RN HESI: Peds Retake
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1. The nurse has document- ANS: C
ed that a child's level of
consciousness is obtunded. Obtunded describes a level of conscious-
Which describes this level ofness in which the child is arousable with stim-
consciousness? ulation. Stupor is a state in which the child re-
mains in a deep sleep, responsive only to vig-
a. Slow response to vigorous orous and repeated stimulation. Confusion is
and repeated stimulation impaired decision making. Disorientation is
b. Impaired decision making confusion regarding time and place.
c. Arousable with stimula-
tion
d. Confusion regarding time
and place
2. Parents are concerned that ANS: B
their 6-year-old son contin-
ues to occasionally wet the Further data must be gathered before the
bed. What does the nurse ex- diagnosis of enuresis is made. Enuresis is the
plain? inappropriate voiding of urine at least twice a
week. This child does meet the age criterion,
a. This is likely because of but the parents need to be questioned about
increased stress at home. and keep a diary on the frequency of events.
b. Enuresis usually ceases If the bedwetting is infrequent, parents can
between 6 and 8 years of be encouraged that the child may grow out
age. of this behavior. Drug therapy will not be
c. Drug therapy will be pre- prescribed until a more complete evaluation
scribed to treat the enuresis. is done. Additional assessment information
d. Testing will be necessary must be gathered, but at this time, there is no
to determine what type of indication of renal disease.
kidney problem exists
3. A nurse is preparing for the c) conjunctival hyperemia
admission of a child with
a diagnosis of acute-stage
Kawasaki disease. On as-
sessment of the child, the
nurse expects to note which
clinical manifestation of the
acute stage of the disease?
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a) cracked lips
b) a normal appearance
c) conjunctival hyperemia
d) desquamation of the skin
4. Which signs and symptoms Murmur
would lead a nurse to sus-
pect a child has tetralogy of History of squatting
Fallot? Select all that apply.
Cyanosis
Tachypnea
5. A nurse is caring for an in- Tachycardia
fant with congenital heart
disease is monitoring the in-
fant closely for signs of con-
gestive heart failure (CHF).
The nurse assess the infant
for which early sign of CHF?
6. A child with Kawasaki dis- Stop the aspirin
ease is receiving low-dose
aspirin. The mother calls Watch for fever.
the clinic and states that
the child has been exposed
to influenza. Which recom-
mendation should the nurse
make? Select all that apply.
7. Discharge teaching for a a. Give the medication at regular intervals.
3-month-old infant with a
cardiac defect who is to re- d. Notify the HCP of poor feeding or vomiting.
ceive digoxin should include
which information? Select f. Notify the HCP if more than two consecutive
all that apply. doses are missed.
a. Give the medication at reg-
ular intervals.
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b. Mix the medication with a
small volume of breast milk
or formula.
c. Repeat the dose one time
if the child vomits immedi-
ately after administration.
d. Notify the HCP of poor
feeding or vomiting.
e. Make up any missed dos-
es as soon as realized.
f. Notify the HCP if more than
two consecutive doses are
missed.
8. When developing the dis- 4. Phosphorus.
charge teaching plan for a
child with chronic renal fail-
ure and the family, the nurse
should emphasize restric-
tion of which of the following
nutrients?
9. The nurse is creating a plan 1. Time the seizure.
of care for a child who is at
risk for seizures. Which in- 3. Stay with the child.
terventions apply if the child
has a seizure? Select all that 5. Move furniture away from the child.
apply.
Rationale: A seizure is a disorder that occurs
1. Time the seizure. as a result of excessive and unorganized
2. Restrain the child. neuronal discharges in the brain that activate
3. Stay with the child. associated motor and sensory organs. Dur-
4. Place the child in a prone ing a seizure, the child is placed on his or
position. her side in a lateral position. Positioning on
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5. Move furniture away from the side prevents aspiration because saliva
the child. drains out the corner of the child's mouth.
6. Insert a padded tongue The child is not restrained because this could
blade in the child's mouth. cause injury to the child. The nurse would
loosen clothing around the child's neck and
ensure a patent airway. Nothing is placed into
the child's mouth during a seizure because
this action may cause injury to the child's
mouth, gums, or teeth. The nurse would stay
with the child to reduce the risk of injury
and allow for observation and timing of the
seizure.
10. The nurse creates a plan of 4. Suctioning equipment and oxygen
care for a child at risk for
tonic-clonic seizures. In the
A seizure results from the excessive and un-
plan of care, the nurse iden-
organized neuronal discharges in the brain
tifies seizure precautions that activate associated motor and senso-
and documents that which ry organs. A type of generalized seizure is
item(s) need to be placed ata tonic-clonic seizure. This type of seizure
the child's bedside? causes rigidity of all body muscles, followed
by intense jerking movements. Because in-
1. Emergency cart creased oral secretions and apnea can oc-
2. Tracheotomy set cur during and after the seizure, oxygen and
3. Padded tongue blade suctioning equipment are placed at the bed-
4. Suctioning equipment and side. A tracheotomy is not perform ed dur-
oxygen ing a seizure. No object, including a padded
tongue blade, is placed into the child's mouth
during a seizure. An emergency cart would
not be left at the bedside, but would be avail-
able in the treatment room or nearby on the
nursing unit.
11. A nurse is caring for an in- b) reposition the infant frequently
fant with a diagnosis of hy-
drocephalus. Preoperatively, Hydrocephalus occurs as a result of imbal-
a priority nursing interven- ance of cerebrospinal fluid absorption or pro-
tion is to: duction that is caused by malformations, tu-
mors, hemorrhage, infections, or trauma. It
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