HESI
Exam Pediatric II (A
Grade), Latest Questions and
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A
1. The nurse
is teaching a 12-year-old male adolescent and his family about taking
injections of growth hormone
for idiopathic hypopituitarism. Which adverse
symptoms, commonly associated with growth hormone
therapy, should the nurse plan to describe to the child and his family?
Polyuria and polydipsia.
2. The nurse is teaching a mother to give 4 ml of a liquid antibiotic to a 10-month-old infant.
Which statement by the parent
indicates a need for further teaching?
Using a teaspoon will help
me measure this correctly.
3. When evaluating the effectiveness of interventions to improve the nutritional status of an infant
with gastro-esophageal reflux,
which intervention is most
important for the nurse to implement?
Record weight daily.
4. A 15-year-old girl tells the school nurse that all of her friends have started their periods and she feels
abnormal because she has not. Which response is best for the nurse provide?
Explain that menarche varies
and occurs between
the ages of 12
and 18 years.
5. The nurse
is developing a plan of care for a 3-year-old who is scheduled for a cardiac catheterization. To assist in
decreasing anxiety for the
child on the day of the procedure, which intervention is best for the nurse to
implement?
Give the child a ride on a gurney to visit
the cardiac catheterization
lab and meet a nurse who
works there.
6. All of the
following interventions can be used
to evaluate the effectiveness of nursing
and medical interventions
used to treat diarrhea. Which intervention is least useful in the nurse's evaluation of a 20-month-old
child?
Assessing fontanels.
7. The mother
of a 6-month-old asks the nurse when her baby will get the first measles,
mumps, and rubella (MMR) vaccine.
Based on the recommended childhood immunization schedule published by the Centers for Disease Control, which response is accurate?
12 to 15 months.
8. A
6-month-old boy and his mother are at the healthcare provider's office for a
well-baby check- up and routine
immunizations. The healthcare provider recommends to the mother that the child receive
an influenza vaccine.
What medications should the nurse plan to administer today?
All the immunizations with the influenza
vaccine given at a separate site from any other injection
9. A 5-month-old is admitted
to the hospital with vomiting
and diarrhea. The pediatrician
prescribes dextrose
5% and 0.25% normal saline with 2 mEq KCl/100
ml to be infused at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding?
Serum BUN and creatinine levels.
10. A premature
newborn girl, born 24 hours ago, is diagnosed with a patent ductus arteriosus (PDA) and placed under an oxygen hood at
35%. The parents visit the nursery and ask to hold
her. Which response should the nurse provide to the
parents?
The oxygen hood is
holding the baby's oxygen level just
at the point which is needed. You may
stroke and talk to her.
11. The nurse
is teaching the parents of a 5-year-old with cystic fibrosis about respiratory treatments. Which statement indicates
to the nurse that the parents understand?
Administer aerosol therapy followed by postural drainage
before meals.
12. Preoperative nursing
care for a child with Wilms' tumor should
include which intervention?
Put a sign on the bed reading, "DO
NOT PALPATE ABDOMEN."
13. Which behavior should the nurse expect a two-year-old child to exhibit?
Display possessiveness of toys.
14. The mother of a
preschool-aged child asks the nurse if it is all right to administer Pepto
Bismol to her son when he "has a tummy
ache." (aspirin)
Do
not give if the child has chickenpox,
the flu, or any other viral illness.
15. A nurse who
is working in the Poison Control Center receives several telephone calls from parents whose children have ingested
possible poisons. The nurse should recommend inducing vomiting for which child?
16-month old who drank 2 ounces
of acetaminophen (Tylenol) elixir.
16.
The mother of a 2-year-old
boy consults the nurse about
her son's increased temper tantrums.
What should she do?
Walk away from him and ignore the behavior.
17. When evaluating the effectiveness of interventions to improve the nutritional
status of an infant with gastro-esophageal reflux, which
intervention is most important for the nurse
to implement?
Record weight daily.
18. When taking
the health history of a child, the nurse know what which finding is an early indication of hypothyroidism in
children?
Cessation of growth in a child that had
been normal
Since the thyroid gland is responsible for metabolism, cessation of growth which as previously
with in normal range,
is the most common for hypothyroidism in children. The child with
hypothyroidism is likely to be
HYPOactive not (HYPERactive), although there is delay in the
eruption of permanent teeth
& slow sexual development happen
with hypothyroidism, they are
LATE signs.. (NOT EARLY indications) and are
signs more often assoc with lack of
growth
hormone
19. The nurse received a lab report stating a child with asthma
has theophylline level
of 15 mcg/dl.
What action will the nurse
take?
Hold the next dose of theophylline
Therapeutic levels of theophylline is 10-10 mcg/dl,
so the child's level is with in the therapeutic
rage.
20. Surgery is being delayed
for an infant with undescended testes.
In collaboration with the health care
provider and the family,
which prescription should the
nurse anticipapte?
A
trial of HCG may aid in
testicular descent, but does not replace surgical repair for true
undescended testes. (cryptorchidism: may
be found in the inguinal
canal due to exaggerated
cremasteric reflex
21. Which menu selection by a child with celiac
disease indicates to the nurse that the
child understands necessary dietary
considerations?
Oven baked potato chips &
cola
Celiac disease causes an intolerance to the protein
gluten found in oats,
rye, wheat, and barley.
The
child should avoid any produces
containing these ingredients to avoid symptoms such as diarrhea.
22.
The mother of a 2-year-old
boy consults the nurse about
her son's increased temper tantrums.
The mother states, "yesterday he threw
a fit in the grocery store,
and I did not know what to do. I was so
embarrassed. What can I do if this occurs again?" Which recommendation is
best for the nurse to provide this mother?
Walk away from him and ignore the behavior
The best approach for a toddler is to ignor the attention- seeking
behavior. The parents should be
somewhat nearby, within view of the
child but should avoid
reinforcing the behavior in any way.
Tantrums can sometimes be avoided
by talking to the
child before the situation occurs
23. The mother of a 4-year-old child asks the nurse what she can do
to help her other children
cope with their sibling's hospitalizations. Which is
the best response that the
nurse should offer?
Encourage the mother to have the children visit the hospitalized sibling.
Needs of a sibling will be better
met with factual information and contact with the ill
child, so
siblings visitation should be encouraged (D). Parents are experts on their
children and should
determine when their children are old enough to visit. (A) In the hospital/ Separation fr. a family &
home (B) may intensify fear & anxiety
(suggest that the child visit
a grandmother until the sibling
returns home. Children may have difficulty expressing questions
(C) Ask the mother
if the child asks when the
sibling will be discharged,
so the support of parents
& other caregivers are needed to help
alleviate their fears.
24. The nurse
is giving preoperative instruction to a 14-year-old female client who is
scheduled for surgery to correct a
spinal curvature. Which statement by the client best demonstrates that learning has taken
place?
I
understand that I will be in a body cast and I will show you how you taught me to turn
Outcome of learning is best demonstrated when the client not only verbalizes an
understand, but
can also provide a return demonstration
25. The clinic nurse is taking the hx for a new 6-month-old client. The mother reports that she took a great deal of aspirin while pregnant.
Which assessment should the nurse obtain?
Type of reaction to loud noises
Ototoxicity diminishes hear acuity and causes symptoms of tinnitus and vertigo
in older children
who can express subjective symptoms, so assessing the infant's reation
to loud noises (A) helps to
determine an infant's risk for hearing
deficit r/t to a hx of the mother taking ototoxic drug, such as
aspirin, while pregnancy (B, C, D
are not assoc with the
exposure to aspirin in utero
26. The mother
of a preschool aged child asks the nurse if it is all right to administer Pepto
Bismol to her son when he has a
"tummy ache" After reminding the mother to check the label of all OTC drugs for the presence of aspirin, which
instruction should the nurse include when replying to this mother's
question?
Do
not give if the child has chickenpox,
the flu, or any other viral illness
Pepto Bismol contains aspirin
and there is the potential
of Reye's syndrome
(B). (a) is a common
effect of pepto bismol
and does not warrant
discontinuation. Pepto Bismol
can be used by children
(C). Pepto Bismol does not cause rebound
hyperacidity (D) complication of antacids containing
calcium
27. A 3 moth old infant
develops oral thrush. Which pharmacologic agent should
the nurse plan to administer for treatment of this disorder?
Nystatin (Mycostatin)
Nystatin (mycostatin) (A) is an antifungal drug that is effective in treating thrush,
an oral fungal
infection
28. The nurse
is developing a plan of care for a 3 yr old who is scheduled for a cardiac catheterization. To assist in decreasing
anxiety for the child on the day of
the procedure, which
intervention is best for the nurse to implement?
Give the child a ride on a gurney
to visit the cardiac catheterization lab
and meet a nurse who
works there
Familizaring the child and mother with the department will
help decrease anxiety of the
child and
mother (who may have more anxiety than the
child). Three is a difficult age to undergo a procedure
that requires cooperation. Restraints and possible
sedation may be required
29. A 3 yr old boy is
brought to the ER because
he swallowed an entire bottle of children's vitamin pills. Which intervention should the nurse implement first?
Determine the child's pulse and respirations
The most important principle in dealing with a poisoning is
to treat the child first, not the poison.
Initiate immediate life support
measures with assessment of VS (B), in
particular, respirations.
Inserting an airway or initiating mechanical ventilation may be necessary. Assessment and
identification of the poison should occur prior to A. (C
& D after assessing the airway.)
30. A 4- year- old girl
continues to interrupt her mother during a routine clinic visit. The mother appears
irritated with the child and asks the nurse, "Is this normal behavior
for a child this age?"
The nurse's response
should be based on which
information?
Children need to retain
a sense of initiative without impinging on the rights and privileges others
Children aged 3-6 are in Erickson's initiative vs. guilt stage,
which is characterized by vigorous,
intrusive behavior, enterprise, and strong imagination. At this age, children develop
a conscience
and must learn to retain a sense of initiative without
impinging on the rights
of others
31. The nurse
is planning the care of a 2 year old with severe eczema on the face, next, and
scalp fr. scratching the affected areas. Which nursing intervention is most effective in preventing further
excoriation due to the
purities?
Place elbow restraints on the child's
arms.
Elbow restraints prevent arm
flexion and scratching of involved area, but do not inhibit use of the
nads for play activities. Others can be removed easily
32. A 6- year old admitted to the pediatric unit after falling of a bicycle.
Which intervention should the nurse implement to assist the child's adjustments to hospitalization?
Altered daily schedules and loss of
rituals are upsetting to children and increase separation anxiety,
and active sensitivity to the needs of children can minimize the negative
effects of hospitalization.
Explaining the hospital schedules (A) and establishing an individual schedule
familiarizes the child
to
the hospital environment and decreases anxiety.
33. The nurse
is caring for a 12 year-old with Syndrome of Inappropriate Antidiuretic Hormone
(SIADH). This child should be
carefully assessed for which
complication?
Changes in LOC
The child must be monitored for S/S of hypontremia, which creates secondary central
nervous
system alterations such as changes in LOC, seizure
coma.
34. A child
falls on the playground and is brought
to the school nurse with
a small laceration on the forearm. Which action should the nurse
implement first?
Wash the wound gently
with mild soap and water
A
small, superficial laceration to the skin should be washed gently with mild soap and water for
several minutes, followed by thorough
rinsing.
35. A 6-month-old infant with congestive heart
failure (CHF) is receiving digoxin elixir. Which
observation by the nurse warrants immediate intervention?
Apical heart rate of 60
A
heart rate of 60 is
much lower than normal for a
6-month old and warrants immediate
intervention. The normal heart rate for a 6 month
old is 80-150 when awake, and a rate of 70 while
sleeping is considered within
normal limits.
36. To assess
the effectiveness of an analgesic administered to a 4-yr old, what intervention
is best for the nurse to
implement?
Use a happy-face/sad face pain scale.
A
4 year old can readily identify
with simple picures to show the
nurse how he/she
is feeling.
Could be used to validate what the
child is telling the nurse via
the "faces" pain scale, but it is best
to
elicit the child's
assessment of his/her
pain level (C-assess
for changes in the child's
vs), may not
accurately reflect the effectiveness of pain medication as they can
also be affected by other
variables, such as fear
37. The nurse is assessing an 8 month
old child who has a medical diagnosis of tetrology of Fallot.
Which symptom is the client most likely to exhibit?
Clubbed fingers
Tetrology of fallot, a cyanotic heart defect, causes clubbing of fingers and toes
due to tissue
hypoxia
38. Which action by the nurse is most
helpful in communicating with
a preschool aged child?
Use a doll to play and communicate
Communicating through
play with a doll or other toy gives time for the child to feel comfortable
with a stranger
39. The nurse
observes a 4 yr old boy in a daycare
setting. Which behavior
would the nurse consider normal for this child?
Demonstrates aggressiveness by boasting
when telling a story
4yr old children are aggressive in their behavior and enjoy "tale telling"
40. A 2 yrs.
old child with Down syndrome is brought to the clinic for his regular physical examination. The nurse knows
which problem is frequently associated with Down syndrome?
Congenital heart disease
Is
the most common
assoc with defect
in children with Down syndrome.
41. In developing a teaching plan for a 5 year old
child with diabetes, which component of diabetic management should the nurse plan for the child to manage first?
Process of glucose testing
Developmentally a 5 yr. old
has the cognitive
and psychomotor skills
to use a glucometer and to
read the number (it is especially
helpful if the nurse presents this activity as a game
42. The nurse
is assessing a 13 yr. old girl with suspected hyperthyroidism. Which question
is most important for the
nurse to ask her during the admission
interview?
Are you experiencing any type of nervousness?
Assessing the client's physiological state upon admission is priority, and nervousness,
apprehension, hyper excitability, and palpitations are signs of hyperthyroidism, but assessing loss
(even with a hearty
appetite) (A) occurs
in those with hyperthyroidism, but assessing the
client's
neurological state has a higher priority.
Hormone replacement is not administered to a client who is
already producing too much thyroid
43. The mother of a 6 month old asks the nurse when her
baby will get the first
MMR vaccine.
Based on the
recommended childhood immunization schedule published by the CDC, which response
is accurate?
The MMR vaccine should be given
no sooner than 12 months of age, and ideally
between 12 & 15
months of age. (a) 3-6
months should not receive the MMR vaccine
due to the presence of
maternal antibodies. MMR is
not routinely administered @ 18-24,
but others like dTaP and
Hep B
may be given at that time.
44. A 6 month old returns fr. surgery with
elbow restraints in place. What nursing
care should be included when caring for any restrained
child?
Remove restraints one at a time and provide range of
motion exercises
Removing restraints one at a time
(B) is safer than removing
all of them at once. The child
needs to
exercise and should not be kept in restraints at all times
45. A 17 yr old male student
reports to the school clinic
one morning ofr a scheduled
health exam.
He tells the nurse that he just finished football practice and is on his way to class. The nurse
assess his VS: temp 100, pulse, 80, RR 20, and BP is 122/82.
What is the best action for the nurse to take?
Tell the student to
proceed directly to his regularly scheduled class.
The student has just completed football
practice, and increased muscle activity increases body heat production. A temp of 100F is NORMAL for
this student @ this time. The student should attend class
46. A full term
infant is admitted to the newborn nursery. After careful assessment, the nurse suspects
that the infant may have esophageal atresia. Which symptoms are this newborn
likely to exhibit?
Choking, coughing, and
cyanosis
Includes the "3 Cs" of esophageal atresia caused by the overflow of secretions into the
trachea.
47. A 5 month
old is admitted to the hospital with vomiting and diarrhea. The pediatrician prescribes dextrose 5% and 0.25% normal saline with 2 mEq KCL/100
ml to be infused at 25
ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding?
Serum BUN & Creatinine levels
Regardless of a client's age, adequate renal function must be present
before adding potassium
ot IV
fluids, is important in determining the need for fluid
replacement
48. A
hospitalized 16 yr old male refuses all visits fr. his classmates because he is
concerned about his distorted
appearance. To increase the clients’ social interaction, what intervention is best for the nurse
to initiate?
Arrange for an internet
connection in the client's
room for email communication
Body image and peer
acceptance are key concerns
for the adolescent © allows for social
interaction without face to face contact,
thus protecting his self-image while also
promoting social
interaction
49. The parents of a 3 week
old infant report that the child eats well but vomits after each
feeding.
What information is most important for the nurse to
obtain?
Description of vomiting episodes
in past 24 hrs.
A
description of the vomiting episodes will assist the nurse in determining the reason for the
symptoms, which may be helpful in developing a plan
of care for this infant.
50. A premature newborn girl,
born 24 hours
ago, is diagnosed with a patent ductus
arteriosus PDA and placed under an
oxygen good at 35%.
The parents visit the nursery and ask to hold her. Which
response should the nurse provide
to the parents?
Oxygen hood is holding the baby's
oxygen level just at the point which is needed. You may stroke
and talk to her.
The baby is at 35% which is must more than room air (21%) and at this time the baby should not
be
moved fr. under the hood. The nurse should offer the parents an alternative
such as to stroke and
reassure the infant.
51. To take the VS of a 4 month old
child, which order provides the most accurate results?
Respiratory rate, heart rate, and then
rectal temperature
The respiratory rate should be take first in
infants, since touching them or
performing unpleasant
procedures usually makes the
cry, elevating the heart
rate and making respirations
difficult to
count. Rectal temp is the most
invasive procedure, and is most likely to precipitate crying, so
should be done last
52. A preschool-aged child who is hospitalized fy hypospadias repair is most strongly influenced by which behavior?
The preschoolers’ major
stressor is concern for his body integrity. He fears that his "insides will
leak out" A child undergoing surgery
to his genitalia is even more concerned about body integrity.
The preschooler is quite verbal,
so comprehension of the words he
uses or hears may be inaccurate,
while his imagination and
fears may fantasize the reality
53. All of the following interventions can be used to evaluate the effectiveness of
nursing and medical interventions used to treat diarrhea. Which intervention is least
useful in the nurse's
evaluation of a 20 month old child?
Assessing fontanels
All of these interventions evaluate fluid status
in infants (weight
diapers, checking skin turgor,
observing mucous membranes for
moisture and checking for fluid status)
54. The nurse
assigning care for 5 yr old
child with otitis media is concerned about
the child's increasing temperature over the past 24
hours. Which statement is accurate and should be considered when
planning care for the remainder of the shift?
Tympanic and oral temps are equally accurate
A
tympanic membrane sensor
approximates core temps
because the hypothalamus and eardrum are
perfused by the same circulation. Tympanic readings obtained using proper technique correlated
moderately too strongly with oral temperatures in recent research studies.
55. At 8am the
unlicensed assistive personnel (UAP) informed the charge nurse that a female adolescent client with acute
glomerulonephritis has a BP of 210/110. The 4am BP reading was 170/88.
The client reports to the UAP that she is upset because her boyfriend did not
visit last night. What action should the nurse take first?
Administer PRN prescription of nifedipine (Procardia) sublingually
Sublingual procardia lowers
blood pressure very quickly, and this should be done first
56. A 12-month-old is admitted with a respiratory infection and possible
pneumonia. He is placed in a
tent with oxygen. Which nursing intervention has the greatest priority for this infant?
A
patent airway has the highest priority. Humidification
will liquefy the nasal secretions thereby
increasing the amount of
secretions and making having
a bulb syringe the highest priority
57. A three month old boy weighing
10 lbs 15 oz an axillary temp of
98.8. The nurse determines
the daily caloric need for this
child is approximately
C-
10 lbs 15 oz = 10.9. Convert lbs by dividing
2.2; 10.9/2.2=4.59kg, rounded
to 5kg. An infant
requires 108 calories/kg/day (108 x 5=540 calories/day.)
However this infant requires 10% more
calories because he has one
degree temperature elevation. 10% of 540 and
540 + 54= 594. This
infant will require approx 600 calories/day.
58. The nurse is teaching the parents
of a
5 yr old w. cystic fibrosis about respiratory treatment.
Which statement indicates to the
nruse that the parents understand?
Administer aerosol therapy followed
by a
postural drainage before
meals.
Postural drainage for a child with cystic fibrosis
is most effective when performed after
nebulization and before meals or
at least 1 hour after eating to prevent
nausea & vomiting. Postural
drainage uses gravity to promote mucous removal after nebulization (which open airways).
Pulmonary toileting or
respiratory treatment should be given 3-4 times daily, not episodically
59. A 4 year
old boy was admitted to the emergency room with fractured right ulna and a short
arm cast is applied. When preparing
the parents to take the child home, which discharge instruction has the highest
priority?
Call the healthcare provider
immediately if his nail beds appear blue.
Cyanosis indicates impaired circulation to fingers and should be reported immediately. Although
the actions described may be indicated, they are implemented rather excessively & might tend to
frighten the parents. It is not necessary to check the child's ability to move his fingers hourly for 2
days.
60. A 3 week
old newborn is brought to the clinic for a follow up after a home birth. The
mother reports that her child bottle
feeds for 5 min only and falls asleep. The nurse auscultates a loud murmur characteristic of a ventricular septal
defect (VSD), and finds the newborn is acyanotic
with respiratory rate of 64 breaths
per min. What instruction should the nurse provide the mother to ensure
the infant is receiving adequate intake?
(Select all that apply)
Monitor the infant's weight
and # of wet diapers per day
Increase the infant's intake per feeding by 1-2 ounces per week
Allow the infant to rest
and reefed on demand or every
2 hrs
Use a softer nipple or increase the size of the nipple
opening
Rationale: Correct responses are
A, B, D, E. neonates who have
VSD may fatigue quickly
during
feeding and ingest inadequate amounts. They should be monitored for weight gain and at least 6
wet diapers per day. A one month
old should ingest 2-4 ounces of formula per feeding and progress
to
about 30 ounces per day by 4 months
of age. Due to fatigue, the infant should rest, but feed at
least every 2 hours to
ensure adequate intake. A softer
(preemie) nipple or a larger slit in
the nipple
helps to reduce the sucking
effort and energy expenditure, thus allowing the infant
to ingest more
with less effort. Antibiotic prophylaxis is recommended for infants with VSD's, but should not be
mixed in a bottle of
formula because it is difficult to ensure that the total dose is consumed
61. The nurse is teaching a mother to give 4 mL of a liquid antibiotic to a 10 month old infant.
Which statement by the parent
indicates a need for further teaching?
Using a teaspoon will help
me measure this correctly
The prescribed medication is
4 mL dosage and is measured
with the most accuracy using a syringe,
so
if the parent uses teaspoon which is
equivalent to 5 mL, further teaching is indicated
62. A 3 yr old
client with sickle cell anemia is admitted to the ER with abdominal pain. The
nurse palpates an enlarged liver,
and x ray reveals
an enlarged spleen,
and a CBC reveals anemia.
These findings indicate
which type of crisis?
Sequestration this support
a sequestration crisis where blood pools in the spleen,
and is
characterized by abdominal pain anemia
63. A 14 yr old
female client tells the nurse that she is concerned about the acne she has
recently developed/ which recommendation should the nurse provide?
Wash the hair and skin frequently with soap and hot
water
Washing the hair & skin with soap
& hot water removes oil debris fr. the skin and
helps prevent &
treat acne. Oily skin especially bothersome during adolescence when hormones cause enlargement
of
sebaceous glands and increased glandular
secretions which predispose the teenager to acne is
contraindicated. Cosmetics "medicated" or not should be used sparingly to avoid
further blocking
sebaceous gland ducts.
Might be indicated at a later time, if healthcare recommendations are not
successful.
64. An 18 month old is
admitted to the hospital with possible Hirschsprung's disease. When
obtaining a nursing
hx the nurse asks about bowel habits.
What description of the disease?
Ribbon-like and brown
Hirschsprung's disease
is a mechanical obstruction caused by
inadequate motility in a part of the
intestines. The condition results
fr. failure of ganglion cells to migrate
craniocaudally along the GI
tract during gestation. The lack of peristalsis in the affected
bowel segment causes
constipation and
smaller diameter, brown colored
stools
65. A 15 yr old girl tells the school nurse that all of her
friends have started their periods
and she feels
abnormal because she has not. Which response is best for the nurse provide?
Explain that menarche varies
and occurs between the ages of 12-18 years
66. A 2 yr old
child with gastro-esophageal reflux has developed a fear of eating.
What instruction should
the nurse include in the
parent's teaching plan?
A
2- year old child is
comforted by consistency
67. The nurse
is assessing a 2 year old. What behavior indicates that the child's
language development is within normal limits?
Half of a child's speech
is understandable
Between approximately 15 & 24 months of age, a child's speech is only
½ understandable
68. What preoperative nursing intervention
should be included in the plan of
care for an infant with pyloric stenosis?
Observe for projectile vomiting
Projectile vomiting, which contributes to metabolic alkalosis is the classic
sign of pyloric
stenosis
69. When
evaluating the effectiveness of interventions to improve the nutritional status
of an infant with gastro-esophageal reflux, which
intervention is most important for the nurse
to implement?
Record weight daily
The most definitive measure of improved nutrition is an infant is obtaining the child's daily
weight
70. Which finding in a 19 yr old female client should trigger further assessment
by the nurse?
Menstruation has not occurred
Menstruation is an expected secondary sex characteristic that occurs with pubescence and typically
occurs by age 18, so A should
prompt further investigation to determine the cause of this
primary
amenorrhea. Children receive tetanus
as part of the DPT childhood immunization series, and a
booster is not typically given until age 16.
71. A 6 month
old boy and his mother are at healthcare provider's office for a well-baby
checkup and routine immunizations.
The healthcare provider recommends to the mother that the child receive
an influenza vaccine. What medications should
the nurse plan to administer today?
B-
All the immunizations with the influenza vaccine given at a separate site fr. any other
injection
At
6 months of age, the routine immunizations should HEP B, DTaP, Hib, PCV
(pneumococcal) ,
IPV (inactivated poliovirus) and influenza. The influenza vaccine
should be given at
a separate site
fr. any other injection.
72. The mother of a 4-year-old child asks the nurse what
she can do to help her other children
cope
with their
sibling's repeated hospitalizations. Which is the best response that the nurse
should offer?
Encourage the mother to have the
children visit the hospitalized sibling
73. When planning
the care for a child who has had a cleft lip repair,
the nurse knows that crying should
be minimized because it
Stresses the fracture.
Prevention of stress on the lip suture line is essential for optimum healing and
the cosmetic appearance of a cleft lip repair. Although
crying causes (increased salvation, leads to
vomiting, stresses the suture
line) these conditions do not create a problem for the child with a cleft
lip repair
74. The nurse assigning care for
a 5-year-old child with otitis media is
concerned about the child's
increasing temperature over the past 24 hours. Which statement is
accurate and should be considered when planning care for the remainder
of the shift?
Tympanic and oral temperatures are equally accurate.
75. A 2-year-old child with gastro-esophageal reflux has developed
a fear of eating. What
instruction should the nurse include
in the parents' teaching plan?
Consistently follow a set mealtime routine.
76. What preoperative nursing intervention should be included in the
plan of care for an infant with pyloric stenosis?
Observe for projectile vomiting.
77. The nurse
is assessing a 2-year-old. What behavior indicates that the child's language
development is within normal
limits?
Half of child's speech
is understandable.
78. The nurse receives
a lab report stating a child
with asthma has a theophylline level of
15 mcg/dl. What action will the nurse take?
Pass the information on in
the report.
79. A 4-year-old girl continues to interrupt her mother during
a routine clinic
visit. The mother
appears irritated with the child and asks the nurse, "Is this
normal behavior for a child this age?" The nurse's
response should be based on which information?
Children need to retain
a sense of initiative without impinging on the rights
and privileges of
others.
80. A
6-month-old infant with congestive heart failure (CHF) is receiving digoxin
elixir. Which observation by the
nurse warrants immediate intervention?
Apical heart rate of 60.
81. Which restraint should be used for a toddler
after a cleft
palate repair?
Elbow
Elbow restraints prevent children from bending their arms and
brining their hands to the oral
surgical site, (A) restrains the hands but the child can bend and bring their
head to their hands. (B)
Is
used during procedures (mummy). (D)-jacket, restrains
the body torso and is not appropriate
82. When taking
the health history of a child, the nurse knows that which finding is an early indication of hypothyroidism in children? Cessation
of growth in a child that had been normal.
The mother of a preschool-aged child asks the nurse if it
is all right to administer Pepto Bismol to
her son when he "has a tummy ache." After
reminding the mother to check the
label of all over-the-
counter drugs for the presence
of aspirin, which instruct do not give if the child has chickenpox,
the flu, or any other viral illness.
83. Which growth
and development characteristic should the nurse consider when monitoring the effects
of a topical medication for an
infant?
A
thin stratum corneum
that increases topical
absorption.
84. The nurse
is preparing a health teaching program for parents of toddlers and preschoolers
and plans to include information
about prevention of accidental poisonings. It is most important for the nurse to include which instruction?
Store all toxic agents
and medicines in locked cabinets.
The only reliable way to prevent
poisoning in young children is to make them
inaccessible
85.
A 16-year-old is brought to
the Emergency Center with a crushed
leg after falling off a horse.
The adolescent's last tetanus toxoid
booster was received
eight years ago. What action
should the nurse
take?
Administer the tetanus toxoid booster.
After the completion of the initial tetanus immunization schedule, the recommended booster
for an
adolescent or adult if every 10 years or less
if a traumatic injury occurs
that is contaminated by
dirt, feces, soil, or saliva,
such as puncture or crushing injuries, avulsions, wounds fr. missiles,
burns or frostbite. The adolescent's injury is considered a contaminated wound requiring
prophylactic therapy, so the tetanus toxoid
booster should be administered
86. During administration of a blood
transfusion, a child
complains of chills, headache, and nausea.
Which action should the nurse implement?
Stop the infusion
immediately and notify the healthcare provider
The child is exhibiting signs of a reaction to the blood transfusion. The blood transfusion should be
stopped immediately and the healthcare provider
notified ©. After the transfusion is discontinued,
IV access should be maintained. (A) With fluids
that do not introduce any more cellular
products.
(B
& D) place
the child @ risk for further
blood reactions
87. A hospitalized 16-year-old male refuses
all visits from his classmates because he is concerned about his distorted appearance. To
increase the client's social interaction, what intervention is best for the nurse to initiate?
Arrange for an Internet
connection in the client's room for email communication.
88. The nurse
is caring for a
12-year-old with Syndrome
of Inappropriate Antidiuretic Hormone
(SIADH). This child should be
carefully assessed for which
complication?
Changes in level of consciousness.
89. The nurse
is assessing the neurovascular status of a child in Russell's traction. Which
finding should the nurse report to the healthcare provider?
Pale bluish coloration of the
toes
Russell's skin traction is used for fractures of the
femur in young children and adolescents whose
growth plates remain open and is
applied to the lower leg
using moleskin and elastic wrap
bandages, which can compress the perineal nerve and arteries that supply the foot. Assessment of
adequate circulation, movement, & sensation of the toes and skin
distal to the application is make
to
identify compromised blood flow, so cyanosis should be reported
immediately
90. Which class of antiinfective drugs is contraindicated for use in children under 8 years of age?
Tetracyclines
Tetracyclines cause enamel hypoplasia & tooth discoloration in children under 8 yrs of age
91. The nurse
is assessing an 8-month-old child who has a medical diagnosis of Tetrology of Fallot.
Which symptom is this client most likely to exhibit?
Clubbed fingers.
92. The mother of a 2-year-old boy consults the nurse about her son's increased temper tantrums.
The mother states, "Yesterday he threw a fit in the grocery store, and I did not
know what to do. I was so embarrassed. What can I do
if this occurs again?" Which Advice should the nurse give?
Walk away from him and ignore the behavior.
93. A nurse
provides the parents with information on health maintenance for their child
with sickle cell disease. Which information reflected by the parents
indicates understanding of the
child's care?
Plenty of fluids should be consumed daily.
94. When assessing a child with asthma, the nurse should expect intercostal retractions during
Inspiration
Intercostals retractions result fr. respiratory effort to draw air into restricted
airways
The nurse is planning
the care of a 2-year-old with severe eczema on the face, neck,
and scalp from
scratching the affected areas.
95. Which nursing
intervention is most effective in preventing further excoriation due to the pruritis?
Place elbow restraints on the child's
arms.
96. A
3-year-old client with sickle cell anemia is admitted to the Emergency
Department with abdominal pain.
The nurse palpates an enlarged liver, an x-ray
reveals an enlarged spleen, and a
CBC reveals anemia. These findings indicate
which type of crisis?
Sequestration
97. A female
teenager is taking oral tetracycline HCL (Achromycin V) for acne
vulgaris. What is the most important instruction for the nurse to include in this client's teaching plan?
Use sunscreen when lying by the pool
Photosensitivity is a common
side effect of tetracycline HCL (Achromycin V) therapy. Severe
sunburn can occur with minimal sun exposure and clients should
be instructed to avoid sunlight
and to use sunscreen
98. The nurse
is giving a liquid iron preparation to a 3-year-old child. Which technique
should the nurse implement to engage the child's
cooperation?
Use a colorful straw.
99. The nurse
is giving preoperative instructions to a 14-year-old female client who is scheduled for surgery to correct a spinal curvature. Which statement by
the client best demonstrates that learning has taken place?
I
understand that I will be in a body cast and I will show you how you taught me to turn.
100. Surgery is
being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate?
A
trial of human chorionic gonadotrophic hormone
101. A 12-month-old boy is admitted with a
respiratory infection and possible pneumonia. He is placed in a mist
tent with oxygen. Which nursing intervention has the greatest priority for this infant?
Have a bulb syringe readily
available to remove secretions.
102. The nurse
is planning care for school-aged children at a community care center. Which activity is best for the children?
Playing follow the leader
School aged children strive for independence and productivity (ericksons industry vs. inferiority)
& enjoy individual
& group activities r/t real life situation,
such as playing follow the leader
103. Which measurements should be used to accurately calculate a pediatric medication dosage? (Select
all that apply.)
Child's height and weight.
Body surface area of child.
Nomogram determined
mathematical
constant.
104. During
routine screening at a school clinic, an otoscope examination of a child's ear
reveals a tympanic membrane
that is pearly gray, slightly bulging,
and not movable. What action should the nurse take next?
Ask the child if he/she
has had cold, runny nose, or any ear pain lately.
More information is needed
to interpret these finding, the tympanic membrane is normally pearly
gray, not bulging, and moves when the
client blows against resistance or a small
puff of air is
blown into the ear canal.
Since this child's
findings are not completely normal,
further assessment
of
hx and related s/s is indicated for accurate interpretation of the finding.
105. Which finding in a 19-year-old female client should trigger
further assessment by the nurse?
Menstruation has not occurred.
106. In developing a teaching plan for
a 5-year-old child with diabetes, which component of diabetic management should the nurse
plan for the child to manage first?
Process of glucose testing
107. The nurse is
having difficulty communicating with a hospitalized 6-year-old child. Which approach by the nurse is most helpful in establishing communication?
Engage the child through drawing pictures
Drawing pictures is a valuable fr. nonverbal communication. As the
nurse & child look at the
drawings, a verbal story
can be told that projects
the child's thinking
108. The nurse is
assigning care for a 4-year-old child with otitis media and is concerned about the child's
increasing temperature over the past 24 hours. When planning care for this
child, it is important for the nurse to consider that
A
tympanic measurement of temperature will provide the most accurate reading
A
tympanic membrane sensor
is an excellent site because both the eardrum and hypothalamus
(temperature-regulating center)
are perfused by the same
circulation. The sensor is
unaffected by
cerumen and the presence
of suppurative or nonsuppurative otitis
media does not effect
measurement. RULE OF THUMB:
for management sterile procedures should be assigned
to
licensed personnel. Management skill
will tested on the NCLEX.
An RN is not required to do:
rectal temp
109. A 14-year-old female client tells the nurse that she
is concerned about the acne she has recently developed. Which recommendation should the
nurse provide?
Wash the hair and skin
frequently with soap and
hot water.
110. When discussing discipline with the
mother of a 4-year-old child, the nurse
should include which
guideline?
Parental control should be consistent
Discipline should be a positive
and necessary component of
childrearing that is started in
infancy
& should teach socially
acceptable behavior, help children protect
themselves fr. danger, and
channel undesirable behavior into constructive activity.
Misbehavior may result
fr. inconsistent
rules or messages, so parental attention should be clear, reasonable, and consistent.
111. A child
falls on the playground and is
brought to the school nurse with a small
laceration on the forearm. Which action should the nurse implement first?
Wash the wound gently
with mild soap and water
112. The nurse is assessing a 13-year-old girl with
suspected hyperthyroidism. Which question is
most important for the nurse
to ask her during
the admission interview?
Are you experiencing any type of nervousness?
113. A
6-year-old is admitted to the pediatric unit after falling off a bicycle. Which
intervention should the nurse implement to assist the child's
adjustment to hospitalization?
Explain hospital schedules to the child,
such as mealtimes.
114. At 8 a.m.
the unlicensed assistive personnel (UAP) informs the charge nurse that a female adolescent client with acute glomerulonephritis has a blood
pressure of 210/110. The 4 a.m. blood pressure reading was 170/88.
The client reports to the UAP
that she
Administer PRN prescription of nifedipine (Procardia) sublingually.
115. A six-month-old returns from surgery with elbow restraints in place. What nursing
care should be included
when caring for any restrained child?
Remove restraints one at a time and provide range of
motion exercises.
116. Which action by the nurse is
most helpful in communicating with a
preschool-aged child?
Use a doll to play and communicate.
117. A 2-year-old child
recently diagnosed with hemophilia A is discharged home. What information should
the nurse include in a teaching plan about home care?
Apply pressure and ice for bleeding while elevating and resting the extremity.
118. The clinic
nurse is taking the history for a new 6-month-old client. The mother reports
that she took a great deal of
aspirin while pregnant. Which assessment should the nurse obtain?
Type of reaction to loud noises.
119. A full term
infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an
esophageal atresia. Which symptoms are this newborn likely to exhibit?
Choking, coughing, and
cyanosis.
120. The parents
of a 3-week-old infant report
that the child eats well
but vomits after each feeding. What information is most important for the nurse to
obtain?
Description of vomiting episodes in past 24 hours.
121. Which behavior should the nurse expect
a two-year-old child to exhibit?
Display possessiveness of toys
Two year old children
are egocentric and unable to share
with other children
and behaviors of a
preschooler.
122. A three-month old boy weighing 10 lbs 15 oz has an axillary temperature of 98.9° F. The
nurse determines the daily caloric
need for this child is
approximately
600 calories per day
123. The nurse
reviews the latest laboratory results for a child who received chemotherapy
last week and identifies a reduced
neutrophil count. Which
nursing diagnosis has the
highest priority for this
child?
Risk for infection
124. A child
with cystic fibrosis is
having stools that float
and are foul smelling. Which
descriptive term should the nurse use to document
the finding?
Steatorrhea
125. The nurse observes a 4-year-old
boy in a daycare setting. Which behavior would the nurse
consider normal for this
child?
Demonstrates aggressiveness by boasting when telling a story.
126. An infant
is born with a ventricular septal defect (VSD)
and surgery is planned to correct the defect. The nurse recognizes that surgical correction
is designed to achieve which outcome?
Prevent the return of oxygenated blood to the lungs.
Closure of VSDs stops oxygenated blood fr. being shunted fr. the
left ventricle to the right
ventricle. VSDs are acyanotic defects, which means
that no deoxygenated blood enters the
systemic circulation is common
with tetralogy of Fallot, which
is a cyanotic defects.
127. The vital signs of a 4-year-old child
with polyuria are: BP 80/40,
Pulse 118, and Respirations
24. The child's pedal pulses are present with a
volume of +1, and no edema is observed. What action should the nurse implement first?
Start an IV infusion of normal saline
The current VS readings
and the decreased peripheral pulse volume indicate that the child
is
experiencing fluid volume deficit
due to the polyuria, so the priority
action is to restore fluid
volume.
128. A burned
child is brought to the emergency room. In estimating the percentage of the
body burned, the nurse uses a modified
"Rule of Nines." Which part of a child's
body is calculated as a larger
percentage of total body surface
than an adult's?
Head & Neck
A
child's head & neck are proportionately larger to their body than an
adult's. The standard "Rule
of
nines" is inaccurate for determining burned body surface areas
with children, and must be
modified for use with children. Specially designed charts for children
and are commonly used to
determine body surface are involvement
129. A 3-year-old boy is brought to the
emergency room because he swallowed
an entire bottle of children's vitamin pills. Which
intervention should the nurse implement first?
Determine the child's pulse and respirations.
130. To assess
the effectiveness of an analgesic administered to a 4- year-old, what
intervention is best for the
nurse to implement?
Use a happy-face/sad-face pain scale.
131. Preoperative nursing
care for a child with
Wilms' tumor should include
which intervention?
Put a sign on the bed reading, "DO
NOT PALPATE ABDOMEN"
Prevention of abdominal palpation
minimizes the risk of rupturing the encapsulated tumor
and
subsequent metastasis.
132. A
2-year-old child with Down syndrome is brought to the clinic for his regular
physical examination. The nurse knows
which problem is frequently associated with Down syndrome?
Congenital heart disease.
133. A 3-month-old infant develops oral thrush.
Which pharmacologic agent
should the nurse plan to administer for treatment
of this disorder?
Nystatin (Mycostatin).
134. A preschool-age child who is
hospitalized for hypospadias repair is most strongly
influenced by which behavior?
Concern for body integrity.
135. A
4-year-old boy was admitted to the emergency room with a fractured right ulna
and a short arm cast is applied.
When preparing the parents
to take the child home,
which discharge instruction has the highest
priority?
Call the healthcare provider
immediately if his nail beds appear blue.
136. A
3-week-old newborn is brought to the clinic for follow-up after a home birth.
The mother reports that her child bottle feeds for 5 minutes only and then
falls asleep. The nurse auscultates a loud murmur
characteristic of a ventricular septal defect (VSD)
Monitor the infant's weight
and number of wet diapers per day.
Use a softer nipple or increase the
size of the nipple opening.
Increase the infant's intake per feeding by 1 to 2 ounces
per week. Allow the
infant to rest and
refeed on demand or every
2 hours.
137. During discharge teaching of a child with juvenile rheumatoid arthritis, the nurse should
stress to the parents
the importance of obtaining which diagnostic
testing?
Eye exams
Visual changes leading to blindness
an occur in children with
JRA/ Regular eye exams can help
to
prevent this complication
138. As part of the physical assessment of children, the nurse observes
and palpates the fontanels.
Which child's fontanel finding
should be reported to the healthcare provider?
A
6 moth old with failure to thrive that has a closed
anterior fontanel
@
6 months of age the anterior fontanel should be open, and it should
not be closed until approx.
18
months
139. To take the vital signs
of a 4-month-old child, which
order provides the most accurate results?
Respiratory rate, heart rate, and then rectal temperature.
140. A child is
rescued from a burning house and brought to the emergency room with partial- thickness burns on the face and chest. Which action should the nurse implemented first?
Assess the child's respiratory status
141. A
17-year-old male student reports to the school clinic one morning for a
scheduled health exam. He tells
the nurse that he just finished football practice and is
on his way to class. The nurse assesses his vital signs:
temperature 100° F, pulse
80, respirations 20, and blood pressure
122/82
Tell the student to proceed
directly to his regularly scheduled class.
Category | HESI |
Release date | 2021-09-07 |
Latest update | 2021-09-07 |
Pages | 38 |
Language | English |
Comments | 0 |
High resolution | Yes |
Sales | 0 |
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