faster healing
B) Administer oral antifungal therapy as prescribed
Rationale: Tinea capitis requires oral antifungal treatment (such as griseofulvin or terbinafine), as topical therapies are ineffective for deeper fungal infections of the scalp.
A child is receiving treatment for tinea pedis. Which of the following interventions should the nurse prioritize to reduce the risk of spreading the infection to others?
A) Instruct the child to apply an antifungal cream to the entire foot.
B) Recommend the child wears open-toed shoes to allow air circulation.
C) Ensure the child takes daily antifungal medication.
D) Instruct the child to avoid walking barefoot in public areas such as pools and gyms.
D) Instruct the child to avoid walking barefoot in public areas such as pools and gyms.
Rationale: Tinea pedis is highly contagious and can be spread in warm, damp environments like public pools and gyms. Wearing protective footwear can help prevent transmission to others.
A nurse is assessing a 4-year-old child with a burn injury. The skin appears red, swollen, and painful, but there are no blisters present. Which type of burn is this most likely to be?
A) First-degree burn
B) Second-degree burn
C) Third-degree burn
D) Fourth-degree burn
A) First-degree burn
Rationale: First-degree burns involve only the epidermis, causing redness, pain, and mild swelling without blistering. These burns are typically superficial and heal within a few days.
A child with a second-degree burn presents with blisters that are intact, with a pink to red appearance of the skin and moderate swelling. Which of the following actions is most appropriate for the nurse to take?
A) Apply a topical antibiotic ointment and cover the burn with a sterile dressing.
B) Place ice directly on the burn to reduce swelling.
C) Use a heating pad to promote circulation to the burned area.
D) Let the blisters rupture to prevent infection.
A) Apply a topical antibiotic ointment and cover the burn with a sterile dressing.
Rationale: Second-degree burns involve both the epidermis and dermis, causing blisters, redness, and swelling. It is important to prevent infection by applying a topical antibiotic and covering the area with a sterile dressing.
A 6-year-old child with a deep third-degree burn is admitted to the hospital. The burn area appears dry, leathery, and white, with no pain in the affected area. What is the priority action for the nurse?
A) Administer oral pain medications to the child.
B) Clean the burn with soap and water to prevent infection.
C) Apply a wet compress to the burned area to reduce swelling.
D) Assess the child’s airway, breathing, and circulation.
D) Assess the child’s airway, breathing, and circulation.
Rationale: Third-degree burns involve full-thickness injury, damaging all layers of the skin. The nurse’s priority is to assess the child’s ABCs (airway, breathing, circulation), as severe burns may lead to respiratory distress or circulatory shock.
A child is brought into the ER with a fourth-degree burn on their arm from a chemical spill. The burn appears charred and extends to the underlying muscle and bone. What is the nurse’s immediate concern?
A) Assess for signs of pain and administer analgesics.
B) Evaluate the depth and size of the burn to determine treatment.
C) Check the child’s immunization status for tetanus.
D) Monitor for signs of respiratory distress and shock.
D) Monitor for signs of respiratory distress and shock.
Rationale: Fourth-degree burns involve tissue destruction down to the muscle or bone. The nurse must prioritize monitoring for signs of shock, respiratory distress, and other life-threatening complications due to the extent of the injury.
A child is experiencing a first-degree burn from a sunburn. Which of the following interventions is most appropriate for managing the burn?
A) Cover the burn with petroleum jelly and apply a tight dressing.
B) Apply a cold compress and administer acetaminophen for pain relief.
C) Irrigate the area with cool water and apply a topical corticosteroid.
D) Apply a hot compress to reduce inflammation.
B) Apply a cold compress and administer acetaminophen for pain relief.
Rationale: First-degree burns are typically superficial and can be managed with cold compresses for comfort and acetaminophen for pain relief. Avoid applying petroleum jelly or hot compresses, which could worsen the burn.
A nurse is caring for a child with a deep partial-thickness (second-degree) burn. The child is at risk for developing complications. Which of the following interventions should the nurse prioritize?
A) Encourage the child to move the affected limb to prevent stiffness.
B) Apply an antimicrobial cream to the burn area once daily.
C) Prevent infection by keeping the burn area clean and dry.
D) Use a heat lamp to promote healing of the burned tissue.
C) Prevent infection by keeping the burn area clean and dry.
Rationale: Preventing infection is a priority for second-degree burns, as they involve the dermis and may have open blisters. Keeping the area clean and dry helps prevent bacterial contamination and promotes healing.
A pediatric patient has a burn injury on their lower leg. The burn is painful, has blistering, and appears red with some swelling. What classification would you assign this burn?
A) First-degree burn
B) Second-degree burn
C) Third-degree burn
D) Fourth-degree burn
B) Second-degree burn
Rationale: Second-degree burns affect both the epidermis and dermis, causing redness, pain, blisters, and swelling. This classification is consistent with the described symptoms.
A nurse is caring for a child with a severe third-degree burn to the chest and abdomen. What is the primary concern in the immediate post-burn period?
A) Fluid and electrolyte imbalance due to massive fluid loss.
B) Pain management, as the child will experience severe pain.
C) Preventing infection by applying topical antibiotics to the burn area.
D) Restoring normal skin appearance through cosmetic surgery.
A) Fluid and electrolyte imbalance due to massive fluid loss.
Rationale: Third-degree burns cause significant damage to the skin, leading to fluid loss, electrolyte imbalances, and hypovolemia. Fluid resuscitation is the primary concern in the early post-burn phase.
A nurse is caring for a child with a first-degree burn on the arm from a hot surface. Which of the following findings would suggest that the burn is healing appropriately?
A) Redness and swelling have subsided.
B) The skin has developed a crust and blisters are present.
C) The area is cold and pale with no pain.
D) The child continues to experience severe pain and itching.
A) Redness and swelling have subsided.
Rationale: In a first-degree burn, the skin should heal within a few days with the subsidence of redness and swelling. The absence of blisters or severe pain suggests appropriate healing.
A child with a burn injury is in the emergency department. The burn appears to affect the epidermis and part of the dermis, with redness, pain, and blisters. What is the nurse’s primary goal in managing this burn?
A) Prevent shock by monitoring vital signs and fluid status.
B) Manage pain and prevent infection by applying appropriate dressings.
C) Promote cosmetic healing through skin grafting and surgery.
D) Encourage the child to engage in physical therapy to prevent contractures.
B) Manage pain and prevent infection by applying appropriate dressings.
Rationale: For second-degree burns, the focus is on managing pain and preventing infection. This is done by applying appropriate dressings and monitoring for signs of infection or complications.
