Answer: It is more common for the bones to buckle than break in toddlers.
Question: The nurse is caring for a newborn who has just undergone surgery for hydrocephalus. What action(s) will the nurse include in the plan of care? Select all that apply.
Answer: Place in a flat position initially. Monitor for signs of peritonitis. Measure abdominal circumference. Do not elevate the head of the bed more than 45 degrees.
Question: An adolescent with bipolar disorder has been prescribed olanzapine 5 mg two times a day and lamotrigine 25 mg two times a day. Which adverse effect(s) should the nurse report to the health care provider immediately? Select all that apply.
Answer: Rash Hyperthermia Muscle rigidity
Question: The nurse suspects that a newborn has an imperforate anus. Which assessment finding(s) support the nurse’s hypothesis?
Answer: Missing opening to the anus Failure to pass first stool within or after birth 48 hours of life Stool passes out of the vagina, base of penis, scrotum, or urethra
Question: The nurse is developing a nursing care plan for a child with sickle cell anemia. Which of the following goals will prevent sickle cell crisis? Select all that apply.
Answer: Client will stay warm Client will stay well hydrated Client will be free from infection
Question: The nurse is teaching the parents of a child with cerebral palsy who has just had a gastrostomy tube inserted due to gastric reflux. The nurse will determine the session is successful when the parents point out which situation(s) to report to the health care provider? Select all that apply.
Answer: Nausea Diarrhea Clogged tube Redness at insertion site Decreased urine output
Question: The nurse is reviewing behavioral techniques for the parents to use with their 8-year-old child with attention deficit hyperactivity disorder (ADHD). Which technique(s) should the nurse include in the teaching? Select all that apply.
Answer: Set an alarm for administering the prescribed treatment. Adhere to a specific routine when the child needs to focus. Provide structured responsibilities during the child’s routine. Prepare items needed in the morning, such as clothing, the night before.
Question: The nurse is assessing a 12-month-old child with cleft palate who is awaiting surgical repair in 2 weeks. The nurse knows the child is at increased risk for otitis media due to which issue?
Answer: Dysfunction of eustachian tubes
Question: A preschooler child is brought to the emergency room for an item lodged in the left ear. The parents stated that it may be a mosquito. Which of the following nursing actions is best to dislodge mosquito?
Answer: Instillation of diluted alcohol
Question: The nurse is assessing a child for signs of a blood transfusion reaction. Which finding indicates the child is having a transfusion reaction?
Answer: Diaphoresis
Question: A nurse interviews the parent of a middle-school student who is exhibiting behavioral problems, including substance abuse, after a sibling’s suicide. The parent says, “I’m a single parent who has to work hard to support my family, and now I’ve lost a child, and my other child is acting out and making me crazy! I just can’t take all this stress!” Which issue is the priority?
Answer: The potential suicidal thoughts and plans of both family members