A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take? Show
Minimize physical contact with the child initially A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in temporary loss of vision. Which of the following interventions should the nurse include in the plan of care? 1. Assign an assistive personnel to feed the child 2. explain sounds the child is hearing 3. rotate nurses caring for the child 4. Have the child use a cane when ambulating 2. explain sounds the child is hearing A nurse is preparing to administer a liquid medication to an infant. Which of the following actions should the nurse take? 1. Administer the medication slowly while holding the nares closed 2. Give the medication at the side of the infant's mouth 3. Add the medication to a full bottle of the infant's formula 4. Administer the medication while the infant is supine 2. Give the medication at the side of the infant's mouth A nurse is assessing a 9-month-old infant during a well-child visit. Which of the following findings indicates that the infant has a developmental delay? 1. Uses crude pincer grasp 2. inability to vocalize vowel sounds 3. stands by holding onto support 4. creeps on hands and knees 2. inability to vocalize vowel sounds A nurse is caring for a toddler and is preparing to administer 0.9% sodium chloride 100mL IV to infuse over 4 hours. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? A nurse is planning to implement relaxation strategies with a young child prior to a painful procedure. Which of the following actions should the nurse take? 1. Rock the child in long rhythmic movements 2. Ask the child to describe a pleasurable event 3. Bounce the child while holding him upright 4. Ask the child to hold his breath and then blow it out slowly 1. Rock the child in long rhythmic movements A nurse in a pediatric clinic is caring for a 3-year-old child who has a blood lead level of 3 mcg/dL. When teaching the toddler's parents about the correlation of nutrition with lead poisoning, which of the following information is appropriate for the nurse to include in the teaching? 1. Give pancreatic enzymes to the child with meals and snacks 2. Ensure the child's dietary intake of calcium and iron is adequate 3. Decrease the child's vitamin C intake until the blood lead level decreases to zero 4. Administer a folic acid supplement to the child each day 2. Ensure the child's dietary intake of calcium and iron is adequate A nurse is assisting a provider during a femoral venipuncture on a toddler. The nurse should place the child in which of the following positions? 1. Semi-recumbent 2. Flexed sitting 3. Side-lying 4. Supine A nurse is assessing a 3-year-old child who is 1 day postoperative following a tonsillectomy. Which of the following methods should the nurse use to determine if the child is experiencing pain? 1. Check the child's temperature 2. Ask the parents 3. Use the numeric rating scale 4. Use the FACES scale A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? -The child views death as similar to sleep -The child is interested in what happens to his body after death -The child believes his thoughts can cause death -The child recognizes that death is permanent -The child thinks death is a punishment -The child views death as similar to sleep A nurse is planning to collect a specimen from a male infant using a urine collection bag. Which of the following actions should the nurse take? 1. Apply a small coating of water-soluble lubricant to the skin of the infant's perineal area 2. Avoid placing the scrotum inside the collection bag 3. Wait several hours after positioning the device before checking it. 4. Wash and dry the infant's genitalia and perineum thoroughly 4. Wash and dry the infant's genitalia and perineum thoroughly A nurse is teaching the parent of a toddler about home safety. Which of the following statements by the parent indicates an understanding of the teaching? 1. I keep my child's crib mattress at the highest level 2. I will give my child syrup of ipecac if she swallows something poisonous 3. I lock my medications in the medicine cabinet 4. I turn pot handles tot he side of my stove while cooking 3. I lock my medications in the medicine cabinet A nurse in the emergency department is caring for a 12-year-old child who has ingested bleach. Which of the following statements by the nurse indicated an understanding of this ingestion? 1. Immediate administration of activated charcoal is warranted 2. Treatment focuses on neutralization of the chemical 3. Injury by a corrosive liquid is more extensive than by a corrosive solid 4. The absence of oral burns excludes the possibility of esophageal burns 3. Injury by a corrosive liquid is more extensive than by a corrosive solid A nurse is assessing a 30-month-old toddler during a well-child visit. Which of the following findings requires further assessment by the nurse? 1. Unable to hop on one foot 2. Primary dentition is complete 3. Birth weight is tripled 4. Able to state first and last name 3. Birth weight is tripled A nurse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child? 1. Building towers of blocks 2. Drawing stick figures using crayons 3. Cutting figures from colored paper 4. Riding a tricycle 1. Building towers of blocks A nurse in the emergency department is caring for a 2-year-old child who was found by his parents crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse? 1. Remove the child's contaminated clothing 2. Check the child's respiratory status 3. Establish IV access for the child 4. Administer an antidote to the child 2. Check the child's respiratory status A nurse is preparing to administer recommended immunizations to a 2-month-old infant. Which of the following immunizations should the nurse plan to administer? 1. Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV) 2. Varicella (VAR) and live attenuated influenza vaccine (LAIV) 3. Human papillomavirus (HPV) and hepatis A 4. Measles, mumps, rubella (MMR), and tetanus, diphtheria and acellular pertussis (TDaP)
1. Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV) A nurse is teaching a parent of a 12-month old child about development during the toddler years. Which of the following statements should the nurse include? 1. Your child should be able to scribble spontaneously using a crayon at the age of 15 months 2. A toddler's interest in looking at pictures occurs at 20 months of age 3. Your child should be referring to himself using the appropriate pronoun by 18 months of age 4. A toddler should have daytime control of his bowel and bladder by 24 months of age 1. Your child should be able to scribble spontaneously using a crayon at the age of 15 months A nurse at a pediatric clinic is assessing a 5-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? 1. Absence of startle and crawl reflexes 2. Inability to pick up a rattle after dropping it 3. Head lags when pulled from a lying to sitting position 4. rolls from back to side 3. Head lags when pulled from a lying to sitting position A nurse is assessing a 12-month-old male infant's vital signs during a well-child visit. The infant is in the 90th percentile of height. Which of the following findings should the nurse report to the provider? 1. Temperature 37.6 C (99.7) 2. Blood pressure 88/40mmHg 3. Respiratory rate 26/min 4. Heart rate 175/min A nurse on a pediatric unit is reviewing the health record of a client who is demonstrating increasing levels of stress after admission. The nurse should identify which of the following findings as a risk factor for a stress-related reaction to hospitalization? 1. Calm, quiet demeanor 2. male gender 3. first hospitalization 4. age 10 A nurse is caring for a 15-month-old toddler who requires droplet precautions. Which of the following actions should the nurse take? 1. Have the toddler wear a disposable gown when in the unit playroom 2. Wear a mask when assisting the toddler with meals 3. Ask visitors to wear an N-95 mask when entering the room 4. Wear sterile gloves when changing the toddler's diapers 2. Wear a mask when assisting the toddler with meals A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should inform the client that he should receive which of the following immunizations prior to moving into a campus dormitory? 1. Pneumococcal polysaccharide 2. Herpes zoster 3. Rotavirus 4. Meningococcal Polysaccharide 4. Meningococcal Polysaccharide A nurse is caring for an adolescent who is receiving pain medication via a PCA pump. When the nurse assess the client's pain at 0800, the client describes the pain as a 3 on a scale of 1 to 10. At 100, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hr. Which of the following actions should the nurse take? 1. Reinforce teaching with the client about how to push the button to deliver the medication 2. Suggest the client's parent push the button for the client if the parent thinks the adolescent is having pain 3. Ask the provider to discontinue the PCA so the nurse can administer PRN pain medications 4. Reevaluate the client 1 hour since a pain level of 5 is acceptable on a scale of 1 to 10. 1. Reinforce teaching with the client about how to push the button to deliver the medication A nurse is teaching the parent of an infant about food allergens. Which of the following foods should the nurse include as being the most common food allergy in children? 1. Cow's milk 2. Wheat bread 3. Corn syrup 4. Eggs A nurse is planning care for a 10-month-old infant who has suspected failure to thrive (FTT). Which of the following interventions should the nurse include in the plan of care? -Sit beside the child's high chair when feeding the child -Observe the parents' actions when feeding the child -Maintain a detailed record of food and fluid intake - Play music vides during scheduled meal times - Follow the child's cues as to when food and fluids are provided -Observe the parents' actions when feeding the child -Maintain a detailed record of food and fluid intake A nurse is assessing a 7-year-old child's psychosocial development. Which of the following findings should the nurse recognize as requiring further evaluation? 1. The child complains daily about going to school 2. The child enjoys spending time alone 3. The child is competitive when playing board games 4. The child prefers playmates of the same sex 1. The child complains daily about going to school A nurse in an emergency department is caring for an 8-year old who is up-to-date with current immunization recommendations and has a deep puncture injury. Which of the following should the nurse anticipate administering? 1. Adult tetanus booster 2. A single injection of tetanus immune globulin (TIG) mixed with the pediatric tetanus booster (DT) 3. Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine 4. Diphtheria, tetanus, and acellular pertussis _DTaP) vaccine A nurse is providing education to the parent of a toddler who is about to receive her first dose of the MMR (measles, mumps and rubella) immunization. Which of the following statements by the parent indicates an understanding of the teaching?
1. My child might have some discharge from the injection site 2. I will need to return in 2 weeks for my child to receive the varicella immunization 3. I am not going to let my child play with other children for 2 days 4. I can give my child acetaminophen for discomfort associated with the immunization 4. I can give my child acetaminophen for discomfort associated with the immunization A nurse is caring for a child who has a bacterial endocarditis. The child is scheduled to receive moderate term antibiotic therapy and requires a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include when teaching the child's parent? 1. You will need to make certain the arm board is in place at all times 2. The PICC line will last several weeks with proper care 3. The public health nurse will rotate the insertion site every 3 days 4. Your child will go to the operating room to have the line placed 2. The PICC line will last several weeks with proper care A nurse is observing a mother who is playing peek-a-boo with her 8-month-old child. The mother asks if this game has any developmental significance. The nurse should inform the mother that peek-a-boo helps develop which of the following concepts in the child? 1. Hand-eye coordination 2. Sense of trust 3. Object permanence 4. Egocentrism A nurse is performing a physical assessment on a 6-month-old infant. Which of the following reflexes should the nurse expect to find? 1. Stepping 2. Moro 3. Babinski 4. Extrusion A nurse is providing teaching about promoting sleep with the parent of a 3-year-old toddler. Which of the following information should the nurse include? 1. Reward the child with a food treat just prior to sleep if the child goes to bed on time 2. Encourage active play prior to bedtime 3. Let the child remain awake until tired enough to go to sleep 4. Follow a nightly routine and established bedtime 4. Follow a nightly routine and established bedtime A nurse is providing anticipatory guidance about accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance? 1. Induce vomiting 2. Call the poison control center 3. Give the toddler milk 4. Go to an emergency department 2. Call the poison control center A nurse is teaching the parent of an infant about home safety. Which of the following information should the nurse include? -Position the car seat so it is rear-facing -Use a wheel infant walker - Place soft pillows around the edge of the infants crib -Secure a safety gate at the top and bottom of the stairs -Maintain the water heater temperature at 49 C (120 F) -Position the car seat so it is rear-facing A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings indicates the need for further assessment? 1. Birth weight has doubled 2. Grabs feet and pulls them to her mouth 3. Posterior fontanel is closed 4. Legs remain crossed and extended when supine 4. Legs remain crossed and extended when supine A nurse is providing teaching to the parents of a 4-year-old child about fine motor development. Which of the following tasks should the nurse include in the teaching as an expected finding for this age group? 1. Begins writing in cursive 2. Cuts foods using a table knife 3. Copies a circle 4. Prints first and last name clearly A nurse is assessing a 6-year-old child at a well-child visit. Which of the
following findings requires further assessment by the nurse? 1. Decreased head circumference compared to full height 2. Presence of sparse, fine pubic hair A nurse is teaching the parent of a 12-month-old infant about nutrition. Which of the following statements by the parent indicates a need for further teaching? 1. My infant drinks at least 2 quarts of skim milk each day 2. I will offer my baby dry cereal and chilled banana slices as snacks 3. I can give my baby 4 ounces of juice to drink each day 4. I am introducing my baby to the same foods the family eats 1. My infant drinks at least 2 quarts of skim milk each day A nurse on a pediatric unit is admitting a 4-year-old child. Which of the following toys should the nurse plan to provide for the child to engage in independent play? 1. Brightly colored mobile 2. Small piece jigsaw puzzle 3. Plastic stethoscope 4. A book of short stories When performing physical examination in an infant the following are appropriate nursing actions?When performing the physical assessment, the nurse uses the four basic techniques of inspection, palpation, percussion, and auscultation, generally in that order. During the abdominal examination, the sequence is altered; inspection is performed first, and then auscultation, percussion, and palpation.
What is the best way to approach a toddler when performing a physical assessment?Approach to physical assessment
Introduce yourself to the child and family and establish rapport. Use play techniques for infants and young children. Use systematic approach; but be flexible to accommodate child's behaviour. Encourage the child and family to ask questions and voice any concerns.
Which action by a nurse is appropriate before beginning a physical examination of a client?Which action is most important to take before beginning the examination? Wash hands before examination in the examination room. The nurse should wash hands before examination in the examination room in front of the client to assure the client that his or her safety is first priority.
When performing a physical examination the nurse should examine the body in which order?WHEN YOU PERFORM a physical assessment, you'll use four techniques: inspection, palpation, percussion, and auscultation. Use them in sequence—unless you're performing an abdominal assessment. Palpation and percussion can alter bowel sounds, so you'd inspect, auscultate, percuss, then palpate an abdomen.
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Which action would the nurse take when performing a physical assessment on a young child?
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