54.
A mother brings her 3-month-old child into the emergency department. The child is listless with dry mucous membranes, tenting of the skin on the forehead, a depressed fontanel, and a history of vomiting and diarrhea for the last 36 hours. In what order from fi rst to last should the nurse implement the physician’s orders?2. Insert an I.V. and infuse fl uids.
3. Apply a urine collection bag.
4. Draw blood for laboratory tests.
1. Obtain vital signs and weight.
55.
A child is admitted with a tentative diagnosis of shigella. The nurse should do which of the fol- lowing? Select all that apply.■ 1. Assess the child for nausea and vomiting.
■ 2. Collect a stool specimen for white blood cells (WBCs).
■ 3. Place the child on strict isolation.
■ 4. Monitor the child for signs and symptoms of dehydration.
■ 5. Initiate an intake and output record.
56.
Which of the following would most likely alert the nurse to the possibility that a preschooler is experiencing moderate dehydration?■ 1. Deep, rapid respirations.
■ 2. Diaphoresis.
■ 3. Absence of tear formation.
■ 4. Decreased urine specifi c gravity.
57.
Which of the following would be an impor- tant assessment fi nding for an 8-month-old infant admitted with severe diarrhea?■ 1. Absent bowel sounds.
■ 2. Pale yellow urine.
■ 3. Normal skin elasticity.
■ 4. Depressed anterior fontanel.
50.
An infant diagnosed with Hirschsprung’s dis- ease undergoes surgery with the creation of a tempo- rary colostomy. Which of the following statements by the parent regarding the colostomy indicates the need for further teaching?■ 1. “The colostomy is only temporary.”
■ 2. “The colostomy will give time for the nerves to return to normal.”
■ 3. “The colostomy may include two separate abdominal openings.”
■ 4. “Right after the procedure the stoma may appear purple.”
51.
When teaching the mother of an infant who has received a temporary colostomy for treatment of Hirschsprung’s disease about how the stoma should normally appear, which of the following descrip- tions about the stoma’s appearance should the nurse include in the teaching?■ 1. Becoming dark brown in 2 months.
■ 2. Staying deep red in color.
■ 3. Changing to several shades of pink.
■ 4. Turning almost purple in color.
52.
When teaching the parent of an infant with Hirschsprung’s disease who received a temporary colostomy about the types of foods the infant will be able to eat, which of the following would the nurse recommend?■ 1. High-fi ber diet.
■ 2. Low-fat diet.
■ 3. High-residue diet.
■ 4. Regular diet.
53.
An infant with Hirschsprung’s disease is to be discharged 1 or 2 days after surgery to create a colostomy. After teaching the infant’s parents about the overall effects of their infant’s surgery, the nurse determines that the teaching has been effective when the parents state which of the following?■ 1. “His abdomen will be large for awhile.”
■ 2. “When he’s ready, toilet training may be diffi cult.”
■ 3. “We need to limit his intake of dairy products.”
■ 4. “We will give him vitamin supplements until he is an adolescent.”
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63.
Which of the following should the nurse use to determine achievement of the expected outcome for an infant with severe diarrhea and a nursing diagnosis of Defi cient fl uid volume related to pas- sage of profuse amounts of watery diarrhea?■ 1. Moist mucous membranes.
■ 2. Passage of a soft, formed stool.
■ 3. Absence of diarrhea for a 4-hour period.
■ 4. Ability to tolerate intravenous fl uids well.
64.
Which of the following should the nurse include when teaching the father of an infant just admitted with gastroenteritis about initial treatment for his infant?■ 1. The infant will receive no liquids by mouth.
■ 2. Intravenous antibiotics will be started.
■ 3. The infant will be placed in a mist tent.
■ 4. An iron-fortifi ed formula will be used.
65.
The nurse teaches the father of an infant hospitalized with gastroenteritis about the next step of the treatment plan once the infant’s condition has been controlled. The nurse should determine that the father understands when he explains that which of the following will occur with his infant?■ 1. The infant will receive clear liquids for a period of time.
■ 2. Formula and juice will be offered.
■ 3. Blood will be drawn daily to test for anemia.
■ 4. The infant will be allowed to go to the play- room.
66.
The mother of a toddler who has just been admitted with severe dehydration secondary to gas- troenteritis says that she cannot stay with her child because she has to take care of her other children at home. Which of the responses by the nurse would be most appropriate?■ 1. “You really shouldn’t leave right now. Your child is very sick.”
■ 2. “I understand, but feel free to visit or call anytime to see how your child is doing.”
■ 3. “It really isn’t necessary to stay with your child. We’ll take very good care of him.”
■ 4. “Can you fi nd someone to stay with your chil- dren? Your child needs you here.”
67.
A child is admitted to the pediatric unit with the diagnosis of severe gastroenteritis. To prevent spread of the disease the nurse should?■ 1. Institute standard precautions.
■ 2. Place the child in a semiprivate room.
■ 3. Serve meals with eating utensils that can be sterilized.
■ 4. Single-bag all linens.
58.
Which of the following would be the best activity for the nurse to include in the plan of care for an infant experiencing severe diarrhea?■ 1. Monitoring the total 8-hour formula intake.
■ 2. Weighing the infant each day.
■ 3. Checking the anterior fontanel every shift.
■ 4. Monitoring abdominal skin turgor every shift.
59.
The physician orders an intravenous infusion of 5% dextrose in 0.25 normal saline to be infused at 2 mL/kg/hour in an infant who weighs 9 lb. How many milliliters per hour of the solution should the nurse infuse? Round to one decimal.________________________
mL/hour.60.
The nurse is evaluating an infant who has an intravenous infusion secured to a sandbag (see fi gure). The nurse should:■ 1. Add tape to cover the toe.
■ 2. Secure the right leg to a sandbag.
■ 3. Check the infusion rate every hour.
■ 4. Change the sandbag to an extremity restraint
61.
Which of the following would be most appropriate for the nurse to teach the mother of a 6-month-old infant hospitalized with severe diar- rhea to help her comfort her infant who is fussy?■ 1. Offering a pacifi er.
■ 2. Placing a mobile above the crib.
■ 3. Sitting at crib side talking to the infant.
■ 4. Turning the television on to cartoons.
62.
Which of the following nursing diagnoses would be appropriate for the nurse to identify as a priority diagnosis for an infant just admitted to the hospital with a diagnosis of gastroenteritis?■ 1. Pain related to repeated episodes of vomiting.
■ 2. Defi cient fl uid volume related to excessive losses from severe diarrhea.
■ 3. Impaired parenting related to infant’s loss of fl uid.
■ 4. Impaired urinary elimination related to increased fl uid intake feeding pattern.
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74.
When obtaining a history from the parents of a child diagnosed with diarrhea due to Salmonella, the nurse should ask the parents if the child has been exposed to which of the following possible sources of infection?■ 1. Nonrefrigerated custard.
■ 2. A pet canary.
■ 3. Undercooked eggs.
■ 4. Unwashed fruit.
75.
On a home visit following discharge from the hospital after treatment for severe gastroenteritis, the mother tells the nurse that her toddler answers“No!” and is diffi cult to manage. After discussing this further with the mother, the nurse explains that the child’s behavior is most likely the result of which of the following?
■ 1. Beginning leadership skills.
■ 2. Inherited personality trait.
■ 3. Expression of individuality.
■ 4. Usual lack of interest in everything.
76.
The mother of a toddler hospitalized for episodes of diarrhea reports that when her toddler cannot have things the way she wants, she throws her legs and arms around, screams, and cries. The mother says, “I don’t know what to do!” After teach- ing the mother about ways to manage this behavior, which of the following statements indicates that the nurse’s teaching was successful?■ 1. “Next time she screams and throws her legs, I’ll ignore the behavior.”
■ 2. “I’ll allow her to have what she wants once in a while.”
■ 3. “I’ll explain why she cannot have what she wants.”
■ 4. “When she behaves like this, I’ll tell her that she is being a bad girl.”
77.
The mother of a toilet-trained toddler who was admitted to the hospital for severe gastroenteri- tis and subsequent dehydration and is now at home asks the nurse why the child still wets the bed.Which of the following should be the nurse’s best response?
■ 1. “Hospitalization is a traumatic experience for children. Regression is common and it takes time for them to return to their former behavior.”
■ 2. “The stress of hospitalization is hard for many children, but usually they have no problems when they return home.”
■ 3. “After returning home from being hospital- ized, children still feel they should be the center of attention.”
■ 4. “Children do not feel comfortable in their home surroundings once they return home from being hospitalized.”
68.
A 9-month-old is admitted because of dehydra- tion. How should the nurse go about accurately moni- toring fl uid intake and output? Select all that apply.■ 1. Weighing and recording all wet diapers.
■ 2. Obtaining a urine specifi c gravity measure.
■ 3. Obtaining an accurate daily weight.
■ 4. Restricting fl uids prior to weighing the child.
■ 5. Obtaining an accurate stool count.
69.
The physician orders intravenous fl uid replace- ment therapy with potassium chloride to be added for a child with severe gastroenteritis. Before adding the potassium chloride to the intravenous fl uid, which of the following assessments would be most important?■ 1. Ability to void.
■ 2. Passage of stool today.
■ 3. Baseline electrocardiogram.
■ 4. Serum calcium level.
70.
Which of the following would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload?■ 1. A drop in blood pressure.
■ 2. Change to slow, deep respirations.
■ 3. Auscultation of moist crackles.
■ 4. Marked increase in urine output.
71.
The stool culture of a child with profuse diarrhea reveals Salmonella bacilli. After teaching the mother about the course of Salmonella enteriti- dis, which of the following statements by the mother indicates effective teaching?■ 1. “Some people become carriers and stay infec- tious for a long time.”
■ 2. “After the acute stage passes, the organism is usually not present in the stool.”
■ 3. “Although the organism may be alive indefi - nitely, in time it will be of no danger to anyone.”
■ 4. “If my child continues to have the organism in the stool, an antitoxin can help destroy the organism.”
72.
A child is started on a soft diet after having been on clear liquids following an episode of severe gastroenteritis. When helping the mother choose foods for her child, which of the following foods would be most appropriate?■ 1. Muffi ns and eggs.
■ 2. Bananas and rice cereal.
■ 3. Bran cereal and a bagel.
■ 4. Pancakes and sausage.
73.
A child undergoes rehydration therapy after having diarrhea and dehydration. A nurse is teach- ing the child’s parents about dietary management.The nurse understands that the teaching plan has been successful when the parents tell the nurse that they will follow which type of diet?
■ 1. Regular.
■ 2. Clear liquid.
■ 3. Full liquid.
■ 4. Soft.
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81.
When obtaining the initial health history from a 10-year-old child with abdominal pain and suspected appendicitis, which of the following questions would be most helpful in eliciting data to help support the diagnosis?■ 1. “Where did the pain start?”
■ 2. “What did you do for the pain?”
■ 3. “How often do you have a bowel movement?”
■ 4. “Is the pain continuous, or does it let up?”
82.
When developing the plan of care for a school- age child with a suspected diagnosis of appendicitis who is complaining of severe abdominal pain, which of the following measures should the nurse expect to include in the child’s plan of care?■ 1. Application of a heating pad.
■ 2. Insertion of a rectal tube.
■ 3. Application of an ice bag.
■ 4. Administration of an intravenous narcotic.
83.
Which of the following assessment fi ndings should alert the nurse to suspect appendicitis in a male adolescent complaining of severe abdominal pain?■ 1. Abdomen appears slightly rounded.
■ 2. Bowel sounds are heard twice in 2 minutes.
■ 3. All four abdominal quadrants reveal tympany.
■ 4. The client demonstrates a cremasteric refl ex.
84.
An adolescent male client scheduled for an emergency appendectomy is to be transferred directly from the emergency room to the operating room. Which of the following statements by the cli- ent should the nurse interpret as most signifi cant?■ 1. “All of a sudden it doesn’t hurt at all.”
■ 2. “The pain is centered around my navel.”
■ 3. “I feel like I’m going to throw up.”
■ 4. “It hurts when you press on my stomach.”
85.
Which of the following should be the priority assessment for an adolescent on return to the nurs- ing unit after an appendectomy?■ 1. The dressing on the surgical site.
■ 2. Intravenous fl uid infusion site.
■ 3. Nasogastric (NG) tube function.
■ 4. Amount of pain.
86.
An adolescent who has had an appendec- tomy and developed peritonitis has nausea. Which of the following should the nurse do fi rst?■ 1. Administer an antiemetic.
■ 2. Irrigate the nasogastric (NG) tube.
■ 3. Notify the surgeon.
■ 4. Take the blood pressure.
87.
When developing the postoperative plan of care for an adolescent who has undergone an appen- dectomy for a ruptured appendix, in which of the following positions should the nurse expect to place the client during the early postoperative period?■ 1. The semi-Fowler’s position.
■ 2. Supine.
■ 3. Lithotomy position.
■ 4. Prone.