NC of Children 1 Flashcards
NC of Children 1
From ATI
A nurse is assessing a 3-year-old child who is 1 day postoperative following a tonsillectomy. Which of the following methods should the nurse use to determine if the child is experiencing pain?
Ask the parents.
Use the FACES scale.
Use the numeric rating scale.
Check the child’s temperature.
Pain is a subjective experience even for a 3-year-old child. Asking the parents is not appropriate as pain is considered a personal experience.
The FACES scale can be used to accurately determine the presence of pain in children as young as 3 years of age.
The numeric rating scale is appropriate for children who are 5 years of age or older.
The child’s temperature is not an indicator of pain. While changes in heart rate, BP, and respiratory rate can be indicators of pain, these are not reliable, because pain is a subjective manifestation.
The FACES scale can be used to accurately determine the presence of pain in children as young as
3 years of age.
The numeric rating scale is appropriate for children who are
5 years of age or older.
The child’s temperature is not an
indicator of pain.
While changes in heart rate, BP, and respiratory rate can be indicators of pain, these are not reliable, because
pain is a subjective manifestation.
A nurse is caring for an adolescent who is receiving pain medication via a PCA pump. When the nurse assesses the client’s pain at 0800, the client describes the pain as a 3 on a scale of 1 to 10. At 1000, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hr. Which of the following actions should the nurse take?
Ask the provider to discontinue the PCA so the nurse can administer PRN pain medication.
A PCA device allows the adolescent to be in charge of pain management and is an effective method to control pain.
Suggest the client’s parent push the button for the client if the parent thinks the adolescent is having pain.
Reevaluate the client in 1 hr since a pain level of 5 is acceptable on a scale of 1 to 10.
Reinforce teaching with the client about how to push the button to deliver the medication.
A nurse is caring for an adolescent who is receiving pain medication via a PCA pump. When the nurse assesses the client’s pain at 0800, the client describes the pain as a 3 on a scale of 1 to 10. At 1000, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hr. Which of the following actions should the nurse take?
Ask the provider to discontinue the PCA so the nurse can administer PRN pain medication.
A PCA device allows the adolescent to be in charge of pain management and is an effective method to control pain.
Suggest the client’s parent push the button for the client if the parent thinks the adolescent is having pain.
Reevaluate the client in 1 hr since a pain level of 5 is acceptable on a scale of 1 to 10.
Reinforce teaching with the client about how to push the button to deliver the medication.
One of the principles of PCA is that
no one other than the client or nurse pushes the button to deliver the medication.
An adolescent is capable of maintaining effective pain control using a
PCA.
Moderate (5 to 6) or severe pain (7 to 10) requires the use of ______ for effective pain management.
opioids
A PCA delivers an appropriate amount of opioid to treat
moderate pain and the client should be encouraged to push the PCA button to deliver medication at this time.
A nurse in the emergency department is caring for a 12-year-old child who has ingested bleach. Which of the following statements by the nurse indicates an understanding of this ingestion?
“The absence of oral burns excludes the possibility of esophageal burns.”
“Treatment focuses on neutralization of the chemical.”
“Injury by a corrosive liquid is more extensive than by a corrosive solid.”
“Immediate administration of activated charcoal is warranted.”
Injury by a corrosive liquid is more extensive than by a corrosive solid.
The absence of oral or pharyngeal burns does not eliminate the possibility of
esophageal burns.
The existence and extent of burns depend on
the substance and the length of time it has been in contact with tissues.
It is possible to have a burn in the esophagus without the existence of WHAT?
a burn in the mouth.
Neutralization can result in heat injury to tissues due to an _____?
This might result in both
exothermic reaction.
chemical and thermal burns of tissues.
The coating action of liquids permits larger areas of
contact with tissues and results in more extensive injury.
Activated charcoal is not administered to an adolescent who has ingested a corrosive substance, because
it can infiltrate any tissue that is burned.
A nurse is preparing to administer a liquid medication to an infant. Which of the following actions should the nurse take?
Give the medication at the side of the infant’s mouth.
Administering the medication to the infant while she is supine can cause the infant to
choke and aspirate.
When administering medications to an infant, a needleless oral syringe or medicine dropper is placed WHERE? WHY?
in the side of the mouth (buccal cavity alongside the tongue)
to prevent gagging and aspiration.
Medication should never be mixed into an infant’s what?
Why?
regular formula given through a bottle.
Cannot ensure all medication has been administered
might cause infant not to take bottle / formula in future (associates unpleasant taste or activity.)
An infant’s nasal passages should never be blocked to assure that oral medications are swallowed because
Young infants are obligatory nose breathers and holding the nares closed can increase an infant’s distress. This method of administration increases the risk of aspiration.
A nurse is caring for a child who has bacterial endocarditis. The child is scheduled to receive moderate term antibiotic therapy and requires a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include when teaching the child’s parent?
The PICC line will last several weeks with proper care.
The public health nurse will rotate the insertion site every 3 days.
You will need to make certain the arm board is in place at all times.
Your child will go to the operating room to have the line placed.
“The PICC line will last several weeks with proper care.”
PICC lines are the preferred venous access device for
short to moderate term IV therapy. They can remain in place for long periods with proper care.
The PICC line is meant to remain in place for how long?
the duration of therapy.
What is the main advantace of PICC lines over traditional IV lines
The PICC line is meant to remain in place for the duration of therapy.
The catheters designed for use as PICC lines are highly flexible, so it is not necessary to
immobilize the client’s arm or limit movement.
PICC lines are inserted using what type of anesthetic
local anesthetic by trained personnel.
A nurse is assessing a 7-year-old child’s psychosocial development. Which of the following findings should the nurse recognize as requiring further evaluation?
The child prefers playmates of the same sex.
The child is competitive when playing board games.
The child complains daily about going to school.
The child enjoys spending time alone.
The child complains daily about going to school.
Male and female children who are 7 years old prefer to play with peers who are
the same gender.
School-age children enjoy engaging in various types of ________ games and are learning about the concept of ________
competitive
winning
Complaining every day about going to school is an _______finding for a 7-year-old child.
unexpected
What stage of Ericksons psychosocial development - seven year old child
The child is in Erikson’s psychosocial development stage of industry vs. inferiority.
in Erikson’s psychosocial development stage of industry vs. inferiority. Children want to
learn and master new concepts. If the child complains daily about going to school, it warrants further evaluation.
A 7-year-old child doesn’t require the same amount of what as older school-age children; therefore, the fact that this child enjoys spending time alone is an expected finding.
companionship
A nurse providing teaching about promoting sleep with the parent of a 3-year-old toddler. Which of the following information should the nurse include?
Follow a nightly routine and established bedtime.
Encourage active play prior to bedtime.
Let the child remain awake until tired enough to go to sleep.
Reward the child with a food treat just prior to sleep if the child goes to bed on time.
Follow a nightly routine and established bedtime.
Preschool-age children test what?
limits. Consistency in approach to bedtime is very important. Bedtime is more likely to be pleasant for everyone if a routine is established and followed every night.
Active play at bedtime is likely to promote the preschool-age child’s resistance to
sleep rather than to promote fatigue.
Active Play at bedtime is likely to result in an
overtired child who is awake and unpleasant.
Children taught to maintain a bedtime routine at an early age will
make the evening more pleasant for everyone, including themselves, and avoid sleep disturbances.
Part of a preschool-age child’s bedtime routine should be
nightly oral care. Following this with a food treat is inappropriate.
A nurse in a pediatric clinic is caring for a 3-year-old child who has a blood lead level of 3 mcg/dL. When teaching the toddler’s parent about the correlation of nutrition with lead poisoning, which of the following information is appropriate for the nurse to include in the teaching?
Decrease the child’s vitamin C intake until the blood lead level decreases to zero.
Administer a folic acid supplement to the child each day.
Give pancreatic enzymes to the child with meals and snacks.
Ensure the child’s dietary intake of calcium and iron is adequate.
Ensure the child’s dietary intake of calcium and iron is adequate.
Vitamin C does not influence ________ or _______ of lead, and intake does not need to be reduced for a child who has a blood lead level of 3 mcg/dL. Over time, this can result in a vitamin C deficiency.
absorption or excretion
A 3-year-old child does not need a folic acid supplement. This will not influence absorption or excretion of
lead.
Pancreatic enzymes are administered to children who have
cystic fibrosis, not an elevated blood lead level.
A child who has an elevated blood lead level should have an adequate intake of
calcium and iron to reduce the absorption and effects of the lead. Dietary recommendations should include milk as a good source of calcium.
A nurse on a pediatric unit is admitting a 4-year-old child. Which of the following toys should the nurse plan to provide for the child to engage in independent play?
Brightly colored mobile
Plastic stethoscope
Small piece jigsaw puzzle
A book of short stories
Plastic stethoscope
A brightly colored mobile is appropriate for what age?
young infant. It does not meet the activity needs of a preschool-age child.
Preschool play centers on wha type of activities?
imitative activities. Providing a stethoscope allows the child an opportunity for therapeutic play. Imitating health care personnel helps to ease the fear of unfamiliar equipment.
A small piece jigsaw puzzle is too difficult for what age children?
most preschool-age children and can frustrate them rather than entertain them.
A 4-year-old child is not able to do what independently.
read independently. The nurse should provide the child with a picture book instead.
A nurse is providing teaching to the parents of a 4-year-old child about fine motor development. Which of the following tasks should the nurse include in the teaching as an expected finding for this age group?
Copies a circle
Cuts foods using a table knife
Begins writing in cursive
Prints first and last name clearly
Copies a circle
The nurse should explain that copying a circle is a skill achieved by what age?
age of 4 years.
The nurse should explain that cutting food using a table knife is a fine-motor skill expected of what age?
7-year-old children.
Initial use of cursive writing is an expected skill for what age?
an 8- to 9-year-old child.
The nurse should explain that children will print their first name around what age?
the age of 5 years.
A nurse is performing a physical assessment on a 6-month-old infant. Which of the following highlight reflexes should the nurse expect to find?
Stepping
Babinski
Extrusion
Moro
Babinski
The stepping reflex, in which the infant does what?
takes reflexive steps when placed on his or her feet in an upright position,
The stepping reflex, disappears by what age?
disappears by the age of 4 weeks.
The Babinski reflex, which is elicited by
stroking the bottom of the foot and causing the toes to fan and the big toe to dorsiflex,
The Babinski reflex, should be present until the age of
1 year.
Persistence of neonatal reflexes might indicate
neurological deficits.
The extrusion reflex, which causes the infant to
spit out food placed on the tongue rather than moving it to the back of the mouth,
The extrusion reflex, is absent by what age?
is absent by the age of 4 months.
The Moro reflex is an extension of the
arms and flexion of the elbows in response to a sudden jarring, followed by flexion and adduction of the extremities.
The Moro reflex should disappear by what age?
at the age of 3 to 4 months.
A nurse is preparing to administer recommended highlight immunizations to a 2-month-old infant. Which of the following immunizations should the nurse plan to administer?
Human papillomavirus (HPV) and hepatitis A
Measles, mumps, rubella (MMR) and tetanus, diphtheria, and acellular pertussis (TDaP)
Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV)
Varicella (VAR) and live attenuated influenza vaccine (LAIV)
Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV)
The HPV immunization series is started at what age?
the age of 11 years,
The hepatitis A immunization series is started at what age?
the age of 12 months.
The first dose of the MMR immunization is administered at what age?
12 to 15 months of age,
The TDaP immunization is administered at wehat age?
11 to 12 years of age.
The recommended immunizations for a 2-month-old infant include
Hib and IPV.
The Hib immunization series consists of
3 to 4 doses, depending on the immunization used, and at a minimum is administered at the ages of 2 months, 4 months, and 12 to 15 months.
The IPV immunization series consists of
4 doses and is administered at the ages of 2 months, 4 months, 6 to 18 months, and 4 to 6 years.
Varicella is not administered to children younger than
12 months,
LAIV immunization is not administered to children under what age?
2 years of age.
A nurse is observing a mother who is playing peek-a-boo with her 8-month-old child. The mother asks if this game has any developmental significance. The nurse should inform the mother that peek-a-boo helps develop which of the following concepts in the child?
Hand-eye coordination
Sense of trust
Object permanence
Egocentrism
Object permanence
Playing peek-a-boo does not further refine which skills?
the infant’s fine-motor skills unless the infant is using his hands to locate the hidden object himself.
This is necessary for fine motor skills.
Hand-eye coordination
Playing peek-a-boo does not serve to establish what?
a sense of trust.
Trust is developed by what?
the consistent care given in the first year of life.
Object permanence refers to what skill
cognitive skill of knowing an object still exists even when it is out of sight. In discovering a hidden object while playing peek-a-boo, the infant experiences validation of this concept.
Egocentrism refers to the fact that infants are
self-centered and cannot see things from a point of view other than their own.
An 8-month-old infant is considered
egocentric.
A nurse is planning care for a 10-month-old infant who has suspected failure to thrive (FTT). Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
Observe the parents’ actions when feeding the child.
Maintain a detailed record of food and fluid intake.
Follow the child’s cues as to when food and fluids are provided.
Sit beside the child’s high chair when feeding the child.
Play music videos during scheduled meal times.
Observe the parents’ actions when feeding the child.
Maintain a detailed record of food and fluid intake.
Inappropriate feeding techniques and meal patterns provided by parents can contribute to
a child’s growth failure.
A nutritional goal for the child who has suspected FTT is to
correct nutritional deficiencies, which can be identified by recording all food and fluid intake.
A consistent structured routine of feeding the child at the same time and place is used to
promote weight gain.
A child who has failure to thrive might not offer
feeding cues.
Caregivers should sit where during feeding and promote eye contact. The emphasis is on encouraging feeding.
directly in front of the child to maintain a face-to-face position
A quiet, stimulation-free environment should be provided at meal times to avoid
distractions and focus attention on food intake.
A nurse is teaching the parent of an infant about home safety. Which of the following information should the nurse include? (Select all that apply.)
Use a wheeled infant walker.
Place soft pillows around the edge of the infant’s crib.
Position the car seat so it is rear-facing.
Secure a safety gate at the top and bottom of the stairs.
Maintain the water heater temperature at 49° C (120° F).
Position the car seat so it is rear-facing.
Secure a safety gate at the top and bottom of the stairs.
Maintain the water heater temperature at 49° C (120° F).
Wheeled infant walkers can
quickly move across uneven surfaces and result in injury.
Soft pillows and cushions should not be used in cribs due to
the increased risk of suffocation.
Infants and children should remain in the rear-facing position when in a car seat until the age of __ years or until they reach the what?
2
recommended height and weight per the manufacturer’s guidelines.
As the infant begins to crawl and becomes more mobile, the risk of falls increases. These should be used at the stairs?
safety gate at the top and bottom of the stairs
To prevent a burn injury, the temperature of the water heater should not exceed
49° C (120° F).
A nurse is assessing a 6-year-old child at a well-child visit. Which of the following findings requires further assessment by the nurse?
Presence of sparse, fine pubic hair
Decreased head circumference compared to full height
Increased leg length related to height
Presence of a loose, central incisor
Presence of sparse, fine pubic hair
The development of sexual characteristics prior to what age in in boys, and girls, is an indication of precocious puberty and requires further evaluation.
9 in boys and 8 in girls
precocious puberty
??
The head circumference of a school-age child decreases when compared to full height due to
skeletal lengthening.
Body proportion varies with a slimmer appearance and longer legs in what age children?
the school-age child.
At what age are deciduous teeth are being shed at this age, starting with the lower central incisors
approximately the age of 6.
What happens to leg length and waist circumference in school age children?
Leg length increases and waist circumference decreases when related to height in this age group.
A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the following interventions should the nurse include in the plan of care?
Assign an assistive personnel to feed the child.
Explain sounds the child is hearing.
Have the child use a cane when ambulating.
Rotate nurses caring for the child.
Explain sounds the child is hearing.
Children who experience a loss of vision should be encouraged to participate in self-care activities, such as
feeding, as much as possible. Items on the meal tray should be organized and the child oriented to their location. Finger foods should be offered.
