Which of the following would the nurse identify as a priority nursing diagnosis when preparing the preoperative plan of care for a 4-year-old undergoing a tonsillectomy and adenoidectomy (T&A)?
Anxiety related to surgery.
Impaired Parenting related to surgery.
Pain related to surgery.
Imbalanced Nutrition: Less Than Body Requirements related to surgery.
The nurse identifies a nursing diagnosis of Risk for Perioperative-Positioning Injury related to the surgical procedure for a school-aged child scheduled for a tonsillectomy. Which of the following would be the most appropriate expected outcome for this nursing diagnosis?
The child is able to tell about the surgery and recovery.
The child remains NPO for the designated preoperative period.
The child and family demonstrate an understanding of the procedure.
The child knows the parents will not leave.
After a T&A, which of the following findings would alert the nurse to suspect early hemorrhage in a 5-year-old child?
Drooling of bright red secretions.
Pulse rate of 95 bpm.
Vomiting of 25 mL of dark brown emesis.
Blood pressure of 95/56 mm Hg.
After teaching the parents of a preschooler who has undergone a T&A about appropriate foods to give the child after discharge, which of the following, if stated by the parents as appropriate foods, indicates successful teaching?
Meat loaf and uncooked carrots.
Pork and noodle casserole.
Cream of chicken soup and orange sherbet.
Hot dog and potato chips.
The nurse teaches the parents about the possibility of postoperative hemorrhage after a T&A, explaining that the risk is greatest at which of the following times?
2 to 4 days after surgery.
5 to 7 days after surgery.
8 to 10 days after surgery.
11 to 13 days after surgery.
When determining the parents' compliance with treatment for their toddler who has recurrent otitis media, which of the following measures would the nurse expect the parents to describe?
Cleaning the child's ear canals with hydrogen peroxide.
Instilling ear drops regularly to prevent cerumen accumulation
Holding the child upright when feeding with a bottle.
A toddler is scheduled to have tympanostomy tubes inserted. When approaching the toddler for the first time, which of the following would the nurse do?
Talk to the mother first so that the toddler can get used to the new person.
Hold the toddler so that the toddler becomes more comfortable.
Walk over and pick the toddler up right away so that the mother can relax.
Pick up the toddler and take the child to the play area so that the mother can rest.
After insertion of bilateral tympanostomy tubes, which of the following instructions would the nurse include in a child's discharge plan for the parents?
Insert ear plugs into the canals when the child bathes.
Blow the nose forcibly during a cold.
Administer the prescribed antibiotic while the tubes are in place.
Disregard any drainage from the ear after 1 week.
A child brought to the emergency department by his parents is diagnosed with a foreign body aspiration. Which of the following nursing diagnoses would the nurse identify as the priority for this child?
Ineffective Airway Clearance related to foreign body aspiration.
Risk for Injury related to foreign body aspiration.
Impaired Parenting related to foreign body aspiration
Ineffective Health Maintenance related to foreign body aspiration.
The mother asks the nurse why peanuts are one of the worst things a child can aspirate. Which of the following would the nurse include in the explanation as the main reason for the problem associated with aspirating peanuts?
They swell when wet.
They contain a fixed oil.
They decompose when wet.
They contain sodium.
After teaching the parents of a toddler about commonly aspirated foods, which of the following foods, if identified by the parents as easily aspirated, would indicate the need for additional teaching?
Popcorn.
Raw vegetables.
Round candy.
Crackers.
A toddler who has been treated for a foreign body aspiration begins to fuss and cry when the parents attempt to leave the hospital for an hour. The parents will be returning to take the toddler home. As the nurse tries to take the child out of the crib, the child pushes the nurse away. The nurse interprets this behavior as indicating separation anxiety involving which of the following?
Protest.
Despair.
Regression.
Detachment.
After teaching the parents of an 18-month-old who was treated for a foreign body obstruction about the three cardinal signs indicative of choking, the nurse determines that the teaching has been successful when the parents state that a child is choking when he or she cannot speak, turns blue, and does which of the following?
Vomits.
Gasps.
Gags.
Collapses.
When preparing the teaching plan for the mother of a child with asthma, which of the following would the nurse include as signs to alert the mother that her child is having an asthma attack?
Secretion of thin, copious mucus.
Tight, productive cough.
Wheezing on expiration.
Temperature of 99.4°F (37.4°C).
Which assessment findings would lead the nurse to suspect that a toddler is experiencing respiratory distress? Select all that apply.
Respiratory rate of 35 breaths per minute.
Heart rate of 95 bpm.
Restlessness.
Diaphoresis.
A 10-year-old child with a history of asthma who is 5 feet 4 inches (138 cm) tall uses an inhaled bronchodilator only when needed. He takes no other medications routinely. His best peak expiratory flow rate is 270 L/minute. The child's current peak flow reading is 180 L/minute. The nurse interprets this reading as indicating which of the following?
The child's asthma is under good control, so the routine treatment plan should continue.
The child needs to start a short-acting inhaled 2-agonist medication.
This is a medical emergency requiring a trip to the emergency department for treatment.
The child needs to begin treatment with inhaled cromolyn sodium (Intal) for asthma control.
An adolescent complains of chest pain and goes to the school nurse. The nurse determines that the teenager also has a history of asthma but has had no problems for years. Which of the following would the nurse do next?
Call the adolescent's parent.
Have the adolescent lie down for 30 minutes.
Obtain a peak flow reading
Give two puffs of a short-acting bronchodilator.
A 7-year-old child with a history of asthma controlled without medications is referred to the school nurse by the teacher because of persistent coughing. Which of the following would the nurse do first?
Obtain the child's heart rate.
Give the child a nebulizer treatment.
Call a parent to obtain more information.
Have a parent come and pick up the child.
When developing a teaching plan for the mother of an asthmatic child concerning measures to reduce allergic triggers, which of the following suggestions would the nurse expect to include?
Keep the humidity in the home between 50% and 60%.
Have the child sleep in the bottom bunk bed.
Use a scented room deodorizer to keep the room fresh.
Vacuum the carpet once or twice a week.
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 disease?
"We try to keep him happy at all costs; otherwise, he has an asthma attack."
"We keep our child away from other children to help cut down on infections."
"Although our child's disease is serious, we try not to let it be the focus of our family."
"I'm afraid that when my child gets older, he won't be able to care for himself like I do."
An 8-year-old child with asthma states, "I want to play some sports like my friends. What can I do?" The nurse responds to the child based on the understanding of which of the following?
Physical activities are inappropriate for children with asthma.
Children with asthma must be excluded from team sports.
Vigorous physical exercise frequently precipitates an asthmatic episode.
Most children with asthma can participate in sports if the asthma is controlled.
When developing the plan of care for a child with cystic fibrosis (CF) who is scheduled to receive postural drainage, the nurse would anticipate performing postural drainage at which of the following times?
After meals.
Before meals.
After rest periods.
Before inhalation treatments.
When teaching the parents of an older infant with CF about the type of diet the child should consume, which of the following would be most appropriate?
Low-protein diet.
High-fat diet.
Low-carbohydrate diet.
High-calorie diet.
At a follow-up appointment after being hospitalized, an adolescent with a history of CF describes his stools to the nurse. Which of the following descriptions would the nurse interpret as indicative of continued problems with malabsorption?
Soft with little odor.
Large and foul-smelling.
Loose with bits of food.
Hard with streaks of blood.
When developing a recreational therapy plan of care for a 3-year-old child hospitalized with pneumonia and CF, which of the following toys would be most supportive?
100-piece jigsaw puzzle
Child's favorite doll.
Fuzzy stuffed animal.
Scissors, paper, and paste.
Which of the following, if described by the parents of a child with CF, indicates that the parents understand the underlying problem of the disease?
An abnormality in the body's mucus-secreting glands.
Formation of fibrous cysts in various body organs.
Failure of the pancreatic ducts to develop properly.
Reaction to the formation of antibodies against streptococcus.
Which of the following outcome criteria would the nurse develop for a child with CF who has a nursing diagnosis of Ineffective Airway Clearance related to increased pulmonary secretions and inability to expectorate?
Respiratory rate and rhythm within expected range.
Absence of chills and fever.
Ability to engage in age-related activities.
Ability to tolerate usual diet without vomiting.
A school-aged child with CF asks the nurse what sports she can become involved in as she becomes older. Which of the following activities would be most appropriate for the nurse to suggest?
Swimming.
Track.
Baseball.
Javelin throwing.
After the parents bring their infant to the emergency department, the nurse obtains a brief history of events occurring before and after the parents found the infant not breathing. Which of the following questions would be most appropriate for the nurse to ask the parents?
"Was the infant sleeping while wrapped in a blanket?"
Was the infant lying on his stomach?"
"What did the infant look like when you found him?"
"When had you last checked on the infant?"
When planning a visit to the parents of an infant who died of sudden infant death syndrome (SIDS) at home, the community health nurse would expect to visit the parents at which of the following times?
A few days after the funeral.
Two weeks after the funeral.
As soon as the parents are ready to talk.
As soon after the infant's death as possible.
When developing the ongoing plan of care for the parents whose infant died of SIDS, the community health nurse would expect to accomplish which of the following on the second home visit?
Allow the parents to express their feelings.
Have the parents gain an understanding of the disease.
Assess the impact of the infant's death on their other children.
Deal with issues such as having other children.
On finding a child who is not breathing, which of the following would the nurse do first?
Clear the airway.
Begin mouth-to-mouth resuscitation.
Initiate oxygen therapy.
Start chest compressions.
Which of the following rates would the nurse use when performing rescue breathing during cardiopulmonary resuscitation (CPR) for a 5-year-old?
10 breaths/minute.
12 breaths/minute.
15 breaths/minute.
20 breaths/minute.
At which of the following rates would the nurse deliver external chest compressions to a 5-year-old child who is pulseless?
60 compressions/minute.
80 compressions/minute.
100 compressions/minute.
120 compressions/minute.
As part of a health education program, the nurse teaches a group of parents of preschoolers how to perform chest compressions during CPR. The nurse determines that the teaching has been effective when the parents state that the child's chest should be compressed to which of the following depths?
1 to 1.5 inches.
1.5 to 2 inches.
2 to 2.5 inches.
2.5 to 3 inches.
When performing CPR, which of the following assessments would indicate to the nurse that external chest compressions are effective?
Mottling of the skin.
Pupillary dilation.
Palpable pulse.
Cool, dry skin.
A nurse walks into the room just as a 10-month-old infant places an object in his mouth and starts to choke. After opening the infant's mouth, which of the following would the nurse do next to clear the airway?
Use blind finger sweeps.
Deliver back blows and chest thrusts.
Apply four subdiaphragmatic abdominal thrusts.
Attempt to visualize the object.
When preparing to deliver back blows to an infant who is choking on a foreign body, in which of the following positions would the nurse position the infant?
Head down and lower than the trunk.
Head up and raised above the trunk.
Head to one side and even with the trunk lower than the head.
Head parallel to the nurse and supported at the buttocks.
When teaching the parents of an infant how to perform back blows to dislodge a foreign body, which of the following would the nurse tell the parents to use to deliver the blows?
Palm of the hand.
Heel of the hand.
Fingertips.
Entire hand.
While the nurse is delivering abdominal thrusts to a 6-year old who is choking on a foreign body, the child begins to cry. Which of the following would the nurse do next?
Tap or gently shake the shoulders.
Deliver back blows.
Perform a blind finger sweep of the mouth.
Observe the child closely.
The father of a 16-month-old child calls the clinic because the child has a low-grade fever, cold symptoms, and a hoarse cough. Which of the following would the nurse suggest that the father do?
Offer extra fluids frequently.
Bring the child to the clinic immediately.
Count the child's respiratory rate.
Use a hot air vaporizer.
A 21-month-old child admitted with the diagnosis of croup now has a respiratory rate of 48 breaths/minute, a heart rate of 120 bpm, and a temperature of 100.8°F (38.2°C) rectally. The nurse is having difficulty calming the child. Which of the following would the nurse do next?
Administer acetaminophen (Tylenol).
Notify the physician immediately.
Allow the toddler to continue to cry.
Offer clear fluids every few minutes
A father brings his 3-month-old infant to the clinic, reporting that the infant has a cold, is having trouble breathing, and "just doesn't seem to be acting right." Which of the following actions would the nurse do first?
Check the infant's heart rate.
Weigh the infant.
Assess the infant's oxygen saturation.
Obtain more information from the father.
While the nurse is working in a homeless shelter, assessment of a 6-month-old infant reveals a respiratory rate of 52 breaths/minute, retractions, and wheezing. The mother states that her infant was doing fine until yesterday. Which of the following actions would be most appropriate?
Administer a nebulizer treatment.
Send the infant for a chest radiograph.
Refer the infant to the emergency department.
Provide teaching about cold care to the mother.
An infant is being treated at home for bronchiolitis. Which of the following would the nurse teach the parent about home care? Select all that apply.
Offering small amounts of fluids frequently.
Allowing the infant to sleep prone.
Calling the clinic if the infant vomits.
Watching for difficulty breathing.
In preparation for discharge, the nurse teaches the mother of an infant diagnosed with bronchiolitis about the condition and its treatment. Which of the following statements by the mother indicates successful teaching?
"I need to be sure to take my child's temperature every day."
"I hope I don't get a cold from my child."
"Next time my child gets a cold I need to listen to the chest."