1. The nurse has documented that a child's level of consciousness is obtunded.
Which describes this level of consciousness?
a. Slow response to vigorous and repeated stimulation
b. Impaired decision making
c. Arousable with stimulation
d. Confusion regarding time and place: ANS: C
Obtunded describes a level of consciousness in which the child is arousable with
stimulation. Stupor is a state in which the child remains in a deep sleep, responsive only
to vigorous and repeated stimulation. Confusion is impaired decision making.
Disorientation is confusion regarding time and place.
2. Parents are concerned that their 6-year-old son continues to occasionally wet the
bed. What does the nurse explain?
a. This is likely because of increased stress at home.
b. Enuresis usually ceases between 6 and 8 years of age.
c. Drug therapy will be prescribed to treat the enuresis.
d. Testing will be necessary to determine what type of kidney problem exists-: ANS:
B
Further data must be gathered before the diagnosis of enuresis is made. Enuresis is the
inappropriate voiding of urine at least twice a week. This child does meet the age
criterion, but the parents need to be questioned about and keep a diary on the frequency
of events. If the bedwetting is infrequent, parents can be encouraged that the child may
grow out of this behavior. Drug therapy will not be prescribed until a more complete
evaluation is done. Additional assessment information must be gathered, but at this time,
there is no indication of renal disease.
3. A nurse is preparing for the admission of a child with a diagnosis of acute-stage
Kawasaki disease. On assessment of the child, the nurse expects to note which
clinical manifestation of the acute stage of the disease? a) cracked lips
b) a normal appearance
c) conjunctival hyperemia
,d) desquamation of the skin: c) conjunctival hyperemia
4. Which signs and symptoms would lead a nurse to suspect a child has tetralogy
of Fallot? Select all that apply.: Murmur
History of squatting
Cyanosis
Tachypnea
5. A nurse is caring for an infant with congenital heart disease is monitoring the
infant closely for signs of congestive heart failure (CHF). The nurse assess the infant
for which early sign of CHF?: Tachycardia
6. A child with Kawasaki disease is receiving low-dose aspirin. The mother calls
the clinic and states that the child has been exposed to influenza. Which
recommendation should the nurse make? Select all that apply.: Stop the aspirin
Watch for fever.
7. Discharge teaching for a 3-month-old infant with a cardiac defect who is to
receive digoxin should include which information? Select all that apply.
a. Give the medication at regular intervals.
b. Mix the medication with a small volume of breast milk or formula.
c. Repeat the dose one time if the child vomits immediately after administra-tion.
d. Notify the HCP of poor feeding or vomiting.
e. Make up any missed doses as soon as realized.
f. Notify the HCP if more than two consecutive doses are missed.: a. Give the
medication at regular intervals.
d. Notify the HCP of poor feeding or vomiting.
f. Notify the HCP if more than two consecutive doses are missed.
8. When developing the discharge teaching plan for a child with chronic renal
failure and the family, the nurse should emphasize restriction of which of the
following nutrients?
1. Ascorbic acid.
2. Calcium.
, 3. Magnesium.
4. Phosphorus.: 4. Phosphorus.
9. The nurse is creating a plan of care for a child who is at risk for seizures. Which
interventions apply if the child has a seizure? Select all that apply.
1. Time the seizure.
2. Restrain the child.
3. Stay with the child.
4. Place the child in a prone position.
5. Move furniture away from the child.
6. Insert a padded tongue blade in the child's mouth.: 1. Time the seizure.
3. Stay with the child.
5. Move furniture away from the child.
Rationale: A seizure is a disorder that occurs as a result of excessive and unorganized
neuronal discharges in the brain that activate associated motor and sensory organs.
During a seizure, the child is placed on his or her side in a lateral position. Positioning on
the side prevents aspiration because saliva drains out the corner of the child's mouth. The
child is not restrained because this could 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
care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse
identifies seizure precautions and documents that which item(s) need to be placed at
the child's bedside?
1. Emergency cart
2. Tracheotomy set
3. Padded tongue blade
4. Suctioning equipment and oxygen: 4. Suctioning equipment and oxygen
A seizure results from the excessive and unorganized neuronal discharges in the brain
that activate associated motor and sensory organs. A type of generalized seizure is a
tonic-clonic seizure. This type of seizure causes rigidity of all body muscles, followed by
intense jerking movements. Because increased oral secretions and apnea can occur during
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