Exam (elaborations)

Nursing care of children Exam (Version 2)

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Course
Nursing Care

Institution
Nevada State College

Nursing care of children Exam (Version 2).A nurse instructs a parenting class. Which of the following should be included as the best way to prevent the most common cause of death for infants and children? 1. Avoid unknown animals 2. Place infant on back during sleep 3. Secure a child in restrai...

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nursing care
nursing care of children exam version 2
a nurse instructs a parenting class which of the
common car is car accidents
a nurse admits a toddler who is scheduled for

Institution
Nevada State College
Course
Nursing Care

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A nurse instructs a parenting class. Which of the following should be included as the best way to
prevent the most common cause of death for infants and children?

1. Avoid unknown animals
2. Place infant on back during sleep
3. Secure a child in restraint care seat
4. Apply a water safety jacket when near a body of water
3

common car is car accidents
SIDS is not most prominent
rear facing until 20lbs or 1 year
A nurse admits a toddler who is scheduled for surgery. Which of the following should be the
documentation in the care plan?

1. the child's rituals and routines at home
2. the parent's methods of reward and discipline
3. the child's ability to separate from the parents
4. the parent's understanding of the child's hospitalizaition
1.

what do you need to know to give care for the child?
a toddler needs sameness and routine because they are out of their environment in a hospital.

A nurse assesses a toddler who has left-sided heart failure and pulmonary edema. Which of the
following findings should be expected? Select all that apply.

1. Shortness of breath
2. Bounding brachial pulses
3. Edema in dependent areas
4. Orthopnea worsening at night
5. Cough with blood-tinged mucous
1, 4, 5

same as adults
A nurse provides teaching to parents of an infant who has Tetralogy of Fallot. Which of the
following should be included as triggers of hypercyanotic spells? Select all that apply.

1. When resting
2. During feeding
3. After crying episode
4. Soon after awakening
5. During painful procedures
2, 3, 4, 5
A nurse provides discharge teaching to parents of a newborn who has a cleft lip. Which of the
following feeding guidelines should be included? Select all that apply.

,1. Instruct about special feeding devices to facilitate effective sucking
2. Wait to burp until the end of the feeding to increase dietary intake
3. Feed in an upright, sitting position to reduce potential for aspiration
4. Feed slowly over a 20-30 min period to allow for rest periods
5. Angle the nipple toward the side of the mouth with the cleft to facilitate feeding
6. begin to introduce solid foods until 15 months or older to ensure normal growth
1, 3, 4

position bottle at best seal

want to introduce solids at the normal time to promote adding weight so the infant can repair
themselves.
A nurse cares for a toddler who has glomerulonephritis. Which of the following actions should
be the priority of care?

1. Record intake/ output every 2 hours
2. Assess blood pressure every 1 hours
3. Maintain diet with reduced sodium content
4. Plan activities to allow for frequent rest periods
2

1 not 1 because output is not as accurate as weight for child

adrenal complex affects BP so we check it every hour.
A nurse receives report on a group of clients. Which client should be assessed first?

1. An infant with an axillary temperature of 100.1 F (37.8 C) who is tugging at left ear
2. A school-aded client with sore throat who is sitting upright in tripod position and drooling
3. A pre-school aged child with harsh cough, expiratory wheezes, and mild intercostal retractions
4. A toddler with barking cough, infrequent inspiratory stridor, and oxygen saturation 95% on
room air
2

drooling! they are unable to handle secretions.
don't stick anything in mouth, might lose airway.

want to keep a trach kit in this room.
A nurse cares for a client who has sickle cell anemia and cellulitis of the right leg. Which of the
following interventions should be the priority of care?

1. Administer oral and parenteral rehydration therapies
2. Structure activities that encourage energy conservation
3. Elevate and apply cold compresses to the affected areas
4. Instruct client and family about the prevention of crisis

,2.

not in crisis so no IV
focuses on surgical procedure not crisis.
do not elevate and apply col compress because it should be warm to get blood flow to that area.

sickle cell anemia needs fluid, oxygen and pain relief when in crisis.

rehydration, oxygenation and pain relief.

chronic issue is sickle cell and acute is cellulitis.
The parents of a preschooler report to the nurse omitting fluids after dinner to manage enuresis.
Which of the following disorders would be of most concern when reviewing the child's history?

1. Celiac disease
2. Sickle cell anemia
3. Lactose intolerance
4. Type 1 diabetes mellitus
2

never dehydrate and put them in sickle cell anemia crisis.
A nurse admits a client who has sickle cell anemia. Which of the following lab values should be
expected? Select all that apply.

1. Hematocrit 25%
2. WBC 3,800mm3
3. Bilirubin 1.6mg/dl
4. Reticulocytes 2.8%
5. RBC 7,000,000/mm3
6. Hemoglobin 14gm/dl
1, 3, 4

would not have high red cells because that would mean you have a high hgb

bili is the immatures
A nurse cares for a client who has exacerbation of asthma. Place the following interventions in
the appropriate sequential order.

1. Assess bilateral lung sounds
2. Place client in high Fowler's position
3. Administer montelukast PO
4. Administer albuterol nebulizer
5. Administer methylprednisolone IV
2, 1, 4, 5, 3

albuteral is a bronchodilator

, methylprednisome is a steroid
last is PO

between 6 and 8 weeks of age
When does the posterior fontanel close?
between 12 and 18 months of age
When does the anterior fontanel close?
tumbling E, HOTV
what kind of test should you use to test the visual acuity of children who are unable to read
letters and numbers?
Snellen chart or symbol chart
how should older children be tested for visual acuity?
color vision
The Ishihara color test or the Hardy-Rand-Rittler color test are used to assess ____________
_________
50, 70, 60, 90
peripheral visual fields should be-
upward _________ degrees
downward _________ degrees
nasally _________ degrees
temporally _________ degrees

peripheral vision is evaluated by having the client fixate on an object and say when it is moved
out of range.
6 to 8, 20, 32
amount of teeth that infants should have by one year of age: ______ to ______
________ deciduous teeth
________ permanent teeth
gynecomastia
unilateral or bilateral breast enlargement that occurs for males during puberty
4
rooting and sucking reflex should be seen from birth to _____ months
3
palmar grasp should be seen from birth to ______ months
8
plantar grasp, or when the infant's toes curl downward after the sole of their foot is touched, is
seen from birth to ______ months
4
the moro reflex (startle) is seen from birth to ______ months. a typical reaction is when the
infant's arms and legs symmetrically extend and then abduct while her fingers spread to form a C
shape.
tonic neck reflex (or fencer position)
elicited by turning an infant's head to one side. The infant extends the arm and leg on that side
and flexes the arm and leg on the opposite side.

Seen from birth to 3 to 4 months.

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Exam (elaborations)

Nursing care of children Exam (Version 2)

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