A nurse's planning care for a 10 month old infant who has suspected failure to thrive.
Which of the following intervention should the nurse include in the plan of care? (select
all that apply)
A. observe the parents' actions when feeding the child.
B. Maintain a detailed record of food and fluid intake.
C. follow the child's cues as to in food in fluids are provided.
D. sit beside the child's highchair when feeding the child.
E. Play music video during scheduled meal times. - ANS A, B
a nurse is providing anticipatory guidance about accidental ingestion of a toxic
substance to the parents of a child. the nurse should instruct the parents to take which
of the following actions first if the child ingests a hazardous substance?
A. give the toddler milk
B. go to the emergency department
C. call the poison control center
D. induce vomiting - ANS C. call the poison control center
this will identify further actions that the parents should take.
A nurse in the emergency department is caring for a 12-year-old child who ingested
bleach. Which of the following statements made by the nurse indicates an
understanding of this ingestion?
A. The absence of oral burns excludes the possibility of esophageal burns.
B. treatment focuses on the neutralization of the chemical.
C. "Injury by a corrosive liquid is more extensive than by a corrosive solid."
D. "Immediate administration of activated charcoal is warranted." - ANS C. Injury by a
corrosive liquid is more extensive than by a corrosive solid.
The coating action of liquids permits larger areas of contact with tissues and results in
more extensive injury.
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?
A.Hand-eye coordination
B. Sense of trust
C. Object permanence
D. Egocentrism - ANS C. Object permanence
, Object permanence refers to the cognitive skill of knowing an object still exists even
when it is out of sight. In discovering a hidden object while playing peek-a-boo, the
infant experiences validation of this concept.
A nurse is teaching the parents of a 12-month-old infant about nutrition. Which of the
following statements by the parent indicates a need for further teaching?
A. "I can give my baby 4 ounces of juice to drink each day."
B. "I will offer my baby dry cereal and chilled banana slices as snacks."
C. "I am introducing my baby to the same foods the family eats."
D. "My infant drinks at least 2 quarts of skim milk each day." - ANS D.
As the infant transitions into toddlerhood, whole milk intake should average 24 to 30 oz
per day. Too much milk can affect intake of solid foods and result in iron deficiency
anemia. Skim milk is not recommended until after age 2 since it lacks essential fatty
acids which are needed for growth and development.
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?
A. Wash and dry the infant's genitalia and perineum thoroughly.
B. Apply a small coating of water-soluble lubricant to the skin of the infant's perineal
area.
C. Avoid placing the scrotum inside the collection bag.
D. Wait several hours after positioning the device before checking it. - ANS A.
This is the method used to obtain a routine urine specimen of any sort in a child who is
not toilet trained. The skin should be washed and dried to promote application of the
adhesive of the collection device.
A nurse is caring for an adolescent who is receiving pain medication via PCA pump.
When the nurse assesses the clients pain at 0800, the client describes the pain as 3/10.
At 1000, 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 hours.Which of the following
actions should the nurse take?
A. Ask the provider to discontinue the PCA so the nurse can administer PRN pain
medication.
B. Suggest the client's parent push the button for the client if the parent thinks the
adolescent is having pain.
C. Reevaluate the client in 1 hr since a pain level of 5 is acceptable on a scale of 1 to
10.
D. Reinforce teaching with the client about how to push the button to deliver the
medication. - ANS D.
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