A seven-month old infant is admitted with nonorganic failure to thrive (NFTT). To aid the
child's growth and development, which intervention is most important for the nurse to
implement?
Encourage the parents to participate in a planned program of play with the infant.
Refer the parents for psychological counseling to identify parental detachment.
Demonstrate feeding strategies and infant cues that indicate hunger and satiation.
Provide instructions about formula preparation and feeding schedules. - Answer -
Demonstrate feeding strategies and infant cues that indicate hunger and satiation.
The nurse is triaging a child with a fever brought to the emergency department by the
parents. Which finding requires the nurse's immediate intervention?
Prolonged exhalations.
Thick yellow rhinorrhea.
Frequent nonproductive cough.
Oxygen saturation is 95% by pulse oximeter. - Answer -Prolonged exhalations.
The nurse is assessing the coping behaviors of the parents whose child has been
recently diagnosed with a chronic illness. What reaction by the parents is a positive step
in the ability to cope with this new situation?
Endowing the illness with meaning.
Refusing to believe the child is ill.
Entertaining an unrealistic future plan for the child.
Placing complete faith in religion to the point of relinquishing own responsibility. -
Answer -Endowing the illness with meaning.
,A 15-year-old girl tells the school nurse that she wants to have a baby. How should the
nurse respond?
"Will you be able to support the baby?"
"Do you have plans to continue school?"
"Have you talked with your parents about this?"
"Can you tell me how your life will be if you have an infant?" - Answer -"Can you tell me
how your life will be if you have an infant?"
The nurse is caring for a premature infant who needs an IV access restarted. What
action should the nurse take when using adhesive tape?
Remove adhesives with water, mineral oil, or petrolatum.
Avoid using tape and adhesives until skin is more mature.
Use scissors carefully to remove tape instead of pulling tape off.
Employ solvents to remove adhesives instead of pulling on skin. - Answer -Remove
adhesives with water, mineral oil, or petrolatum.
The nurse calculates a 4 ml dose of prescribed digoxin a 9-month-old infant. What
action should the nurse implement?
Mix dose with juice to disguise its taste.
Suspect dosage error and do not give dose.
Check heart rate and administer dose by placing it to the back and side of mouth.
Check heart rate and administer dose by letting the infant suck it through a nipple. -
Answer -Suspect dosage error and do not give dose.
The parents of a toddler brought to the clinic for a well-child visit tell the nurse that their
child becomes upset if even the smallest things change in the environment. What
information should the nurse provide the parents?
A child is insecure because trust is not fostered and developed during infancy.
A toddler should be exposed to different routines to promote adapting to new
experiences.
,Children of this age are comfortable with ritualism and display global thinking.
Objects should be frequently moved in the environment to teach the child to acclimate
to change. - Answer -Children of this age are comfortable with ritualism and display
global thinking.
How should the nurse measure the length of a 14-month-old child ?
A 5-year-old child who is one day postoperative has bilateral eye patches in place and
should be out of bed. What nursing intervention should be implemented first before
leaving the bedside?
Speak to the child when entering the room.
Allow the child to assist in feeding himself.
Orient the child to the immediate surroundings.
Allow the parents to stay in the room with the child. - Answer -Orient the child to the
immediate surroundings.
The nurse observes the interactions of a 2-year-old child who says, "No," even when
"Yes" is what the child really wants to say. The parent says to the nurse, "We, as
parents, are such positive people, why is our child so negative?" How should the nurse
respond?
A 2-year-old often acts in the opposite way to get attention.
This age child is testing the limits of the parent's patience.
The toddler is exhibiting an example of ritualistic behavior.
The child is trying to assert autonomy through negativism. - Answer -The child is trying
to assert autonomy through negativism.
A newborn who is breastfeeding is diagnosed with galactosemia. What action should
the nurse implement?
, Stop the infant breastfeeding.
Add amino acids to breast milk.
Give galactokinase with breast milk.
Substitute a lactose-containing formula. - Answer -Stop the infant breastfeeding.
A 4-year-old child who is ventilator-dependent is receiving tube feedings in the home
setting. The family wants to begin oral feeding of the child, and asks the home health
nurse to feed the child baby food orally. After explaining the risks for aspiration to the
family, list in order which actions the nurse should implement. (Rank in the priority order
from first action to last action.)
1. Refuse to feed the child orally, because the risk is too high.
2. Ask the parents to negotiate a change in feeding methods with the healthcare
provider.
3. Set additional goals for feeding the child with the parents.
4. Acknowledge the request and then explore with the family the available options for
care. - Answer -1. Acknowledge the request and then explore with the family the
available options for care.
2. Set additional goals for feeding the child with the parents.
3. Refuse to feed the child orally, because the risk is too high.
4. Ask the parents to negotiate a change in feeding methods with the healthcare
provider.
What is a priority nursing diagnosis for a child in the subacute stage of Kawasaki
disease?
Alterations in skin integrity.
High risk for altered tissue perfusion, cardiopulmonary.
Risk for imbalanced body temperature, hyperthermia.
High risk for fluid volume deficit. - Answer -High risk for altered tissue perfusion,
cardiopulmonary.
A mother brings her 6-month-old infant to the clinic for a well-child checkup. She
comments, "I want to go back to work, but I don't want my baby to suffer because I'll
have less time at home." How should the nurse respond to the mother?
Stay home until the child starts school.
Find a good baby-sitter close to the house.
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