The nurse is closely monitoring a child with increased intracranial pressure who has been exhibiting decorticate (flexor) posturing. The nurse notes that the child suddenly exhibits decerebrate (extensor) posturing and interprets that this change in the c
D. Deteriorating neurological function
Rationale:
The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants health care provider notification. Options 1, 2, and 3 are inaccurate interpreta
The registered nurse (RN) is reviewing a plan of care developed by a nursing student for a child who is being admitted to the pediatric unit with a diagnosis of seizures. The RN determines that the student nurse needs further teaching and should revise th
B. Restrain the child if a seizure occurs.
Rationale:
Restraints are not to be applied to a child with a seizure because they could cause injury to the child. The bed is maintained in low position to provide safety in the event that the child has a seizur
Which finding would indicate the presence of Kernig's sign?
A. Calf pain when the foot is dorsiflexed
B. Pain when the chin is pulled down to the chest
C. The inability of the child to extend the legs fully when lying supine
D. The flexion of the hips whe
C. The inability of the child to extend the legs fully when lying supine
Rationale:
Kernig's sign is the inability of the child to extend the legs fully when lying supine. Brudzinski's sign is flexion of the hips when the neck is flexed from a supine posi
The nurse is reviewing the laboratory analysis of cerebrospinal fluid (CSF) obtained during a lumbar puncture from a child who is suspected of having bacterial meningitis. Which result would most likely confirm this diagnosis?
A. Clear CSF with low protei
C. Cloudy CSF with high protein and low glucose
Rationale:
A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include increased pressure and cloudy CSF with high protein and
The nurse receives a telephone call from the emergency department and is told that a 7-month-old infant with febrile seizures will be admitted to the pediatric unit. What should the nurse anticipate the need for when planning care for the admission of the
C. Suction equipment and an airway at the bedside
Rationale:
Suctioning may be required during a seizure to remove secretions that obstruct the airway. An airway should also be readily available. During a seizure, the infant should be placed in a side-lyi
A nursing student is asked to conduct a clinical conference about autism. Which characteristic associated with autism should the student plan to include?
A. Normal social play that ceases by age 5
B. Lack of social interaction and awareness
C. The consist
B. Lack of social interaction and awareness
Rationale:
Autism is a severe developmental disorder that begins in infancy or toddlerhood. A primary characteristic is a lack of social interaction and awareness. Social behaviors in children with autism includ
The nurse is monitoring a nursing student who is caring for a child who sustained a head injury from a fall. Which action by the nursing student indicates a need for further teaching?
A. Forcing fluids
B. Performing neurological assessments
C. Keeping the
A. Forcing fluids
Rationale:
A child with a head injury is at risk for increased intracranial pressure (ICP). Forcing fluids may cause fluid overload and increased ICP. Additionally, the nurse should not "force" the client to do something. Neurological as
The nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shunt who will be discharged from the hospital. Which instruction should the nurse include in the plan of care?
A. Expect an increased urine output from the
C. Call the health care provider if the infant has a high-pitched cry.
Rationale:
If the shunt is broken or malfunctioning, the fluid from the ventricular part of the brain will not be diverted to the peritoneal cavity, and the cerebrospinal fluid will bu
The nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure (ICP). The nurse notes that the anterior fontanel bulges when the infant cries. Based on this assessment finding, which action should the nurse take?
A. Do
A. Document the findings.
Rationale:
The anterior fontanel is diamond shaped and located on the top of the head. It should be soft and flat in a normal infant and normally closes by 18 to 24 months of age. The posterior fontanel closes by 2 to 3 months of
When providing care for a child in cervical traction with Crutchfield tongs, which actions should the nurse take?
A. Promote mobility.
B. Provide emotional support.
C. Monitor intake and output (I&O).
D. Maintain proper alignment and prevent infection.
D. Maintain proper alignment and prevent infection.
Rationale:
Caring for a child in traction includes ensuring that the child's body is in proper alignment. Crutchfield tongs are a type of cervical skeletal traction that requires pin-site assessment and
An infant has been found to be human immunodeficiency virus (HIV) positive. When teaching the infant's mother, which action should the nurse instruct the mother to take?
A. Check the anterior fontanel for bulging and the sutures for widening each day.
B.
C. Provide meticulous skin care to the infant and change the infant's diaper after each voiding or stool.
Rationale:
Meticulous skin care helps protect the HIV-infected infant from secondary infections. Bulging fontanels, feeding the infant in an upright
The nurse provides home care instructions to the mother of a child with chickenpox about preventing the transmission of the virus. Which instruction should the nurse include?
A. Isolate the child until the skin vesicles have dried and crusted.
B. Ensure t
A. Isolate the child until the skin vesicles have dried and crusted.
Rationale:
Chickenpox is caused by the varicella-zoster virus. The communicable period is from 1 to 2 days before the onset of the rash to 6 days after the first crop of vesicles, when c
The nurse is performing an assessment on a 3-year-old child with chickenpox. The child's mother tells the nurse that the child keeps scratching at night, and the nurse teaches the mother about measures that will prevent an alteration in skin integrity. Wh
A. "I need to place white gloves on my child's hands at night."
Rationale:
Gloves will keep the child from causing an alteration in skin integrity from scratching. Generous amounts of any topical cream can lead to medication toxicity. Warm milk will have
The nurse is caring for a child with erythema infectiosum (fifth disease). Which clinical manifestation should the nurse expect to note in the child?
A. An intense fiery red edematous rash on the cheeks
B. Pinkish-rose maculopapular rash on the face, neck
A. An intense fiery red edematous rash on the cheeks
Rationale:
Fifth disease is characterized by the presence of an intense fiery red edematous rash on the cheeks, which gives an appearance that the child has been slapped. Options 2 and 3 are clinical ma
In the health care clinic, an adolescent is seen with complaints of chronic fatigue. On physical examination, the nurse notes that the adolescent has swollen lymph nodes. A laboratory test is performed, and the results indicate the presence of Epstein-Bar
D. "I need to call the health care provider if my child complains of abdominal pain or left shoulder pain."
Rationale:
The mother needs to be instructed to notify the health care provider if abdominal pain, especially in the left upper quadrant, or left s
The nurse is developing a plan of care for a child with rubella (German measles). In gathering items to provide direct care to the child, what should the nurse obtain?
A. Goggles and gloves
B. Mask, gloves, and gown
C. Mask, gown, and goggles
D. Gloves, g
B. Mask, gloves, and gown
Rationale:
Care of the child with rubella involves contact isolation. Contact isolation requires the use of masks, gowns, and gloves for contact with any infectious material. Contaminated articles are also bagged and labeled per
The clinic nurse is providing home care instructions to the mother of a child with human immunodeficiency virus (HIV) infection. Which statement by the mother indicates a need for further teaching?
A. "I should delay the polio virus vaccine."
B. "I should
A. "I should delay the polio virus vaccine."
Rationale:
The mother should be instructed to keep immunizations up to date. Additionally, the child will receive inactivated polio vaccine. The other options are correct instructions regarding the care of the
The nurse is assisting in planning an educational session regarding rubella (German measles) for the parents of school children. What incubation period should the nurse tell the parents?
A. 1 to 3 days
B. 3 to 5 days
C. 7 to 14 days
D. 14 to 21 days
D. 14 to 21 days
A mother brings her 15-month-old child to the health care provider's office with complaints that the child has suddenly developed a bright red rash on her cheeks. She has no other symptoms and has been playing and eating as usual. Based on the appearance
C. Fifth disease
Rationale:
Fifth disease has the general appearance of "slapped cheeks." Many children do not have any symptoms prior to the appearance of the reddened cheeks. This characteristic is not associated with the communicable diseases identifie
The school nurse is visiting a kindergarten classroom to teach the students the importance of hand washing. During the teaching session, she notices that one girl is scratching her head. On inspection, she determines that the child has pediculosis capitis
B. "I will call a carpet cleaning service to clean all my carpets in the house."
Rationale:
Teaching the prevention of spread and recurrence of pediculosis capitis includes washing items in hot water, vacuuming carpets, discouraging sharing of personal it
A child is sent to the school nurse by the teacher. On assessment, the school nurse notes that the child has a rash. The nurse suspects that the child has erythema infectiosum (fifth disease), because the skin assessment revealed a rash that has which cha
C. An erythema on the face that has a "slapped face" appearance
Rationale:
The classic rash of erythema infectiosum, or fifth disease, is the erythema on the face. The discrete rose-pink maculopapular rash is the rash of exanthema subitum (roseola). The h
An adolescent is admitted to the orthopedic nursing unit after spinal rod insertion for the treatment of scoliosis. Which assessment is most important in the immediate postoperative period?
A. Pain level
B. Ability to flex and extend the feet
C. Ability t
D. Capillary refill, sensation, and motion in all extremities
Rationale:
When the spinal column is manipulated during surgery, altered neurovascular status is a possible complication; therefore, neurovascular checks including circulation, sensation, and m
A child has just returned from surgery and has a hip spica cast. What is the priority nursing action at this time?
A. Elevate the head of the bed.
B. Abduct the hips, using pillows.
C. Turn the child on the right side.
D. Assess the child's circulatory st
D. Assess the child's circulatory status.
Rationale:
During the first few hours after a cast is applied, the chief concern is swelling that may cause the cast to act as a tourniquet and obstruct circulation, resulting in compartment syndrome; therefore, c
A school nurse is performing screening examinations for scoliosis. Which signs of scoliosis should the nurse assess for? Select all that apply.
A. Chest asymmetry
B. Equal waist angles
C. Unequal rib heights
D. Equal rib prominences
E. Equal shoulder heig
A, C, F
Rationale:
Scoliosis is a lateral curvature of the spine. To ensure early detection and treatment, children ages 9 through 15 years should be screened for scoliosis; those at greatest risk are girls from 10 years of age through adolescence. The ch
Russell's traction, a type of skin traction, is prescribed for a child with a lower leg fracture. The mother of the child asks the nurse the purpose of the traction, and the nurse explains to the mother that this type of traction is used primarily for whi
B. To reduce or realign a fracture site
An adolescent is diagnosed with scoliosis. Which statements regarding scoliosis are correct? Select all that apply.
A. Scoliosis is an abnormal lateral curvature of the spine.
B. Scoliosis is most typically diagnosed in the adolescent child.
C. Surgical i
A, B, C, F
Rationale:
Scoliosis is defined as an abnormal lateral curvature in any area of the spine. When the adolescent faces a growth spurt, this is a common time for this condition to occur. If the spinal curve is very severe, surgery may be the only
A school-age child sustains a fracture along the epiphyseal line of the femur following a fall from the garage roof. What long-term effect might result with this type of fracture?
A. Osteomyelitis
B. Muscle atrophy
C. Growth disturbance
D. Paresthesias an
C. Growth disturbance
Rationale:
Growth takes place at the epiphysis of the long bone. A fracture at this level can destroy the layer of germinal cells of the epiphysis, resulting in growth disturbance. Osteomyelitis is an infection of the bone and would
he clinic nurse is performing an assessment of a 5-month-old infant suspected of having unilateral developmental dysplasia of the hip (DDH). Which assessment finding should the nurse expect to note in this condition?
A. Full range of motion in the affecte
D. Asymmetry of the gluteal skinfolds when the infant is placed prone and the legs are extended against the examining table
Rationale:
Asymmetry of the gluteal skinfolds when the infant is placed prone and the legs are extended against the examining table
The nurse is caring for a child with a fracture who has been placed in skeletal traction. The nurse should monitor for the most serious complication associated with this type of traction by assessing for which specific finding?
A. A lack of appetite
B. An
B. An elevated temperature
Rationale:
The most serious complication associated with skeletal traction is osteomyelitis, an infection involving the bone. Organisms gain access to the bone systemically or through the opening created by the metal pins or wir
The nurse provides instructions about cast care to the parents of a child with a short arm cast. Which statement by a parent indicates that further teaching is necessary regarding cast care?
A. "I should check the skin around the cast edges for irritation
B. "I can use a ruler padded with gauze to scratch under the cast."
Rationale:
No item should be placed inside a cast because of the risk for alteration in skin integrity. A cotton-tipped applicator with rubbing alcohol may be used near the cast edges to
The nurse prepares a teaching plan regarding the administration of eardrops for the parents of a 6-year-old child. The nurse tells the parents that, when administering the drops, which action is appropriate?
A. Wear gloves.
B. Pull the ear up and back.
C.
B. Pull the ear up and back.
Rationale:
To administer eardrops in a child who is more than 3 years old, the ear is pulled upward and back. The ear is pulled down and back in children less than 3 years old. Gloves do not need to be worn by the parents, but
The nurse is providing instructions to the mother of an infant who is seen in the clinic for recurrent episodes of otitis media. Which statement by the mother should indicate an understanding of the methods to decrease the risk of reoccurrence?
A. "I will
A. "I will feed my infant in an upright position."
Rationale:
To decrease the risk of recurrent otitis media, the mother should be encouraged to breast-feed during infancy and to discontinue bottle-feeding as soon as possible. The infant also is fed in an
The nurse evaluates the effectiveness of preventive teaching done with the parents of an infant with recurring acute otitis media. Which statement indicates that more teaching is needed?
A. "My baby will continue to be breast-fed."
B. "No one is permitted
D. "We stopped giving the antibiotics to the baby when her fever subsided."
Rationale:
All antibiotics should be given for the prescribed time even if symptoms disappear, because the infection may not be completely eradicated, and then recurs. This basic
A 1-year-old child is seen in the pediatrician's office with complaints of an elevated temperature the preceding night. When gathering subjective assessment data from the mother, which statement would most likely indicate that the child has an acute otiti
D. The mother noted purulent discharge from the child's ear last night.
Rationale:
Subjective data are what the mother tells the nurse during the initial assessment. This is apparent in option 4 because the mother is explaining the child's ear drainage th
A child is brought to the emergency department following a thermal burn injury. On assessment, the nurse should expect to find which manifestation(s)?
A. Cardiac fibrillation
B. Headache and dizziness
C. Nausea and dehydration
D. Singed eyebrow and nasal
D. Singed eyebrow and nasal hairs
Rationale:
Exposure to or contact with flames, hot liquids, or hot objects causes thermal burns. Thermal burns are those sustained in residential fires, explosive accidents, scald injuries, or ignition of clothing or liqu
The nurse assesses a client's burn injury and determines that the client sustained a full-thickness burn. Based on this determination, which finding did the nurse note?
A. A dry wound surface
B. Charring at the wound site
C. Absence of wound sensation
D.
C. Absence of wound sensation
Rationale:
Decreased or absence of wound sensation would occur in full-thickness or deep full-thickness burns. A partial-thickness superficial burn appears wet, shiny, and weeping, or it may contain blisters. The wound blanch
Veronica is a 14-year-old girl who wears a brace for structural scoliosis; which of the following statements indicate effective use of the brace?
A. "I sure am glad that I only have to wear this awful thing at night."
B. "I'm really glad that I can take t
D. "I'll look forward to taking this thing off to take my bath every day."
Rationale:
Option D: The brace should be dropped for simply 1 hour of every 24-hour period for hygiene and skin care. Option A: Wearing the brace at night would be true only follow
A child requires the use of Pavlik harness; which of the following would the nurse do to best assess the mother's ability to care for her child?
A. Demonstrate to the mother how to remove and reapply the device.
B. Have the mother remove and reapply the h
B. Have the mother remove and reapply the harness before discharge.
Rationale:
Option B: Having the mother remove and reapply the harness before discharge allows the nurse to directly observe the mother's method and comfort level. It also provides time fo
Nurse Kevin is assessing a newborn for developmental dysplasia of the hip (DDH); he would expect to assess which of the following?
A. Characteristic limp
B. Ortolani's sign
C. Symmetrical gluteal folds
D. Trendelenburg's signs
B. Ortolani's sign
Rationale:
Option B: Ortolani's sign is felt and heard when newborn's or neonate's hip is flexed and abducted. Option A: A characteristic limp would be noted in the ambulatory child. Option C: Asymmetrical gluteal folds would be noted i
A teenager is suffering from osteomyelitis. The nurse would expect which of the following symptoms? Select all that apply.
A. Fever
B. Irritability
C. Pallor
D. Tenderness
E. Swelling
A, B, D, E
Rationale:
Options A, B, D, and E: The symptoms for acute and chronic osteomyelitis are very similar and include fever, irritability, fatigue, nausea, tenderness, redness (not pallor in option C), and warmth in the area of the infection, swelli
Nurse Kim is teaching a group of parents about otitis media. When discussing why children are predisposed to this disorder, the nurse should mention the significance of which anatomical feature?
A. Eustachian tubes
B. Nasopharynx
C. Tympanic membrane
D. E
A. Eustachian tubes
When evaluating a severely depressed adolescent, the nurse knows that one indicator of a high risk for suicide is:
A. Depression
B. Excessive sleepiness
C. A history of cocaine use
D. A preoccupation with death
D. A preoccupation with death
Rationale:
An adolescent who demonstrates a preoccupation with death (such as by talking about death frequently) should be considered at high risk for suicide. Although depression, excessive sleepiness, and a history of cocai
Sunshine, age 13, has had a lumbar puncture to examine the CSF to determine if bacterial infection exists. The best position to keep her in after the procedure is:
A. prone for two hours to prevent aspiration, should she vomit.
B. semi-fowler's so she can
C. supine for several hours, to prevent headache.
Rationale:
Lying flat keeps the patient from having a "spinal headache." Increasing the fluid intake will assist in replenishing the lost fluid during this time.
What is the priority intervention for a child with a severe burn?
A. Cool the burn with ice
B. Offer oral rehydration
C. Oxygen by NRB
D. Remove jewelry
C. Oxygen by NRB
How are kids different compared to adults?
A. They have 1/3 the TBSA as adults
B. They have 3X the TBSA as adults
C. They have lessened fluid requirements
D. They have more resilient skin and subcutaneous tissue
B. They have 3X the TBSA as adults
Which factors impact burn severity?
A. Duration of contact and causative agent
B. Duration of contact and child's age
C. Temperature and duration of contact
D. Temperature and consistency of substance
C. Temperature and duration of contact
A patient has superficial partial thickness burns 63% of her body. The patient weighs 91 kg. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringerss that will be given over the next 24 hours?
A. 22,932 mL
B. 26,208 mL
C. 16,380 mL
A. 22,932 mL
A patient has deep partial thickness burns on 37% of her body. The patient weighs 150 lbs. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours?
A. 14,960 mL
B. 12,512 mL
C. 10,064 mL
D.
C. 10,064 mL
A female patient has deep partial thickness burns on 58.5% of her body. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated?
A. 921 mL/hr
B. 938 mL/hr
C. 158 mL/
A. 921 mL/hr
A patient has full thickness burns on 81% of his body. The patient weighs 186 lbs. Use the Parkland Burn Formula: You've already infused fluids during the first 8 hours. Now what will you set the flow rate during the next 16 hours (mL/hr) based on the tot
D. 861 mL/hr
You receive a patient who has experienced a burn on the right leg. You note the burn contains small blisters and is extremely pinkish red and shiny/moist. The patient reports severe pain. You document this burn as:
A. 1st Degree (superficial)
B. 2nd Degre
B. 2nd Degree (partial-thickness)
A patient has a burn on the back of the torso that is extremely red and painful but no blisters are present. When you pressed on the skin it blanches. You document this as a:
A. 1st degree (superficial) burn
B. 2nd degree (partial-thickness) burn
C. 3rd d
A. 1st degree (superficial) burn
What are some patient priorities during the emergent phase of burn management? (select all that apply)
A. Fluid volume
B. Respiratory status
C. Psychosocial
D. Wound closure
E. Nutrition
A and B
During the acute phase of burn management, what is the best diet for a patient who has experienced severe burns?
A. High fiber, low calories, and low protein
B. High calorie, high protein and carbohydrate
C. High potassium, high carbohydrate, and low prot
B. High calorie, high protein and carbohydrate
A 4 year old is admitted to your unit with a severe case of impetigo. It is important the nurse follows _______________ while providing care to this patient:
A. Droplet precautions
B. Standard precautions only
C. Contact precautions
D. Airborne precaution
C. Contact precautions
Rationale:
The nurse will follow contact precautions, which includes following standard precautions as well. Impetigo is a HIGHLY contagious skin infection. Therefore, the nurse should always where a gown and gloves when providing c
A parent brings her child into the clinic due to skin lesions that fail to heal. The lesions are red, reported to be itchy, and exhibit exudate. You suspect the child may have impetigo. What is a hallmark finding with this condition?
A. Round patches with
D. Yellow crusts over the lesions
Yellow crusted over lesions are a hallmark of impetigo. Option A is a hallmark found with ringworm (tinea corporis), Option C is psoriasis, and Option B is scabies.
During a routine pediatric visit, a 2 month old patient will need which of the following vaccines?*
A. MMR (Measles, Mumps, Rubella)
B. Hepatitis A
C. Hepatitis B
D. DTaP (Diphtheria, Tetanus, Pertussis)
E. Hib (Haemophilus Influenzae Type B)
F. Varicella
C, D, E, G, H, and I
Rationale:
At 2 months the patient should receive: DTaP, Hepatitis B, Hib, Polio, RV, and PCV.
A mother calls the pediatric clinic to ask when her daughter will receive the Varicella vaccine. Your answer to her question is:
A. at 2, 4, and 6 months
B. at 12 months and 4-6 years
C. at 6 and 12 months
D. at 4 months and 4-6 years
B. at 12 months and 4-6 years
When should a child receive the first dose of the Hepatitis B vaccine?
A. Birth
B. 2 months
C. 4 months
D. 6 months
A. Birth
A 12 month old receives a series of vaccinations which includes the Hepatitis A vaccine. When should the child receive the 2nd dose of this vaccine?
A. in 3 months
B. at the 18 month visit
C. when the child is 4-6 years old
D. in 2 months
B. at the 18 month visit
Rationale:
The first dose of HepA is given at 12 months and then the second dose is given 6 months from that dose, which would be at the 18 month visit.
4 year old is scheduled for routine immunizations. As the nurse you know the physician will most likely order what vaccinations?
A. DTaP (diphtheria, Tetanus, Pertussis)
B. Polio
C. Hepatitis B
D. RV (Rotavirus)
E. MMR (Measles, Mumps, Rubella)
F. Hib (Ha
A, B, E, G
The immunizations ordered at 4-6 years of age include: DTaP, Polio, MMR, and Varicella.
A parent has a question about the Rotavirus vaccine and when it is administered. As the nurse you know that ________ doses are given, and the last dose is given at ________?
A. 2; 6 months
B. 3; 4 months
C. 4; 4-6 years
D. 3; 6 months
D. 3; 6 months
At what age does a child starting receiving a yearly flu vaccine?
A. 12 months
B. 6 months
C. 2 months
D. 24 months
B. 6 months
You're providing a free educational clinic to new moms about immunizations. You inform the attendees that the Measles, Mumps, and Rubella (MMR) vaccine is given?
A. at 6 and 12 months
B. 12 months and 4-6 years
C. at 4 and 6 months
D. at 2 and 12 months
B. 12 months and 4-6 years
A patient has an accidental fall while going to the bathroom without assistance. It appears the patient has sustained a bone fracture to the left leg. The leg's shape is deformed and the patient is unable to move it. The patient is alert and oriented but
B. Immobilize the fracture with a splint.
After confirming the patient is safe and stable, the nurse would immobilize the fracture with a splinting device. This will prevent the accidental movement of the extremity by the patient. Immobilization is import
Select all the signs and symptoms that will present in compartment syndrome?
A. Capillary refill less than 2 seconds
B. Pallor
C. Pain relief with medication
D. Feeling of tingling in the extremity
E. Affected extremity feels cooler to the touch than the
B, D, E
These symptoms may present with compartment syndrome. Option A and C are normal findings. Remember in compartment syndrome nerve and blood vessel function is being compromised, so expect signs and symptoms that occur when these structures are affe
Which assessment finding found while assessing a patient with a fracture who has traction requires immediate intervention?
A. The weights are freely hanging on the floor.
B. Pin sites are free from drainage.
C. Patient uses the overhead trapeze bar to mov
A. The weights are freely hanging on the floor.
A 5 year old has a fracture of the right upper arm. The x-ray showed that one side of the bone is bent while the other is broken. This known as a __________ fracture?
A. Spiral
B. Greenstick
C. Oblique
D. Transverse
B. Greenstick
This is a greenstick fracture. These types of fractures are more common in the pediatric population because their bones tend to be more flexible and the periosteum is stronger than an adult.
An 18-month-old boy who reportedly fell down the stairs earlier in the day just isn t acting right, according to his caregivers. Assessment reveals multiple bruises on his thighs and back and a deformity of his right thigh. He is alert and crying. What is
A. Explain that you are very concerned about the child's condition and that he needs to be examined at the hospital for a possible a broken leg.
Which of the following findings in a 2-year-old child assists in identifying the cause of a grand mal (Tonic-Clonic) seizure?
A. Crackles in the lungs
B. Cardiac dysrhythmia
C. Fever
D. Abdominal tendernes
C. Fever
When planning care for a 8-year-old boy with Down syndrome, the nurse should:
A. Plan interventions according to the developmental levels of a 5-year-old because the child will have developmental delays
B. Plan interventions according to the developmental
D. Assess the child's current developmental level and plan care accordingly
Nursing care plan should be planned according to the developmental age of a child with Down syndrome, not the chronological age. Because children with Down syndrome can vary from
An adolescent who sustained a tibia fracture in a motor vehicle accident has a cast. What should the nurse do to help relieve the itching?
A. Apply cool air under the cast with a blow-dryer
B. Apply hydrocortisone cream under the cast using sterile applic
A. Apply cool air under the cast with a blow-dryer
Itching underneath a cast can be relieved by directing blow-dyer, set, on the cool setting, toward the itchy area. Skin breakdown can occur if anything is placed under the cast. Therefore, the client shou
A 4-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority?
A. Orienting the parents to the pediatric unit
B. Instituting droplet precautions
C. Administering acetaminophen
B. Instituting droplet precautions
Instituting droplet precautions is a priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be prescribed but administering it doesn't take priority over instituting droplet precautions. Ob
Nurse Taylor suspects that a child, age 4, is being neglected physically. To best assess the child's nutritional status, the nurse should ask the parents which question?
A. "Is your child a picky eater?"
B. "What did your child eat for breakfast?"
C. "Has
B. "What did your child eat for breakfast?"
The nurse should obtain objective information about the child's nutritional intake, such as by asking about what the child ate for a specific meal. The other options ask for subjective replies that would be open
A female child, age 6, is brought to the health clinic for a routine checkup. To assess the child's vision, the nurse should ask:
A. "Do you have any problems seeing different colors?"
B. "Do you have trouble seeing at night?"
C. "How are you doing in sch
C. "How are you doing in school?"
A child's poor progress in school may indicate a visual disturbance. The other options are more appropriate questions to ask when assessing vision in a geriatric patient
A 1 year and 2-month-old child weighing 26 lb (11.8 kg) is admitted for traction to treat congenital hip dislocation. When preparing the patient's room, the nurse anticipates using which traction system?
A. Bryant's traction
B. Overhead suspension tractio
A. Bryant's traction
Bryant's traction is used to treat femoral fractures of congenital hip dislocation in children under age 2 who weigh less than 30 lb (13.6 kg). Buck's extension traction is skin traction used for short-term immobilization or to correc
The parent of a 12-month-old child who has received the MMR, Varivax, and hepatitis A vaccines calls the clinic to report redness and swelling at the vaccine injection sites and a temperature of 100.3� F. The nurse will perform which action?
a. Recommend
b. Recommend acetaminophen and cold compresses
These are common, minor side effects of vaccines and can be treated with acetaminophen and cold compresses. Aspirin is contraindicated in children because of its association with Reye's syndrome. Since these
The school nurse assesses Brook, a child newly diagnosed with attention deficit hyperactivity disorder (ADHD). Which of the following symptoms are characteristic of the disorder? Select all that apply.
A. Constant fidgeting and squirming
B. Excessive fati
A, C, D, and F
These behaviors are all characteristic of ADHD and indicate that the child is inattentive, hyperactive, and impulsive.
Which of the following assessment findings would lead the nurse to suspect Down syndrome in an infant?
A. Transverse palmar crease
B. Small tongue
C. Large nose
D. Restricted joint movement
A. Transverse palmar crease
Option A: Down syndrome is characterized by the following a transverse palmar crease (simian crease), separated sagittal suture, oblique palpebral fissures, small nose, depressed nasal bridge, high arched palate, excess and lax
When caring for a child with severe impetigo, the nurse should include which intervention in the plan of care?
A. Placing mitts on the client's hands
B. Administering systemic antibiotics as prescribed
C. Applying topical antibiotics as prescribed
D. Cont
B. Administering systemic antibiotics as prescribed
Impetigo is a contagious, superficial skin infection caused by beta-hemolytic streptococci. If the condition is severe, the physician typically prescribes systemic antibiotics for 7 to 10 days to prevent
Nurse Imee is implementing a teaching plan to a group of adolescents regarding the causes of acne. Which of the following is an appropriate nursing statement regarding the cause of this disorder?
A. "Acne is caused by oily skin"
B. "The actual cause is no
B. "The actual cause is not known"
The actual cause of acne is unknown. Oily skin or the consumption of foods such as chocolate, nuts, or fatty foods are not causes of acne. Exacerbations that coincide with the menstrual cycle result from hormonal activit
The clinic nurse is preparing to test the visual acuity of a client using a Snellen chart. Which of the following identifies the accurate procedure for this visual acuity test?
A. Both eyes are assessed together, followed by the assessment of the right an
B. The right eye is tested followed by the left eye, and then both eyes are tested.
Visual acuity is assessed in one eye at a time, and then in both eyes together with the client comfortably standing or sitting. The right eye is tested with the left eye c
The clinic nurse notes that the following several eye examinations, the physician has documented a diagnosis of legal blindness in the client's chart. The nurse reviews the results of the Snellen's chart test expecting to note which of the following?
A. 2
D. 20/200 vision
Legal blindness is defined as 20/200 or less with corrected vision (glasses or contact lenses) or visual acuity of less than 20 degrees of the visual field in the better eye.
The client has a large burned area on the right arm. The burned area appears pink, has blisters, and is very painful. How will the nurse categorize this injury?
A. Full-thickness
B. Partial-thickness superficial
C. Partial-thickness deep
D. Superficial
B. Partial-thickness superficial
The characteristics of the wound meet the criteria for a superficial partial-thickness injury: color that is pink or red; blisters and pain present. Blisters are not seen with full-thickness and superficial burns, and are
The client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding are present, and there is just a "small amount of pain." How will the nurse categorize this injury?
A. Full-thickness
B. Partial-thickness superficial
C.
A. Full-thickness
The characteristics of the wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; pain minimal; outer layer firm and inelastiC. Partial-thickness superficial burns appear pin
The nurse provides wound care for a client 48 hours after a burn injury. To achieve the desired outcome of the procedure, which nursing action will be carried out first?
A. Applies silver sulfadiazine (Silvadene) ointment
B. Covers the area with an elasti
D. Removes loose nonviable tissue
All steps are part of the nonsurgical wound care for clients with burn injuries. The first step in this process is removing exudates and necrotic tissue.
Which finding is characteristic during the emergent period after a deep full thickness burn injury?
A. Blood pressure of 170/100 mm Hg
B. Foul-smelling discharge from wound
C. Pain at site of injury
D. Urine output of 10 mL/hr
D. Urine output of 10 mL/hr
During the fluid shift of the emergent period, blood flow to the kidney may not be adequate for glomerular filtration. As a result, urine output is greatly decreaseD. Foul-smelling discharge does not occur during the emergent p
The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized?
A. Superficial
B. Partial-t
D. Full thickness
Option D: The characteristics of the wound meet the criteria for a full-thickness injury (color that is black, brown, yellow, white or red; no blisters; pain minimal; outer layer firm and inelastic).
The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized?
A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full th
B. Partial-thickness superficial
Option B: The characteristics of the wound meet the criteria for a superficial partial-thickness injury (color that is pink or red; blisters; pain present and high).
A toddler develops acute otitis media and is ordered cefpodoxime proxetil (Vantin) 5 mg/kg P.O. every 12 hours. If the child weighs 22 lb, how many milligrams will the nurse administer with each dose?
1. 50 mg
2. 100 mg
3. 110 mg
4. 220 mg
1. 50 mg
The dose is 5 mg/kg and the child weighs 10 kg. To determine the dose, the nurse would calculate: 5 mg/1 kg ? 10 kg = 50 mg per dose.
An infant is diagnosed with a congenital hip dislocation. On assessment, the nurse expects to note:
1. symmetrical thigh and gluteal folds.
2. Ortolani's sign.
3. increased hip abduction.
4. femoral lengthening.
2. Ortolani's sign.
An 8-month-old infant is admitted with a febrile seizure. The infant weighs 17 lb (7.7 kg). The physician orders ceftriaxone (Rocephin), 270 mg I.M. every 12 hours. (The safe dosage range is 50 to 75 mg/kg daily.) The pharmacy sends a vial containing 500
3. 1.08 ml
Rationale:
Because the infant weighs 17 lb (7.7 kg), the safe dosage range is 385 to 578 mg daily. The ordered dosage, 540 mg daily, is safe. To calculate the amount to administer, the nurse may use the following fraction method:
500 mg/2 ml =
A child, age 3, who tests positive for the human immunodeficiency virus (HIV) is placed in foster care. The foster parents ask the nurse how to prevent HIV transmission to other family members. How should the nurse respond?
1. "Make sure the child uses di
4. "Wear gloves when you're likely to come into contact with the child's blood or body fluids."
HIV is transmitted by blood and body fluids. Therefore, the nurse should respond by telling family members they should wear gloves when anticipating contact wi
A nurse is developing a plan to teach a mother how to reduce her infant's risk of developing otitis media. Which direction should the nurse include in the teaching plan?
1. Administer antibiotics whenever the infant has a cold.
2. Place the infant in an u
2. Place the infant in an upright position when giving a bottle.
When assessing a child for impetigo, the nurse expects which assessment findings?
1. Small, brown, benign lesions
2. Honey-colored, crusted lesions
3. Linear, threadlike burrows
4. Circular lesions that clear centrally
2. Honey-colored, crusted lesions
An 8-year-old child is suspected of having meningitis. Signs of meningitis include:
1. Cullen's sign.
2. Koplik's spots.
3. Kernig's sign.
4. Chvostek's sign
3. Kernig's sign.
An emergency department nurse suspects neglect in a 3-year-old boy admitted for failure to thrive. Signs of neglect in the child would include:
1. slapping, kicking, and punching others.
2. poor hygiene and weight loss.
3. loud crying and screaming.
4. pu
2. poor hygiene and weight loss.
A boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella?
1. "I told my husband to give my son aspi
4. "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son."
RATIONALE: By saying she'll call her pregnant neighbor, the mother demonstrates that she understands the implications of rubella. Fetal defects can occur duri
A child is suspected of having amblyopia ("lazy eye"). To help diagnose this disorder, the child will undergo which test?
1. Snellen's test
2. Near vision test
3. Weber's test
4. Peripheral vision test
1. Snellen's test
RATIONALE: To help diagnose amblyopia, the child will undergo the Snellen's test. Snellen's test assesses visual acuity and a child with amblyopia will have decreased visual acuity in the affected eye. The near vision test evaluates near
When assessing a family suspected of abusing its 4-year-old child, which behavior is the most important criterion that would suggest abuse?
1. Attempts by the child to defend or verify what the parent states
2. Incompatibility between the history (mechani
2. Incompatibility between the history (mechanism) and the injury
RATIONALE: The most important criterion on which to base a decision for reporting suspected abuse is an incompatibility between the history and the injury. A maltreated child will rarely be
A nurse is caring for a 3-year-old child with viral meningitis. Which signs and symptoms does the nurse expect to find during the initial assessment? Select all that apply.
1. Bulging anterior fontanel
2. Fever
3. Nuchal rigidity
4. Petechiae
5. Irritabil
2, 3, 5, 6
RATIONALE: Common signs and symptoms of viral meningitis include fever, nuchal rigidity, irritability, and photophobia. A bulging anterior fontanel is a sign of hydrocephalus, which isn't likely to occur in a toddler because the anterior fontan
A nurse formulates a nursing diagnosis of Risk for infection for a child with Down syndrome. Which condition typically seen in children with this syndrome supports this nursing diagnosis?
1. Muscular hypotonicity
2. Muscle spasticity
3. Increased mucus vi
1. Muscular hypotonicity
RATIONALE: Several conditions make the child with Down syndrome highly vulnerable to respiratory infections. For example, the hypotonicity of chest muscles in children with Down syndrome leads to diminished respiratory expansion a
Which nursing diagnosis takes highest priority for a child in the early stages of burn recovery?
1. Risk for infection
2. Impaired physical mobility
3. Disturbed body image
4. Constipation
1. Risk for infection
RATIONALE: Because infection is a serious risk for a client in the early stages of burn recovery, a diagnosis of Risk for infection takes highest priority. Diagnoses of Impaired physical mobility, Disturbed body image, and Constipati
A 2-year-old child is admitted to the pediatric unit with fever, seizures, and vomiting. He's awake and alert. As the nurse is putting a gown on the child, the nurse notices petechiae across the child's chest, abdomen, and back. The nurse should:
1. quest
3. evaluate the child's neurologic status.
RATIONALE: Petechiae across the child's chest, abdomen, and back are signs of meningitis. The priority is to evaluate neurologic status. Petechiae aren't allergic reactions, so the nurse shouldn't ask about aller
A child, age 2, with a history of recurrent ear infections is brought to the clinic with a fever and irritability. To elicit the most pertinent information about the child's ear problems, the nurse should ask the parent:
1. "Does your child's ear hurt?"
2
3. "Does your child tug at either ear?"
RATIONALE: Although all of the options are appropriate questions to ask when assessing a young child's ear problems, questions about the child's behavior, such as "Does your child tug at either ear?" are most useful
A nurse is caring for a preschooler who sustained deep partial-thickness burns on his hands as a result of touching a hot pot on the stove. When performing discharge teaching, the nurse should:
1. include the child in the teaching process.
2. go into the
1. include the child in the teaching process.
RATIONALE: The nurse should include preschoolers in any discharge teaching she performs. Preschoolers have developed reasoning skills and are beginning to understand the concepts of right and wrong and cause a
A child with osteomyelitis is to receive nafcillin I.V. every 6 hours. Before administering the drug, the nurse calculates the appropriate dosage. The recommended dosage is 50 to 100 mg/kg daily; the child weighs 22 lb (10 kg). Which dosage is acceptable?
3. 250 mg every 6 hours
RATIONALE: First, the nurse determines the minimum dose: 50 mg ? 10 kg = 500 mg/day
500 mg/4 doses (for administration every 6 hours) = 125 mg/dose.
Next, the nurse determines the maximum dose:
100 mg ? 10 kg = 1,000 mg/day
1,000 m
A local elementary school has requested scoliosis screening for its students from the hospital's community outreach program. The school should be informed that:
1. these students are too young to screen; instead, older students should be screened.
2. thes
4. this is an appropriate request and arrangements will be made as soon as possible.
RATIONALE: The school's request is appropriate because screening for scoliosis should begin at age 8 and be performed yearly thereafter. Also, because screening for scoli
A child, age 4, fell and broke his arm and had a cast applied. Which of these statements by the child indicates an immediate risk for compartment syndrome?
1. "My arm hurts."
2. "I can't wiggle my fingers."
3. "I need to go home."
4. "Don't touch me.
2. "I can't wiggle my fingers."
RATIONALE: Signs and symptoms of compartment syndrome, such as motor weakness, reflect a deficit or deterioration of neuromuscular status in the involved area. Inability to wiggle fingers indicates an immediate risk for com
A nurse is assessing an 8-month-old child for signs of neurologic deficit and increased intracranial pressure (ICP). These signs include:
1. a depressed fontanel.
2. slurred speech.
3. tachycardia.
4. an altered level of consciousness.
4. an altered level of consciousness.
RATIONALE: One sign of neurologic deficit in an 8-month-old child includes a decreased or altered level of consciousness. The fontanel would bulge � not depress � if he had increased ICP. Slurred speech isn't a sign o
A pediatric nurse is caring for a child suspected of having been sexually abused. Which finding would best support the nurse's suspicions?
1. Poor hygiene
2. Swelling of the genitals
3. Fear of parents
4. Poor eye contact
2. Swelling of the genitals
RATIONALE: The most likely finding for suspected sexual abuse would be difficulty walking or sitting; pain, swelling, or itching in the genitals; or bruises, bleeding, or lacerations of the genital area. Poor hygiene is a sign
Which of the following is the recommended immunization schedule for diphtheria, tetanus toxoids, and acellular pertussis (DTaP)?
1. Birth, 2 months, 6 months, 15 to 18 months, and 10 to 12 years
2. 1 month, 2 months, 6 months, 15 to 18 months, and 4 to 6
3. 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years
RATIONALE: According to the American Academy of Pediatrics and the Committee on Infectious Diseases, the DTaP vaccine should be administered at 2 months, 4 months, 6 months, 15 to 18 month
A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. To help determine the cause of the child's condition, the nurse should ask the parents:
1. "Does water ever get into the baby's ears during shampooing?"
2. "Do you g
2. "Do you give the baby a bottle to take to bed?"
RATIONALE: In a young child, the eustachian tube is relatively short, wide, and horizontal, promoting drainage of secretions from the nasopharynx into the middle ear. Therefore, asking if the child takes
A 3-year-old child with Down syndrome is admitted to the pediatric unit with asthma. The child doesn't enunciate words well and holds onto furniture when he walks. The nurse should ask the mother:
1. how long the child has been like this.
2. if the child
3. how the child's condition today differs from his normal condition.
RATIONALE: The nurse should ask how the child's condition differs from his normal condition in order to identify the chief complaint. Asking how long the child has been like this may be
A nurse is teaching parents how to reduce the spread of impetigo. The nurse should encourage parents to:
1. teach children to cover mouths and noses when they sneeze.
2. have their children immunized against impetigo.
3. teach children the importance of p
3. teach children the importance of proper hand washing.
A 3-month-old infant is admitted to the hospital to rule out nonaccidental trauma. X-ray findings indicate a fractured right humerus, fractured ribs, and a fractured left scapula. In this situation, a nurse is responsible for:
1. ensuring that the suspect
1. ensuring that the suspected child abuse is reported to local authorities.
RATIONALE: Nurses must report suspicions of child abuse to local authorities. The contact procedure may vary among hospitals, but the nurse is responsible for making the report.
A mother asks the nurse why her 12-month-old baby gets otitis media more frequently than her 10-year-old son. What should the nurse tell her?
1. "The baby's eustachian tubes are shorter and lie more horizontally."
2. "The baby is too young to blow his nos
1. "The baby's eustachian tubes are shorter and lie more horizontally."
RATIONALE: Infants and young children are more prone to otitis media because their eustachian tubes are shorter and lie more horizontally. Pathogens from the nasopharynx can more read
Parents of a 6-year-old tell a physician that the child has been having periods of unawareness with short periods of staring. Based on his history, the child is probably having which type of seizure?
1. Complex partial
2. Myoclonic
3. Typical absence
4. T
3. Typical absence
RATIONALE: This child is probably having typical absence seizures. Typical absence seizures have an onset between ages 3 and 12. This type of seizure is exhibited by an abrupt loss of consciousness, amnesia, or unawareness characterized
When teaching parents about fifth disease (erythema infectiosum) and its transmission, the nurse should provide which information?
1. Fifth disease is transmitted by respiratory secretions.
2. Fifth disease has an unknown transmission mode.
3. Fifth disea
1. Fifth disease is transmitted by respiratory secretions.
RATIONALE: Fifth disease is transmitted by respiratory secretions. The transmission mode for roseola is unknown. Rubella is transmitted by respiratory secretions, stool, and urine. Intestinal para
A 15-month-old child is being discharged after treatment for severe otitis media and bacterial meningitis. Which statement by the parents indicates effective discharge teaching?
1. "We should have gone to the physician sooner. Next time, we will."
2. "We'
3. "We'll go to the physician if our child pulls on the ears or won't lie down."
RATIONALE: The parents indicate full understanding of discharge teaching by repeating the specific, common signs of otitis media in toddlers, such as pulling on the ears and
A 13-year-old girl visits the school nurse because she's experiencing back pain, fatigue, and dyspnea. The nurse suspects that the girl may have scoliosis. The nurse should first:
1. send the girl home to recover.
2. inspect the girl for uneven shoulder h
2. inspect the girl for uneven shoulder height or uneven hip height.
RATIONALE: Before deciding on any specific intervention, the school nurse should perform a basic assessment for scoliosis, including inspecting for uneven shoulder or hip height. The nur
For the last 6 days, a 7-month-old infant has been receiving amoxicillin trihydrate (Amoxil) to treat an ear infection. Now the parents report redness in the diaper area and small, red patches on the infant's inner thighs and buttocks. After diagnosing Ca
3. the inside of the infant's mouth.
RATIONALE: The nurse should pay close attention to the inside of the infant's mouth for white patches. Signs of thrush, these patches are common in children with C. albicans infections and should be reported to the phy
A 6-year-old child is being discharged from the emergency department after being diagnosed with varicella (chickenpox). The nurse knows the parents need more medication teaching when they state they will give the child which over-the-counter medication?
1
2. Aspirin
RATIONALE: The parents require additional teaching if they state they will give their child aspirin because using aspirin during a viral infection has been linked to Reye's syndrome, a serious illness that can lead to brain damage and death in
A nurse in a well-child clinic is assessing children for scoliosis. Which child is most at risk for scoliosis?
1. 8-year-old boy
2. Teenage boy
3. 6-year-old girl
4. 10-year-old girl
4. 10-year-old girl
RATIONALE: The 10-year-old girl is most at risk because scoliosis is five times more common in girls than boys, and its peak age of incidence is between ages 8 and 15. The 8-year-old boy or a teenage boy may develop scoliosis but it's
A child, age 10, is hospitalized for treatment of acute osteomyelitis. After assessing swelling and tenderness of the left tibia, the nurse initiates antibiotic therapy as ordered. The child's left leg is immobilized in a splint. What is an appropriate ex
1. "The child will change position with minimal discomfort.
An infant is having his 2-month checkup at the pediatrician's office. The physician tells the parents that she's assessing for Ortolani's sign. The nurse explains that the presence of Ortolani's sign indicates dislocation of what joint?
1. Shoulder
2. Elb
4. Hip
RATIONALE: To assess for Ortolani's sign, the nurse abducts the infant's hips while flexing the legs at the knees. This is performed on all infants to assess for congenital hip dislocation. The examiner listens and feels for a "click" as the femora
When examining school-age and adolescent children, the nurse routinely screens for scoliosis. Which statement accurately summarizes how to perform this screening?
1. Have the child stand firmly on both feet and bend forward at the hips, with the trunk exp
1. Have the child stand firmly on both feet and bend forward at the hips, with the trunk exposed.
RATIONALE: To screen for scoliosis, a lateral curvature of the spine, the nurse has the child stand firmly on both feet with the trunk exposed and examines t
A school-age child begins to have a seizure while walking to the bathroom. What should the nurse do first?
1. Call the physician caring for the child.
2. Ease the child to the floor and turn him on his side.
3. Administer diazepam (Valium) through the I.V
2. Ease the child to the floor and turn him on his side.
RATIONALE: Because the child is standing, he should first be eased to the floor and turned to the side to prevent aspiration. Notifying the physician wouldn't be the first action the nurse would tak
A toddler with bacterial meningitis is admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use?
1. Reverse isolation
2. Strict hand washing
3. Standard precautions
4. Respiratory isolation
4. Respiratory isolation
RATIONALE: Because bacterial meningitis is transmitted by droplets from the nasopharynx, the nurse should prepare to use respiratory isolation. This type of isolation involves wearing a gown and gloves during direct client care an
Parents of a 2-year-old child with chronic otitis media are concerned that the disorder has affected their child's hearing. Which behavior suggests that the child has a hearing impairment?
1. Stuttering
2. Using gestures to express desires
3. Babbling con
2. Using gestures to express desires
RATIONALE: Using gestures instead of verbal communication to express desires � especially in a child older than age 15 months � may indicate a hearing or communication impairment. Stuttering is normal in children ages
A day-shift nurse on the pediatric neurologic unit has just received a report from the previous shift. Which infant should the nurse assess first?
1. An infant with a myelomeningocele who is scheduled for surgical placement of a ventriculoperitoneal shunt
2. A restless infant with a high-pitched cry who was transferred from intensive care unit (ICU) the previous evening
RATIONALE: An infant's restlessness and high-pitched cry can indicate increased intracranial pressure (ICP). Because the infant was transf
An adolescent presents with a large round ring with a swollen border on his left arm. He states that he often plays football in a field behind the school. The nurse suspects that he has:
1. Lyme disease.
2. Kopliks spots.
3. impetigo.
4. mononucleosis.
1. Lyme disease.
RATIONALE: Lyme disease, which results from a tick bite, is characterized by a large round ring with a raised swollen border at the site of the bite. Treatment at this stage can prevent systemic involvement that could lead to cardiac, neu