HESI RN PEDIATRICS PROCTORED EXAM
The nurse is conducting an initial admission assessment of a 12-month-old child in celiac crisis. Which intervention is most important for the nurse to implement?
A. Assess the child's mucous membranes and skin turgor.
B. Contact food services about needed men...
the nurse is conducting an initial admission assessment of a 12 month old child in celiac crisis which intervention is most important for the nurse to implement a
The nurse is conducting an initial admission assessment of a 12-month-old child in
celiac crisis. Which intervention is most important for the nurse to implement?
A. Assess the child's mucous membranes and skin turgor.
B. Contact food services about needed menu restrictions.
C. Determine the child's food likes and dislikes.
D. Ask the parents about the child's recent dietary intake.
Rationale:
An infant having a celiac crisis has severe diarrhea and is at high risk for fluid volume
deficit. The nurse should first assess for indications of fluid volume deficit and then
implement options B, C, and D.
Following the reduction of an incarcerated inguinal hernia, a 4-month-old boy is
scheduled for surgical repair of the inguinal hernia. Under which circumstance should
the parents notify the health care provider prior to surgery?
A. Crying that is unrelieved by comforting measures
B. Presence of an inguinal bulge after gentle palpation
C. Refusal to take oral feedings
D. Straining during defecation
Rationale:
The parents should notify the health care provider if the hernia remains irreducible
after implementing simple measures, such as gentle palpation, warm bath, and
comforting to reduce crying. If a loop of intestines is forced into the inguinal ring or
scrotum and incarcerates, swelling can follow and possible strangulation of the bowel,
intestinal obstruction, or gangrene of the bowel loop can occur, necessitating emergency
surgical release. Options A and D may cause the hernia to protrude but do not
necessitate notification of the health care provider. Option C may not be specific to the
hernia.
A child comes to the school nurse complaining of itching. Further assessment reveals
that the child has impetigo. What action should the nurse take?
A. Send the child home with the parents to see the health care provider before
returning to school.
B. Send the child home with the parents and report this to the health department.
, C. Cover the lesion with a dry gauze dressing and send the child back to class.
D. Wash the lesion with antimicrobial soap, air-dry, and send the child back to class.
Rationale:
Impetigo is a staphylococcal infection and is transmitted by person-to-person contact.
The child should be sent home with a note to the parents explaining the condition.
Option B is not necessary because this is not a public health hazard. Option C slows the
healing process and can contribute to spread of the infection. The lesions should be
washed with soap and water, topical ointment applied, and left open to the air to dry.
This will occur at the child's home.
The nurse expects a 2-year-old child to exhibit which behavior?
A. Build a house with blocks.
B. Ride a small tricycle 6 feet.
C. Display possessiveness with toys.
D. Look at a picture book for 15 minutes.
Rationale:
Two-year-old children are egocentric and unable to share with other children. Options
A, B, and D are behaviors of a preschooler.
A woman whose first child died at 6 weeks of age because of sudden infant death
syndrome (SIDS) is being discharged following the birth of her second child. The
mother tells the nurse that she is fearful that this infant will also develop SIDS. Which
response is best for the nurse to provide this woman?
A. "You can prevent SIDS if your baby sleeps on the side or back. You will have to
monitor the baby carefully."
B. "The fear of losing another child to SIDS is very realistic. Have you thought
about what support
you may need?"
C. "An apnea monitor will alert you if the baby stops breathing. This will give you
the peace of mind that you need."
D. "My neighbor's baby died of SIDS last year, and she went to a SIDS support
group. That really helped her."
Rationale:
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