PN Children Practice 2020A

"I will place a screen in front of the fireplace." The nurse should instruct the parent to place a screen in front of a fireplace or other heating appliances to prevent burns.

White rice (The nurse should reinforce to the guardian that celiac disease is a genetic autoimmune disorder in which eating gluten, even in very small amounts, can damage the child's small intestine. Currently, the only treatment for the disease is a lifelong, strict adherence to a gluten-free diet. The nurse should stress the importance of avoiding foods containing wheat, rye, barley, and oats. The child should consume foods that are gluten-free, such as milk, cheese, rice, corn, eggs, potatoes, fruits, vegetables, fresh poultry, meats, fish, and dried beans.)

Tetanus, diptheria toxoids, and acellular pertussis (Tdap) The Tdap vaccine is recommended between the ages of 11 and 12 years. Therefore, this adolescent should receive the Tdap vaccine now.

Box B (Anatomic position left side) B is correct. The nurse should observe the location over the infant's spleen when monitoring for manifestations of splenic sequestration. Splenic sequestration is an enlargement of the spleen due to pooling of sickled cells in the blood.

Hypothyroidism is correct. The nurse should identify that hypothyroidism and other endocrine disorders are risk factors for primary amenorrhea. Cannabis use is correct. The nurse should identify that cannabis use is a risk factor for primary amenorrhea. Oral contraceptive use is correct. The nurse should identify that oral contraceptive use affects the estrogen and progesterone cycle and is a risk factor for primary amenorrhea. Emotional stress is correct. The nurse should identify that emotional stress causes hypothalamic suppression and is a risk factor for primary amenorrhea.

Have a suction canister and tubing available in the room. (The nurse should have a suction canister and tubing available in the child's room to keep the child's airway patent during a seizure.)

Hives (The nurse should observe for hives first because this is an early manifestation of an anaphylactic reaction.)

Inform the client regarding routes of transmission. (The nurse should inform the client about the transmission of HIV and how to prevent its spread.)

Urticaria (The nurse should monitor the child for an allergic reaction to the contrast dye. Manifestations of the allergic reaction include urticaria, itching, flushing of the skin, and possible anaphylaxis.)

"Put your child's finger under warm, running water prior to collecting blood." (The nurse should instruct the parent that placing the child's finger under warm, running water increases the blood flow to the finger, which will make it easier to obtain the sample.)

"Let's discuss the possible need for transfusion with your parents." (The nurse should offer to involve the child's parents to understand the family's beliefs about blood transfusions.)

Use facial expressions when speaking. (The nurse should instruct the guardians to use facial expressions when speaking to assist in conveying the message being spoken.)

Sodium level 145 mEq/L (The nurse should identify that a sodium level of 145 mEq/L is within the expected reference range of 134 to 150 mEq/L and is an indication that the infant's status is improving.)

A child who has a fever and nuchal rigidity. (A client who has a fever and nuchal rigidity is unstable. This finding indicates bacterial meningitis, which requires urgent data collection and intervention to reduce complications for the child and prevent further spread of the infection. Therefore, the nurse should collect data from this child first.)

Increased irritability (The nurse should recognize that increased irritability, fatigue, vomiting, and headache are early signs of increased intracranial pressure.)

Hgb 6 g/dL (The expected reference range for an adolescent's Hgb level is 10 to 15.5 g/dL. Therefore, an Hgb of 6 g/dL is below the expected reference range and should be reported to the provider.)

Weight loss of 10% (The nurse should expect an infant who has severe dehydration to experience weight loss of up to 10%.)

"I am cold. Can I have an extra blanket?" (The nurse should identify that being cold and having chills is an indication of a transfusion reaction.)

Report the suspected abuse to the authorities (Nurses are required mandatory reporters of child abuse. It is the nurse's responsibility to report any type of abuse to the appropriate agencies. This action will assist with ensuring a safe environment for the adolescent.)

Promote oxygen utilization. (The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is promoting oxygen utilization to prevent further sickling of the red blood cells and promote adequate oxygenation of the tissue.)

The client fasts twice a week to manage dietary intake. (The nurse should identify that adolescents are often at risk for developing poor eating habits. Regular fasting puts this client at risk for nutritional deficits.)

Confirm that the pH of the stomach contents is 5 or less. (The nurse should test the pH of the stomach contents prior to administering the tube feeding in order to confirm tube placement in the stomach. The nurse should identify that a pH of 5 or less indicates gastric placement.)

Restrict the child's sodium intake (The nurse should limit the sodium intake for a child who has APSGN and is hypertensive or who has a decreased urine output to help prevent water retention and edema.) The nurse should monitor the blood pressure of a child who has APSGN every 4 to 6 hr.

Lead 14 mcg/dL (This lead level is above the expected reference range for a preschooler. Therefore, the nurse should report this result to the provider.)

Determine if the child is breathing Empty the child's mouth of remaining pills and residue Identify the medication and dosage strength Call a poison control center Determine if the child is breathing is the first step. The child's respiratory and cardiovascular status should be checked first to determine if CPR is necessary.Empty the child's mouth of remaining pills and residue is the second step. The child's mouth should be emptied of pills and residue to prevent additional exposure to the medication.Identify the medication and dosage strength is the third step. The parent should identify the medication and dosage strength by looking at the medication container.Call a poison control center is the fourth step. The parent should contact a poison control center for advice on the next course of action.

"I will have my child sleep in knee, wrist, and hand splints." The nurse should reinforce with the guardian that splinting the child's joints at night will decrease pain and enhance joint function.

Green, tarry stools Green, tarry stools are an expected outcome of ferrous sulfate therapy. Therefore, this is an indication of adherence to the prescribed medication regimen.

Potassium 3 mEq/L (The nurse should report a potassium level of 3 mEq/L to the provider. A decreased potassium level can place the child at risk for digoxin toxicity.)

Ensure the weights are hanging freely (The nurse should ensure that the weights are hanging freely for a child who is in Buck's traction.)

"Keep your child away from crowded areas." (The nurse should instruct the guardian to keep the child away from crowds and visitors who have an illness to decrease the risk for infection.)

Stand on one foot for several seconds (Standing on one foot for several seconds is an expected behavior for a toddler.)

Sodium 150 mEq/L (Hypernatremia is an adverse effect of prednisone. This level is above the expected reference range for a school-age child. Therefore, the nurse should report this value to the provider.)

"You will need to have two negative pregnancy tests prior to starting this medication." The nurse should reinforce with the client that isotretinoin is teratogenic. Pregnancy must be ruled out prior to administration and before each subsequent refill. The client should use two effective forms of contraception while taking this medication.

"My daughter has bowel movements every 4 to 5 days." The nurse should recognize that this frequency indicates the child is constipated. Therefore, large stool masses might prevent complete emptying of the bladder and lead to urinary stasis and infection.

Eye patch Treatment of strabismus includes covering the strong eye to strengthen the muscles in the weak eye.

Hopping on one foot The nurse should expect to find that a 4-year-old preschooler is able to hop on one foot.

Chronic cough The nurse should identify that a chronic cough is an expected finding in a child who has GERD.

Administer pain medication to the client. According to evidence-based practice, the nurse should first provide pain medication to the client to reduce discomfort during the procedure.

Levalbuterol (The nurse should inform the parent to administer levalbuterol, a short-acting beta2 agonist, to the preschooler for acute asthma attacks.)

Bending forward with back parallel to the floor The nurse should observe for asymmetry and prominence of the rib cage by having the students bend forward with the back parallel to the floor.

Dry cough The nurse should identify that a dry cough is an early manifestation of pertussis.

Apples The nurse should instruct the parents that apples are low in sodium and supply the child with energy needed for recovery.

"A decrease in urine protein indicates that treatment is effective." The desired outcome of steroid therapy in the treatment of nephrotic syndrome is a reduction of proteinuria.

Use a cool mist vaporizer in the infant's room. The nurse should reinforce that a cool mist vaporizer should be used to help thin respiratory secretions and decrease the infant's risk for an upper respiratory infection.

Trim the child's fingernails short. The nurse should instruct the guardian to trim the child's fingernails short to reduce the collection of eggs under their nails and prevent reinfection.

"At this age, your child likely believes his thoughts can cause another person's death." The nurse should reinforce that, at this age, the preschooler might believe that his thoughts can cause another person's death, which can make him feel guilty or responsible for the death.

Report of tingling in the right foot The nurse should identify that the greatest risk to the child is nerve injury. Therefore, tingling in the right foot, which can indicate nerve damage or compartment syndrome, is the priority finding for the nurse to report to the provider.

Vomiting The nurse should identify that vomiting, especially unrelated to feedings, is a manifestation of digoxin toxicity and should be reported to the provider.

Spends a lot of time by herself Spending time alone is an expected characteristic of a 7-year-old female child. When they do spend time with others, children in this age group prefer to socialize with children of the same sex and age.

Sinus rhythm The nurse should identify this heart sound as sinus rhythm. The nurse should auscultate heart sounds at the apical impulse, which is at the left midclavicular line and fifth intercostal space. The expected heart sounds include S1, which is the closure of the atrioventricular valves, and S2, which is the closure of the semilunar valves.

Birth weight doubled The nurse should identify this finding as a deviation from expected growth and development. The infant's birth weight should triple by 12 months of age. Therefore, the nurse should report this finding to the provider.

"I will make sure that electrical devices in the house are grounded." This response by the guardian indicates an understanding of the nurse's instructions. Due to the combustible nature of oxygen, all pieces of electrical equipment in the home should be grounded to decrease the risk of a fire caused by an electrical spark.

Laceration on the side of the torso A laceration on the side of the torso is not an injury that occurs due to the typical clumsiness of a toddler. This finding indicates the need to further investigate for suspected child maltreatment.

690 mL

Place the infant in semi-Fowler's position for 1 hr after the feeding. The nurse should elevate the head of the infant's bed by 30º to 45º for 30 min to 1 hr after the feeding.

Amount and consistency of stools Recording the amount and consistency of the child's stools will help determine the effectiveness of pancrelipase, which is taken to decrease the bulk of feces.

Platelet count 70,000/mm3 This platelet count is below the expected reference range for a preschooler and increases the risk for spontaneous bleeding. The nurse should hold the medication and report this finding to the provider immediately.

Apply pressure to the lacrimal punctum for 1 min following administration. The nurse should apply pressure to the lacrimal punctum to prevent the medication from entering the nasopharynx.

"We will purchase a toy storage box with a lightweight lid." The nurse should instruct the parents to avoid toy boxes with heavy, hinged lids. Toddlers may suffocate or have the lid close on their head or neck, causing injury.

BP 115/70 mm Hg The nurse should identify that this blood pressure is above the expected reference range for a 12-month-old infant and report this finding to the provider. Temperature 37.5° C (99.5° F)