The nurse answers based on the interpretation that the child is experiencing any of the above. The nurse explains that in addition to fatigue, any of the following would be most common.
Managing Care Quality and Safety
The Client with Tonsillitis
After teaching the parents of a preschool child who underwent tonsillectomy and adenoidectomy about appropriate foods to give the child after discharge, which of the following, if the parents list as appropriate foods, indicates successful teaching. The nurse is teaching the parents of a preschool child about the possibility of postoperative bleeding after tonsillectomy and adenoidectomy.
The Client with Otitis Media
The nurse should explain that the risk is greatest at which of the following times.
The Client with Foreign Body Aspiration
The nurse determines that the teenager has a history of asthma but has had no problems for years. After discussing asthma as a chronic condition, which of the following statements by the father of a child with asthma best reflects the family's positive adjustment to this aspect of the child's illness.
The Client with Asthma
Which of the following descriptions should the nurse interpret as a sign of further malabsorption problems? What can I do?” The nurse responds to the child based on the child's understanding of which of the following.
The Client with Cystic Fibrosis and Bronchopneumonia
When developing the care plan for a child with cystic fibrosis (CF) who is scheduled to receive postural drainage, the nurse should expect to perform postural drainage at which of the following times. When teaching the parents of an older infant with cystic fibrosis (CF) about the type of diet the child should eat, which of the following would be appropriate.
The Client Who Requires Immediate Care and Cardiopulmonary
When scheduling a visit with the parents of an infant who died of sudden infant death syndrome (SIDS) at home, the nurse should visit the parents at one of the following times. When developing an ongoing plan of care for parents whose infant died of sudden infant death syndrome (SIDS), the nurse should plan to complete which of the following tasks during the second home visit.
Resuscitation
Assess the airway
Reassure the mother
Check serum acetaminophen levels
Complete a physical examination
Obtain information about how the child obtained the pills
Administer activated charcoal
The Client with Sudden Infant Death Syndrome
Which of the following should the nurse do first when finding a child who is not breathing? After opening the child's mouth to clear the airway, which of the following actions should the nurse perform?
The Client with Croup
During discharge preparations, the nurse educates the mother of an infant diagnosed with bronchiolitis about the disease and its treatment. The nurse is observing an 18-month-old child admitted with a respiratory tract infection (see picture).
The Client with Bronchiolitis or Pharyngitis
Having the child participate in holding the tongue blade while the nurse guides it to facilitate visualization of the throat is proper technique. Although the child's heart rate may indicate hypoxia, none of the other signs indicate a need for oxygen.
The Client with Cystic Fibrosis and Bronchopneumonia
The coach and other team members must be aware of the child's condition and know what to do in case an attack occurs. However, the nurse would not want to interrupt the child's rest period to perform the treatment.
The Client Who Requires Immediate Care and
To administer back blows, the nurse should place the child face down, straddling the nurse's arm, with the head lower than the torso and the head supported. Positioning the child with the head up and above the trunk would not assist in dislodging.
Cardiopulmonary Resuscitation
Obtain a history of the incident
If the object is not visible when the mouth is opened, time is wasted searching for it. This position, together with the back flaps, facilitates the movement and removal of a foreign object and reduces aspiration if vomiting occurs.
Perform a physical exam
The nurse may have difficulty calming the child because the child is experiencing increasing respiratory distress. The child does not need to take preventive measures to eliminate, because viral pharyngitis is not contagious.
The Client Undergoing a Cardiac Catheterization
The Client with a Congenital Heart Defect
After surgery to correct a tetralogy of Fallot, the child's parents express concern to the nurse that their 4-year-old child wants to be held more often than usual. Which statement by the client indicates that the nurse should notify the health care provider.
The Client with Rheumatic Fever
Which of the following results indicates that the activity restriction required for a 7-year-old child with rheumatic fever during the acute phase has been effective. Which of the following initial physical findings indicates the development of carditis in a child with rheumatic fever.
The Client with Sickle Cell Anemia
The Client with Kawasaki Disease
The Client with Hemophilia
The Client with Iron Defi ciency Anemia
Which of the following beverages should the nurse give to a child with leukemia to relieve nausea? Which of the following medications can be prescribed to relieve discomfort in a child with leukemia, if the nurse asks questions?
The Client with Leukemia
As soon as the child is in the position, the nurse can assess whether there is an irregular heartbeat and rhythm. The nurse should assess the amount and complexity of information the child is expected to retain about the extremity.
The Client with a Congenital Heart Defect
The nurse teaches clients to take aspirin to be safe, based on the child's current knowledge. The child is not in critical condition, so parents do not need to be constantly present at the child's bedside.
The Client with Iron Defi ciency Anemia
In this client, the anemia is not caused by insufficient iron intake, but rather by insufficient red blood cells. The anemia is not caused by destruction of red blood cells by lymphocytes or by replacement of bone marrow with scar tissue.
The Client with Cleft Lip and Palate
- Maintain suffi cient fl uid and caloric intake
- Provide emotional comfort to the child
- Apply elbow restraints
- Teach the parents proper feeding methods
- Maintain a clear and adequate airway
On the second postoperative day after repair of a cleft palate, which of the following should the nurse use to feed a toddler. Immediately upon return to the nursing unit after surgical repair of a cleft palate, in which of the following positions should the nurse place the child.
The Client with Tracheoesophageal Fistula
Which of the following should the nurse assess in a newborn diagnosed with an anorectal malformation. Which of the following should the nurse include in the plan to teach the mother about oral feeding.
The Client with an Anorectal Anomaly
When the infant returns to the unit after unreinforced anus repair, the nurse should place the infant in which of the following positions. Which of the following parameters should the nurse expect to use when assessing the client's outcome.
The Client with Pyloric Stenosis
Parents show their understanding of these instructions when they indicate that they can start feeding their child in one of the following periods. Which of the following assessments should be prioritized for an infant who has had surgery to repair an intussusception and is now at risk for developing postoperative paralytic ileus.
The Client with Inguinal Hernia
A nasogastric tube inserted during surgery to correct an infant's bowel no longer clears free gastric secretions. The infant must consume more calories at home than what was consumed in the hospital.
The Client with Intussusception
The Client with Hirschsprung’s Disease
The Client with Diarrhea, Gastroenteritis, or Dehydration
- Insert an I.V. and infuse fl uids
- Apply a urine collection bag
- Draw blood for laboratory tests
- Obtain vital signs and weight
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. Which of the following statements from the client should the nurse interpret as most significant.
The Client with Appendicitis
- Decide to monitor I.V. gauges
- Perform chart audits
- Write a new I.V. insertion policy
- Analyze the data
There is no reason to keep the infant's fingers out of the mouth preoperatively. A nipple placed in the back of the mouth is likely to cause the infant to gag and aspirate.
The Client with an Anorectal Anomaly
Helping parents plan for their baby's discharge involves them in the newborn's care and is important. There is no need to redraw the laboratory value, as the results match the child's condition.
The Client with Diarrhea, Gastroenteritis, or Dehydration
Insert an I.V. and infuse fl uids as ordered
The nurse also wants the child to have less pain because he needs to be more active during the day. In addition, they would not be effective because the accumulation of gas in the lower intestine is not likely to be the cause of the child's discomfort.
The Client with Toxic Substance Ingestion
- Attempt to determine the exact time and amount of drug ingested
- Administer acetylcysteine (Acetadote IV)
- Administer activated charcoal
- Draw acetaminophen serum levels
When developing the plan of care for a young child who has taken an overdose of acetaminophen, which of the following should the nurse expect to include as part of the initial management. While assessing a preschooler brought to the emergency department by her parents after ingesting kerosene, the nurse should be aware of which of the following.
The Client with Lead Poisoning
The Client with Celiac Disease
Because the child's condition is chronic, parents usually want very detailed explanations about the causes and treatments for their child's illness. Parents usually deal with their own guilt for possibly causing their child's illness by asking challenging questions.
The Client with Colic
Although multiple teaching sessions are documented in the client's medical record, the mother again asks the nurse what is causing her child's phenylketonuria (PKU). Parents of a chronically ill child usually need a lot of time to process the grieving process about their child's illness.
The Client with Phenylketonuria
When developing a teaching plan for the mother of an infant about introducing solid foods into the diet, which of the following measures should the nurse expect to include in the plan to help prevent obesity. What information should the nurse include in the teaching plan to help the mother avoid overfeeding her baby.
The Client with Food Sensitivity
- Assess vital signs
- Position to facilitate breathing
- Notify the parents
- Send someone to activate the Emergency Management Systems (EMS)
- Administer the child’s epinephrine (Epipen)
To introduce the baby to the taste of vegetables by mixing them with formula or breast milk. A pregnant mother who has brought her toddler to the clinic for a check-up asks the nurse how she can prevent her next baby from becoming obese.
The Client with Obesity
To meet the short-term outcomes of the infant's plan of care, the nurse should expect to do which of the following. When teaching a mother about measures to prevent lead poisoning in her children, which of the following preventive measures should the nurse include as the most effective.
The Client with Failure to Thrive
After teaching the mother of a 2-year-old child with lactose intolerance which dairy products should be included in the child's diet, which of the following, if indicated by the mother, indicates effective teaching. Frequent blood level measurements may take place during the follow-up phase, but these are not taken as part of the initial treatment.
The Client with Toxic Substance Ingestion
Information on the baby's crying pattern is most helpful in confirming the diagnosis of colic. The small-bowl spoon helps place food on the back of the baby's tongue when feeding.
The Client with Cryptorchidism
Anticipatory guidance for parents and adolescents should focus on which of the following is most important.
The Client with Hydrocele
The Client with Hypospadias
The parents of a child taking sulfamethoxazole and trimethoprim (Bactrim) for a urinary tract infection report that the child has a red, blistered rash. A nurse is teaching the parents of a child diagnosed with a urinary tract infection due to vesicoureteral reflux.
The Client with Glomerulonephritis
A recent history of which of the following should prompt the nurse to gather additional information about the possibility of a urinary tract infection in a 2-year-old child who presents with fever and malaise. The father of the child with a urinary tract infection calls the clinic and explains: "My wife and I are worried because the child refuses to obey us regarding the prevention you told us about.
The Client with Urinary Tract Infection
The nurse plans interventions for the nursing diagnosis Deficient diverting activity for a school-age child. When developing the discharge plan for a school-age child diagnosed with acute poststreptococcal glomerulonephritis, which instruction should the nurse plan to discuss.
The Client with Nephrotic Syndrome
The nurse judges that interventions to reduce fluid retention have been effective when the child with nephrotic syndrome shows evidence of which of the following. When helping the family plan home care, which of the following instructions should the nurse include in the teaching.
The Client with Acute or Chronic Renal Failure
The nurse assesses the child with chronic renal failure who is receiving peritoneal dialysis for edema. Which of the following diet plans would be appropriate for the nurse to discuss with the family of a child with acute renal failure.
The Client with Wilms’ Tumor
Increasing the child's fluid intake may help the urinary tract infection, but does not treat the rash. The abbreviation QOD is on the Joint Commission's "do not use list." The abbreviation D/C can also be interpreted as "interruption" or.
The Client with Myelomeningocele
The parents of an infant with myelomeningocele ask the nurse about their child's future mental abilities. When caring for an infant who has undergone surgical repair of a myelomeningocele, which of the following should the nurse report to the surgeon.
The Client with Hydrocephalus
After surgical repair of a myelomeningocele, which position should the nurse use to prevent musculoskeletal deformity in the infant. Not late!” the child's mother angrily says, "Extraordinary." When responding to this outburst, which of the following responses by the nurse would be most appropriate.
The Client with a Seizure Disorder
- Clear the area of potentially harmful objects and pad the head
- Ease the child to the fl oor
- Roll the child to the side
- Note the time
The nurse states that a group meeting for mothers of mentally retarded children will be held soon.
The Client with Down Syndrome
An adolescent girl with a seizure disorder controlled with phenytoin (Dilantin) and carbamazepine (Tegretol) asks the nurse about getting married and having children. When teaching an adolescent with a seizure disorder who is receiving valproic acid (Depakene), which sign or symptom should the nurse instruct the client to report to the health care provider.
The Client with Meningitis
The parents of a child tell the nurse that they feel guilty because their child almost drowned. You really don't have to feel guilty; you are lucky because your baby will be fine.”
The Client with Guillain-Barré Syndrome (Infectious Polyneuritis)
The Client with Near-Drowning
The parents of a child with a severe head injury ask the nurse if the child will be OK. When developing the plan of care for a child who is unconscious after a severe head injury, in which of the following positions should the nurse place the child.
The Client with a Brain Tumor
It is difficult to say this early, but we will keep you informed of progress.”
The Client with a Head Injury
What action should the nurse take first during the child's admission to the pediatric unit? Which of the following signs and symptoms should the nurse expect the child to exhibit?
The Client with a Spinal Cord Injury
When making a round at the pediatric neurology unit, the nurse manager notes that when I.V. The nurse notes that the client's arms and face are flushed and he is diaphoretic.
Managing Care Quality and Safety
Because of the level of deficiency, the child may be insensitive to pressure or heat. Most parents feel affection and a sense of responsibility for their child, regardless of the child's limitations.
The Client with Guillain-Barré Syndrome (Infectious Polyneuritis)
Although the nurse might be able to reduce the child's anxiety somewhat, it would be impossible to eliminate it. Explaining that such a reaction is normal does not address the child's emotions.
The Client with Torticollis,
Legg-Calvé-Perthes Disease and Musculoskeletal Dysfunction
A mother asks the nurse if her child with hemiparesis due to spastic cerebral palsy will be able to walk normally because he can pull himself to a standing position. Which action should alert the nurse to the possibility of their inability to manage the disease.
The Client with Duchenne’s Muscular Dystrophy
The Client with Cerebral Palsy
When developing the care plan for a child with early Duchenne muscular dystrophy, which of the following nursing goals is a priority. I need to help my son be as active as possible to prevent the progression of the disease.”
The Client with Developmental Dysplasia of the Hip
The nurse is teaching the mother of a young child with Duchenne muscular dystrophy about the disease and its management. A mother asks the nurse about using a car seat for her toddler, who is in a cast.
The Client with Congenital Clubfoot
You will need to obtain special permission from the police so that the car seat is not required.'
The Client with Juvenile Idiopathic Arthritis
Nonsteroidal anti-inflammatories are the drug of choice when treating a child with juvenile idiopathic arthritis. What should the nurse consider when developing the teaching plan for the parents of a child with juvenile idiopathic arthritis being treated with naproxen (Naprosyn).
The Client with a Fracture
Assuming that a 3-year-old child in traction will need diversion, what should the nurse offer the child. Which of the following information points should be most important for the nurse to consider.
The Client with Osteomyelitis
A nurse is assisting a family in planning the discharge of a child who will go home in a cast.
The Client with Scoliosis
When teaching the child with scoliosis treated with a Boston brace about exercises, the nurse explains that the exercises are primarily performed for which of the following purposes. The nurse should develop a teaching plan with the client to include which of the following instructions.
The Client with Torticollis, Legg-Calvé-Perthes Disease
Learning measures to meet the child's physical needs shows some understanding and acceptance of the disease. Because the nurse suspects a possible fracture based on the child's presentation, it is important to assess the neurological and circulatory status of the toes, the tissue distal to the fracture.
The Client with Skin Disorders
The Client with Burns
After educating the mother of a child with severe burns on the importance of specific nutritional support in the management of burns, which of the following options, if selected by the mother from the child's dietary menu, indicates the need for further instruction . When caring for a child with moderate burns from the waist down, which of the following actions should the nurse perform when positioning the child?
The Client with Hyperthyroidism
Which of the following would be most appropriate to institute when a school-aged child with burns becomes angry and combative when it is time to change the dressings and apply mafenide acetate (Sulfamylon). Which of the following suggestions by the mother would indicate that she needs additional teaching.
The Client with Insulin-Dependent Diabetes Mellitus
The child uses correct injection technique, and the nurse can remind the child to change places. However, parents must notify the doctor if problems arise with the control of the child's blood sugar levels.
321The Client with Acute Coronary
Syndromes
Which of the following measures could the nurse suggest would most likely help the client prevent this problem. How should the nurse instruct the client to use the drug when chest pain occurs.
The Client with Heart Failure
In which of the following positions should the nurse place a client with suspected heart failure? The nurse should assess the client based on which compensatory mechanisms are activated in heart failure.
The Client with Valvular Heart Disease
The nurse should teach the client which of the following are common side effects of this medication. The nurse's response should reflect the understanding that the client may be experiencing which of the following.
The Client with Hypertension
Which of the following should the client not engage in until after the 1-month post-discharge appointment with the surgeon? The nurse should instruct the client to be aware of the signs and symptoms of other system failures and encourage the client to report signs of which of the following diseases that are often the result of undetected high blood pressure.
The Client with a Permanent Pacemaker
A client who has received cardiopulmonary resuscitation (CPR) is transported by ambulance to the hospital's emergency department, where the admitting nurse quickly assesses the client's condition. The client who had a permanent pacemaker implanted 2 days earlier is discharged from the hospital.
The Client Requiring
During cardiopulmonary resuscitation (CPR), the xiphoid process at the lower end of the sternum should not be compressed while performing cardiac compressions. Which of the following organs would be most vulnerable to rupture from strong compressions during the xiphoid process.
Cardiopulmonary Resuscitation
Which of the following is the most effective way to provide essential customer information is reported. If the client is symptomatic, atropine and transcutaneous pacing are interventions for symptomatic bradycardia.
The Client with Acute Coronary Syndromes
The stethoscope is placed at the second inter- costal space right of sternum (1) to assess the aortic
Preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart disease to prevent embolism. The client should know the signs and symptoms of MI but is not at risk from the pacemaker.
345The Client with Peripheral
Vascular Disease
- Peripheral pulses
- Urine output
- Incision site
- Postoperative pain
Which of the following explains the impact of aging on the development of peripheral vascular disease. The nurse is assessing the lower extremities of the client with peripheral vascular disease (PVD).
The Client with Peripheral Vascular Disease Having an Amputation
The client asks the nurse, "Why can't the doctor tell me exactly how much of my leg to take off. The nurse should teach the client that after surgery, which of the following leg positions are contraindicated for her while sitting in a chair."
The Client with Vasospastic Disorder
The Client with Buerger’s Disease
During an initial assessment of a client diagnosed with vasospastic disorder (Raynaud's phenomenon), the nurse notices a sudden discoloration to white in the fingers. The nurse should assess the client for risk for developing which of the following complications.
The Client with Thrombophlebitis and Embolus Formation
- Draw blood for laboratory studies
- Regulate the I.V. infusion
- Monitor the pulses
- Inspect the dressing
- Administer pain medication
After the client returns from the recovery room, in what order, from first to last, should the nurse provide care. Before surgery for a known aortic aneurysm, the client's pulse pressure begins to increase, indicating increased aortic valve insufficiency.
The Client with an Aneurysm
Which of the following findings should the nurse consider unexpected and immediately report to the physician. The nurse is planning care for a client who has returned to the medical-surgical unit after repair of an aortic aneurysm.
The Client with Stasis Ulcers
The physician tells the nurse that the current pain medication order for this client is adequate and that the client will feel better in a few days. Explain to the physician that the current pain medication and other strategies are not helping the client and are making it difficult for the client to ambulate as ordered.
The Client with Peripheral Arterial Occlusive Disease
The pain medication and the use of relaxation and imagery techniques do not relieve the client's pain and the client refuses to get out of bed to ambulate as ordered. The nurse contacts the physician, explains the situation, and provides information about drug dosage, frequency of administration, the client's vital signs, and the client's score on the pain scale.
The Client with Peripheral Vascular Disease
The nurse should raise the client's legs above the level of the heart to achieve this goal. The stockings should be applied in the morning before the client gets out of bed.
The Client with Buerger’s Disease
The nurse should report the client's symptoms to the physician, who may prescribe nitroglycerin and possibly discontinue pentoxifylline. The ward complains of numbness in the tips of the fingers, so impaired sensory perception (tactile) is the preferred nursing diagnosis.
The Client with Vasospastic Disorder
Monitoring of the client's PT is done while the client is taking warfarin sodium (Coumadin). The nurse can inspect the client's feet, but the client is not at risk for ulcers at this time.
369The Client with Red Blood
Cell Disorders
- Clean the skin with an antiseptic solution
- Verify the client has signed an informed consent
- Apply ice to the biopsy site
- Position the client in a side-lying position
- Complete the appropriate Transfusion Reaction Form(s)
- Keep the I.V. open with normal saline infusion
- Notify the attending physician and blood bank
When a client is receiving cephalosporins, the nurse should monitor the client for which of the following. The nurse should instruct the client with a platelet count less than 150,000/μL to avoid which of the following activities.
The Client with Platelet Disorders
The nurse should instruct the client to consume a diet high in which of the following. The nurse recognizes a knowledge deficit when the client makes any of the following statements.
The Client with White Blood Cell Disorders
Which of the following statements should the nurse include to provide information to the client about what the client will feel during the procedure. The nurse identifies deficient knowledge when the client who is undergoing induction therapy for leukemia makes which of the following statements.
The Client with Lymphoma
The client with Hodgkin's disease is undergoing an excisional cervical lymph node biopsy under local anesthesia. When assessing the client with Hodgkin's disease, the nurse should observe the client for which of the following findings.
The Client Who Is in Shock
The nurse in the preoperative sitting area is holding a client with abdominal bleeding in a dimly lit environment with a family member present. When assessing a client for early septic shock, the nurse observes for which of the following.
The Client with Red Blood Cell Disorders
Stop the transfusion