Carolinas college. Children and Adolescent Test 2

Question 2

Carolinas college. Children and Adolescent Test 2A child with a cardiac defect is being discharged prior to corrective surgery. When counseling the parents regarding home care, what information should the nurse stress?

• The need to be extremely concerned about cyanotic spells.
• Relaxing discipline and limit-setting to prevent crying.
• Promoting normal growth and development.
• Importance of reducing caloric intake to decrease cardiac demands.

Question 3

What is the best approach used by the nurse when preparing a toddler for a procedure?

• Plan the teaching session to last around twenty minutes total.
• Demonstrate the procedure clearly using a doll for explanation.
• Show the equipment but do not let the child handle any items.
• Avoid offering the child any choices during the preparation process.

Question 4

The nurse is caring for a toddler who fell from a second-story window, was briefly unconscious and has vomited four times. Which action should the nurse take to best evaluate neurologic status?

• Obtain a CT scan to check for brain injury.
• Attach an intracranial pressure monitor to child’s head.
• Assess a Pediatric Glasgow Coma Scale score.
• Administer an antiemetic medication for vomiting episodes.

Question 5

An 8-month-old infant is having a hypercyanotic spell while blood is being drawn. Which action by the nurse would have the greatest impact on relieving the spell?

• Administer supplemental oxygen to increase oxygen saturation levels.
• Calm the infant by minimizing stimulation and reducing environmental stress.
• Notify the healthcare provider of the infant’s acute condition immediately.
• Place the infant in a knee-chest position to improve circulation.

Question 6

A nurse is assessing growth patterns in a 2-year-old child at a well-child visit. Which finding is most consistent with expected toddler growth and development?

• Height increases by 10 inches per year
• Weight doubles from birth weight
• Steady weight gain of 4–6 lb per year
• Weight triples from birth weight

Question 7

A patient weighs 16.4 kg. How many mL of fluid would the nurse calculate per day (mL/day) in order to maintain hydration? (Round to nearest whole number. Use numerical answer only.)

• 1320

Question 8

When caring for a child who is experiencing a seizure which nursing interventions would be implemented? Select ALL that apply.

• Turn the child to the side.
• Obtain a full set of vital signs.
• Place EEG electrodes to help determine cause of the seizure.
• Place a pillow under the child’s head
• Provide oral suction, as needed
• Restrain the child’s movements to prevent injury
• Administer Lorazepam(Ativan) PO, as ordered.
• Describe and record the seizure activity.

Question 9

An 8-year-old patient is diagnosed with juvenile idiopathic arthritis. In establishing goals for this child, the nurse would consider which of the following to be most important?

• Immobilize the joint
• Preserve joint function
• Regain proper alignment
• Limit use of joint

Question 10

The nurse is performing the AM assessment on a 9-year-old child with a diagnosis of severe cognitive impairment. Which assessment finding would be normal for this child?

• Social skills that would parallel biological age
• Sensorimotor functioning of an infant
• A larger active vocabulary than passive vocabulary
• Limited verbal communication

Question 11

Which of the following assessment findings require immediate follow-up? (Drag and drop the 4 correct findings into the box labeled “Requires Immediate Action.”)

• Potassium level of 2.9 mEq/L
• Temperature 98.6°F
• Blood pressure 74/50 mmHg
• No wet diaper in 8 hours
• Heart rate 80 bpm
• Hemoglobin 12.5 g/dL
• Easily arousable but sleepy
• Vomiting and diarrhea
• Sodium level of 136 mEq/L

Question 12

The child is most likely experiencing [digoxin toxicity] and [dehydration].

Question 13

The nurse should expect to [hold digoxin] and [administer IV fluids] as priority actions for acute treatment.

Question 17

A 6-month-old infant does not smile, has poor head control, has a persistent Moro reflex, and often chokes while eating. These nursing assessment findings are most suggestive of what condition?

• hydrocephalus.
• cerebral palsy.
• muscular dystrophy.
• cognitive impairment.

Question 18

The nurse is caring for a teenager post open heart surgery who was just transferred from the ICU. Which of the following should be included in the plan of care?

• Encourage the patient to push up using arms and feet during movement.
• Encourage the patient to splint the chest with a pillow when moving.
• Encourage the patient to pull on bed rails when repositioning in bed.
• Encourage the patient to avoid all upper body movement for several days.

Question 19

Nurse is assessing a 5-year-old boy and suspects that the child may have an autism spectrum disorder. Which assessments would help support the nurse’s suspicions? Select ALL that apply.

• Repetitive motor movements
• Inability to make eye contact
• Stress-induced state of hyper-arousal
• Hypersensitivity to touch
• Distinct interest in others around him
• Lack of facial expression
• Easily distracted from playing

Question 20

A nurse admits a 5-year-old child with bacterial meningitis. Which information obtained during the admission history is most helpful for the nurse to document?

• The child fell off a swing and hit their head 2 months ago.
• The child’s younger sibling has gastroenteritis.
• The child’s mother has a history of herpes simplex.
• The child had a sinus infection two weeks ago.

Question 21

The nurse is performing a neurological assessment on a 2-month-old infant following a motor vehicle crash. Moro, tonic neck, and withdrawal reflexes are present. The nurse should recognize that these reflexes are suggestive of what?

• Severe brain damage
• Decorticate posturing
• Neurologic health
• Decerebrate posturing

Question 22

The patient has the following orders: Carolinas college. Children and Adolescent Test 2

rifampin (Rifadin) 500 mg IV every 8 hours

Pharmacy supplied the medication in a concentration of 25 mg/mL

Heplocked double lumen PICC line

In a medication resource the nurse has identified the following information:

rifampin (Rifadin) must be administered over 4 hours

There are no compatibility issues identified

The nurse has decided to administer this medication on the syringe pump

What is the medication rate (mL/hr) to safely administer this medication? (Round to the nearest whole number. Use a numerical answer only.)

• 5

Question 23

The nurse is preparing a 10-year-old girl for an IV restart in the treatment room. She tells the nurse that she wants her mother with her during the procedure. What is the most appropriate action for the nurse?

• Identify an appropriate substitute for her mother.
• Offer to provide support to her during the procedure.
• Grant her request.
• Explain why this is not possible.

Question 24

Match each of the following characteristics or symptoms with the correct meningitis.

• Irritability: Viral & Bacterial
• Nuchal Rigidity: Viral & Bacterial
• Lethargy: Viral & Bacterial
• Dental Cavities: Bacterial
• HSV: Viral
• Fever: Viral & Bacterial
• Petechial Rash: Bacterial
• Treat the symptoms: Viral
• Isolation: Viral & Bacterial
• Antibiotic therapy: Bacterial

Question 25

The nurse is caring for an 8-year-old girl whose parents indicate she has developed spastic movements of her extremities and trunk, facial grimace, and speech disturbances. They state it seems worse when she is anxious and does not occur while sleeping.

Which assessment question is most important to prioritize to determine the underlying cause of these symptoms?

• “Has your child had a prolonged fever with red eyes, rash, or peeling skin?”
• “Has your child experienced recent head trauma?”
• “Has your child been exposed to anyone with meningitis?”
• “Has your child had a recent sore throat or untreated infection?”

Question 26

When caring for a child with special needs, the nurse will assess the coping mechanisms utilized by the family. Which behavior would the nurse support to assist the family toward adjustment?

• Entertains unrealistic future plans for the child.
• Is unwilling to accept progression of the disease.
• Expresses feelings of anger and reasons for emotional reactions.
• Makes no change in lifestyle to meet the needs of the family.

Question 27

The nurse is assessing the growth and development of a 8-year-old patient. What would be a normal assessment finding for this patient utilizing Piaget’s theory of growth and development?

• Patient cries when told the tech will “shoot” an x-ray of her foot.
• Patient insists on a bandage so the blood won’t leak out.
• Patient states that she wants to be a princess when she grows up.
• Patient refuses to follow directions related to wound care.

Question 28

The physician has ordered acyclovir sodium 800 mg IV q6 to be given. The nurse identifies that the patient weighs 43 kg and the safe dose for amikacin sodium is 20 mg/kg/dose every 6 hours, not to exceed 3 g/day. What is the calculated safe dose per day in mg for amikacin sodium? (Round to the nearest whole number. Use a numerical answer only.)

• 3440

Question 29

A newborn patient has recently been diagnosed with the defect shown in the diagram below. Which nursing assessment finding(s) would most likely be present with this defect? Select ALL that apply.

• High BP in upper extremities
• Cool to touch bilateral lower extremities
• Bilateral clubbing of toes
• Irritability
• Bounding pulses in lower extremities
• Circumoral cyanosis

Question 30

A parent of a 16-month-old child tells the nurse that the child says “No” frequently, has rapid mood swings, becomes upset when corrected, and then immediately seeks comfort by wanting to be held. Which interpretation by the nurse is most appropriate?

• The behaviors are consistent with normal autonomy development and emerging emotional regulation.
• The behaviors reflect early oppositional defiance and should be addressed with firm consequences.
• The behaviors indicate inconsistent discipline and a need for stricter behavioral expectations.
• The behaviors suggest delayed emotional development and inability to form secure attachments.

Question 31

The nurse teaches the parent of a 3-year old patient about muscular dystrophy. Which statement would most likely indicate that the parent has understood the teaching?

• “I understand that muscle relaxants can be effective in some children.”
• “My son will most likely be unable to walk by the time he is 12 years old.”
• “We will avoid exercise of my son’s arms to preserve function.”
• “We will buy a wheelchair as soon as possible to prevent muscle deterioration.”

Question 32

The physician has ordered piperacillin sodium/tazobactam sodium (Zosyn) 250 mg IV every 8 hours. The resource states that the safe dose is piperacillin 100 mg/kg and tazobactam 12.5 mg/kg IV every 8 hours. The nurse identifies that the patient weighs 27 kg and dosing is based on the piperacillin sodium. What is the calculated safe dose for piperacillin sodium/tazobactam sodium (Zosyn)?

• 2700

Question 33

The nurse is discussing adolescent growth and development with a parent. Which statement should the nurse make regarding sexuality?

• Sex can be presented as a normal part of growth and development.
• Adolescent sexuality should be strictly monitored and restricted.
• Sexuality is not a concern until late adolescence.
• Parent-adolescent conversations about sexuality are usually ineffective.

Question 38

The nurse is assessing a patient with Kawasaki disease. Which finding would require further investigation?

• Temperature of 101.6° F
• Erythema of lips
• Irritability
• Vomiting

Question 39

The medication order: ampicillin sodium 360 mg IV every day. In a medication resource the nurse has identified the following information: Pharmacy supplied the medication in a 500 mg powdered vial; ampicillin sodium must be reconstituted with 10 mL of NS; ampicillin sodium must be administered over 15 minutes. The nurse has decided to administer this medication on a syringe pump and the peripheral IV is saline locked. What is the medication VTBI, medication rate, flush volume and flush rate to safely administer this medication? Carolinas college. Children and Adolescent Test 2

• 7.2/28.8/10/30

Question 40

A 12-year-old patient diagnosed with Duchenne muscular dystrophy is hospitalized secondary to a fall. Surgery is necessary as well as skeletal traction. Which of the following complications would be of greatest concern to the nurse?

• Respiratory infection
• Decreased mobility
• Nonunion healing of the fracture
• Infection of pin sites

Question 41

A nurse is caring for a patient 4 hours after a femoral cardiac catheterization. The patient reports a sudden feeling of wetness at the insertion site. Which nursing action is the priority?

• Palpate the distal pulses in the affected extremity and compare bilaterally.
• Assess vital signs and notify the provider of the patient’s condition.
• Apply firm manual pressure slightly above the insertion site immediately.
• Remove the existing dressing and inspect the insertion site directly.

Question 42

When performing the AM assessment of an infant diagnosed with meningitis, which finding would indicate increased intracranial pressure to the nurse?

• purpuric rash on the trunk/legs
• fontanel is non-pulsating
• nausea and vomiting
• elevated heart rate

Question 43

The nurse is assessing a 4-month-old with Hypoplastic Left Heart Syndrome. Which assessment finding would be an early indication of heart failure?

• Respiratory rate of 70 at rest
• Capillary refill > 3 secs
• Urine output of 2mL/kg/hr
• Oxygen saturations 75-85%

Question 44

The nurse knows that which of the following exercises would be best for a child with juvenile idiopathic arthritis?

• Jogging
• Tennis
• Swimming
• Gymnastics

Question 45

A child with a history of infective endocarditis is scheduled for a dental procedure. The parents state, “We don’t think antibiotics are necessary since the infection is gone.” What is the nurse’s best response?

• Agree that antibiotics are unnecessary since the infection has resolved.
• State that antibiotics are only needed if the child develops symptoms.
• Explain that prophylactic antibiotics reduce infection risk after invasive procedures.
• Recommend skipping antibiotics if the child maintains good oral hygiene.

Question 46

Which assessment findings should the nurse expect to see in the infant diagnosed with aortic valve stenosis and heart failure? Select ALL that apply.

• right ventricular hypertrophy
• bradycardia
• sweating
• crackles (rales)
• fatigue
• tachycardia
• left ventricular hypertrophy
• bounding pulses

Question 47

Many of the physical characteristics of Down syndrome present nursing problems. Care of the child should include which intervention?

• Modify diet as needed to minimize diarrhea often seen in these children.
• Use a bulb syringe to keep mucous membranes clear and enhance ability to eat orally.
• Provide calories and meals appropriate for the child’s age.
• Delay feeding solid foods until the tongue protrusion has stopped.

Question 48

The nurse is preparing to administer enalapril (Vasotec) to a 2-year-old child with hypoplastic left heart syndrome. What action should the nurse take?

• Assess the patient’s blood pressure prior to administration.
• Educate parents on the signs/symptoms of hypokalemia.
• Check the patient’s apical pulse prior to administration.
• Advise parents that the medication may cause headache.

Question 49

A child weighs 21.8 kg and is receiving IV therapy for dehydration at 1.5 their maintenance rate. At what IV rate (mL/hr) would the nurse program the pump? (Round to the nearest whole number. Use a numerical answer only.)

• 96

Question 50

The nurse is caring for a 13-year-old child diagnosed with rheumatic fever. When addressing the child’s pain, the nurse should perform which intervention?

• Administer acetaminophen to help control the inflammation.
• Carefully handle the child’s knees, ankles, elbows and wrists.
• Encourage strict bed rest to limit joint movement.
• Teach the child how to use a patient-controlled analgesia. Carolinas college. Children and Adolescent Test 2

Question 51

A 10-year-old boy has been admitted to the hospital for pneumonia. In assuring adequate caloric intake, what should the nurse include in the plan of care?

• Offer dessert each time he cleans his plate.
• Explain, in detailed terms, the relationship between nutrition and healing.
• Arrange for a daily consultation with the dietitian to teach the importance of consuming adequate calories each day.
• Have the parent role-model dietary healthy intake.

Question 52

Which intervention is most important when providing nursing care to a pediatric patient with congestive heart failure?

• Organize activities to allow for uninterrupted sleep.
• Eliminate moderate physical activity to decrease oxygen demands.
• Give larger feedings less often to conserve energy.
• Place in a supine position to increase venous blood return.

Question 53

What is the nurse’s priority action when preparing for removal of a chest tube from a pediatric patient?

• Explain that the procedure may be slightly uncomfortable and call Child Life.
• Administer prescribed analgesic medication before removing the chest tube.
• Encourage slow, deep breathing and controlled coughing during tube removal.
• Monitor for expected bright red drainage for several hours after tube removal.

Question 54

A nurse is developing a feeding plan for an infant with a congenital heart defect who becomes fatigued during feedings and is not gaining weight appropriately. Which dietary recommendation should the nurse prioritize?

• Recommend delaying feedings when the infant shows signs of fatigue.
• Recommend using a concentrated high-calorie formula to support growth.
• Recommend selecting a formula with reduced sodium content for feeding.
• Recommend limiting total daily fluid intake to reduce cardiac workload.

Question 55

A school-age child has sustained a head injury and multiple fractures after being thrown off a horse. The child’s level of consciousness is variable. The parents tell the nurse that they think their child is in pain because of periodic crying and restlessness and are requesting pain medication for him. What is the most appropriate initial nursing action?

• Explain that analgesia is contraindicated with a head injury.
• Consult Child Life to assist with pain control using distraction methods.
• Discuss with practitioner what analgesia can be safely administered.
• Explain that analgesia is unnecessary when the the child is not fully awake and alert.

Question 56

Seventy-two hours after cardiac surgery, a young child has a temperature of 101.5° F. What would the nurse’s first action?

• Apply a hypothermia blanket.
• Report findings to the physician.
• Administer antipyretics.
• Re-check the temperature in 1 hour.

Question 57

The physician orders lanoxin (Digoxin) 35 mcg PO BID for an infant who weighs 7 kg. This medication is available from the pharmacy 0.25 mg/5mL. How many mL should the nurse administer per dose? (If < 1 round to hundredth, if > 1 round to tenth. Use numerical answer only.)

• 0.70

Question 58

A nurse assesses a child after heart surgery to correct tetralogy of Fallot. Which finding would the nurse report to the provider as an indication that the patient has low cardiac output?

• Bounding peripheral pulses with cool, mottled skin appearance.
• Altered level of consciousness with weak, thready peripheral pulses.
• Capillary refill of 2 seconds and blood pressure of 96/67 mmHg.
• Pale skin coloration with extremities remaining warm to touch.

Question 59

The physician has ordered dexamethasone (Decadron) 7 mg IV every 6 hours. Pharmacy has provided a 24 mg/2 mL vial. The nurse reads that this medication must be administered with a concentration of 4 mg/mL. What would be the total volume of medication that the nurse would administer? (If < 1 round to hundredth, if > 1 round to tenth. Use numerical answer only.)

• 1.8

Question 60

A 3-year-old child is hospitalized after a submersion injury. The child’s mother complains to the nurse, “This seems unnecessary when he is perfectly fine.” Which statement would be the nurse’s best reply?

• “I’m sure he is fine, but the doctor wants to make sure.”
• “He will need to be on oxygen for at least 24 hours.”
• “It is important to observe for possible water intoxication.”
• “He could develop complications at any time during the next 24 hours.”

Question 61

Methylprednisolone sodium succinate (Solu-Medrol) is supplied in a 75 mg/2 mL vial from the pharmacy. The nurse needs to deliver 135 mg at a concentration of 7 mg/mL. How many mL of diluent is needed to properly dilute this medication? (If < 1 round to hundredth, if > 1 round to tenth. Use numerical answer only.)

• 15.7

Question 62

When assessing a toddler’s growth and development, the nurse understands that a child in this age group displays behavior that fosters which developmental task?

• Industry
• Trust
• Initiative Carolinas college. Children and Adolescent Test 2
• Autonomy

Question 63

An 3-month-old infant undergoes surgery to place a ventriculoperitoneal (VP) shunt. To detect increased intracranial pressure (ICP) as early as possible, the nurse should stay alert for which postoperative finding?

• Bulging fontanel
• Sunken eyeballs
• Increased heart rate
• Decreased urine output

Question 64

The nurse caring for a 5-year-old child with cerebral palsy (CP) prepares a home care teaching plan for the caregivers on discharge. Which item will the nurse include in the teaching plan?

• Ensure the child’s clothing has only zippers.
• Encourage the child to perform self-care task, as appropriate.
• Remove splints and braces when child complains of discomfort.
• Encourage bed rest when child is not involved in specific activities.

Question 65

The medication order: gentamicin sulfate 585 mg IV once. Pharmacy supplied the medication in a concentration of 50 mg/mL. In a medication resource the nurse has identified the following information: gentamicin sulfate must be further diluted to a concentration of 15 mg/mL. gentamicin sulfate must be administered over 30 minutes. The nurse has decided to administer this medication on a syringe pump and the peripheral IV is saline locked. What is the flush rate (mL/hr) to safely administer this medication? (If < 1 round to hundredth, if > 1 round to tenth. Use a numerical answer only.)

• 78.0

Question 66

A toddler weighing 10.2 kg is 3 days postoperative following repair of Hypoplastic Left Heart Syndrome (HLHS). The nurse reviews the following assessment findings: oxygen saturation 85%, heart rate 120 beats/min, capillary refill time 5 seconds, urine output of 15 mL over the past 3 hours, and mild peripheral edema. Which nursing intervention should be prioritized?

• Notify the provider of the child’s assessment findings.
• Document current findings and continue routine monitoring.
• Elevate the head of the bed to improve respiratory status.
• Apply supplemental oxygen to improve oxygen saturation.