The best position for the delivery room nurse to place a newborn with myelomeningocele at the lumbosacral area in is: Prone. Supine. Side-lying. Trendelenburg. Place the infant with a myelomeningocele on her stomach in a prone position to avoid pressure on the sac, which could cause tears, leaks, and infection. The side-lying position (Answer 3) might be an acceptable second choice, depending on the exact size and location of the sac placing the infant on her back (Answer 2) is absolutely contraindicated, because this would lead to immediate rupture of the sac. Trendelenburg position (Answer 4) is unnecessary for this infant. Picture the anatomy where the problem is and avoid on the back positions (2, 4) A school-age child with rheumatic fever complains of severe joint pains in the knees and ankles. The best method to provide relief would be for the nurse to: Give a warm bath or shower. Apply splints to the affected joints. Refer the child to physical therapy. Place a bed cradle over the child's legs. For a child experiencing migratory polyarthritis secondary to rheumatic fever, even the weight of a single sheet can cause excruciating pain; therefore, a bed cradle will help keep the linens off the child's joints and provide symptomatic relief. This child is most likely on bed rest, thus making a bath or shower (Answer 1) out of the question. Splints or a referral to physical therapy (Answers 2, 3) is unnecessary, because this type of arthritis causes no permanent deformities. Comfort is the priority of care, because of pain associated with migratory polyarthritis A hospitalized school-age child is very quiet and seldom talks to the staff. The nurse can best communicate with this child by saying: I've noticed you seem very quiet. Is anything troubling you? Let's tell each other a secret; you start by telling me what you are thinking. It must be awfully hard to be away from home. Let's call your mom! Draw me some pictures of the things you've seen and done while you've been in the hospital. Projective techniques seem to work best with school-age children in getting them to share their thoughts, feelings, and experiences. Direct questioning (Answer 1) often proves too threatening, causing the child to become even quieter. Challenging the child directly to "tell secrets" (Answer 2) is also too threatening and will likely cause the child to refuse to speak about anything. Calling the child's mother (Answer 3) will not necessarily assist the child to communicate with the nurse. Select the age-appropriate, nonthreatening approach. When in doubt, note the pattern in responses: three arc verbal and one is nonverbal (draw). Choose the method that is different. Three of the following signs or symptoms indicate an improvement in the condition of a toddler with laryngotracheobronchitis. Which one indicates a worsening and should be promptly reported to the physician? Apical pulse = 118. Increase in appetite. Progressive hoarseness. Pink nailbeds. Progressive hoarseness, followed by aphonia, is an ominous sign of impending airway obstruction and respiratory arrest secondary to edema and inflammation. This must be promptly reported to the physician, who will probably do an emergency tracheostomy AN apical pulse of 118 (Answer 1) is normal for a toddler; pink nailbeds (Answer 4) indicate a satisfactory level of oxygenation AS the toddler begins to improve, appetite should also pick up (Answer 2). The question calls for an option that is not normal (not OK) and possibly life threatening The nurse reviews a toddler's immunizations with the parents and finds that the child has had all immunizations recommended during the toddler years. The nurse should advise the parents that, at 4 to 6 years of age, the child should next receive: MMR (measles, mumps, rubella) and hepatitis B. Hepatitis B and varicella. Haemophilus influenzae type b and DTP. MMR (measles, mumps, rubella), polio, and DTP. At preschool age (4-6 years), the child should receive immunizations for DTP, OPV, and MMR. MMR (Answer 1) is correct, but hepatitis D is not. I hepatitis (Answer 2) is completed by 18 months, as is varicella. Haemophilus influenzae (Answer 3) is completed by 15 months, although DTP is correct. The best answer is based on knowing the recommended schedule of immunizations Which is the most common complaint by parents about infants with heart disease? Frequent, severe respiratory infections. Slower development. Stunted growth. Difficult to feed. Typically, the majority of parents of infants with CHD complain about the infant's being very difficult to feed: must be awakened to feed, has a weak suck, may turn blue with feeding, takes an overly long time to feed but falls asleep before finishing. Because of the weak suck and altered cardiopulmonary dynamics, the infant is also prone to aspiration, pneumonia, and various respiratory infections (Answer 1) as well, although parents often do not make the connection between these factors. In addition, because of the difficulty in feeding the infant, the infant typically has developmental delays (Answer 2) and a slow rate of growth (Answer 3), although again this is not what the majority of parents of infants with CHD complain about. Because all answers are correct and interrelated, the clue is in the stem. The parents are most likely to have a daily problem with feeding The nurse in the newborn nursery should plan any interventions with a newborn with myelomeningocele based on the knowledge that the major short-term complication the child is most likely to suffer is: Hydrocephalus. Meningitis. Mental retardation. Paraplegia. The major short-term complication that infants with myelomeningocele face is infection following a tear or rupture of the sac. Hydrocephalus (Answer 1) does occur in 90% of these cases, usually following closure of the sac, but it is thought to be part of the CNS defect rather than a complication. Likewise, paraplegia (Answer 4) is part of the symptom complex these patients have, rather than a complication. Mental retardation (Answer 3) may or may not occur, but if it does occur it is a long-term complication. The question asks for a short-term complication rather than part of the symptoms (one that will be evident within 1-2 wk) The physician orders Tylenol elixir for a 14-month-old with a fever of 102°F. Considering this child's developmental level and diagnosis, which would be the best approach by the nurse? Use the medicine cup and tell the child the "pretty red syrup" will taste sweet like candy. Mix the medication with 4 oz of apple juice and allow the child to drink it through a "crazy straw." Put the medication into a brightly colored plastic cup and give the child a chance to drink it. Raise the child to a sitting position, bring the medicine cup to the lips, and tell the child kindly but firmly to drink it. As a toddler, this child will probably assert autonomy by refusing to take this medication. The best approach is to be firm yet kind, and always calm. No child should be told that medicine is like candy (Answer 1). Medication should be mixed with no more than 1 teaspoon of any nonessential food or beverage (Answer 2). This toddler will probably not drink this medication (Answer 3), and the nurse should not offer this choice because, if the child refuses, a "power struggle" will follow. Look for the choice that addresses the major developmental task for toddler—autonomy A toddler is to be placed in a croupette. The nurse should plan to perform which nursing action? Remove all toys from the crib. Withhold all liquids and solids temporarily. Monitor oxygen concentration daily and record in notes. Evaluate the toddler's reaction to oxygen therapy in terms of vital signs and color. If the toddler responds well to oxygen therapy, the child should show clinical improvement in terms of pink lips and nailbeds and normal vital signs, especially pulse. "All" toys do not have to be removed from the crib (Answer 1), nor will the child have to be NPO (Answer 2), although the child will probably be somewhat anorexic and prefer clear, cool liquids initially. Oxygen concentrations should be monitored and recorded at least every 2 hours (Answer 3). Eliminate the two options with the absolute "all." Also, recall that in the nursing process, nursing interventions are followed by evaluation The nurse should review principles of care with a 12-year-old child with asthma. Which comment by the child would require additional teaching by the nurse? I keep all my stuffed animals on my bookcase now. I have vinyl miniblinds on the windows in my room. I gave my cat to my best friend. I joined the swim team at school. Children with asthma should have no stuffed animals in their rooms, because they tend to collect dust; therefore more teaching would be needed. Additional measures to "allergy proof" the room and home should include using only washable miniblinds rather than curtains (Answer 2) and having no pets in the home (Answer 3). Moderate exercise such as swimming (Answer 4) is recommended. The question is asking for the incorrect response A mother asks the nurse about the normal time for the onset of menstruation. The nurse would be most correct in advising her that menses usually begin at age: 11.2 years 12 years. 12.8 years. 13.5 years. The average age for the onset of menstruation for American girls is 12.8 years of age; girls between 10.5 and 15 years can begin to menstruate within the normal range (Answers1,2,4). "Normal," "usually," and "average" are used as synonyms here. Know age-typical prepubertal and pubertal developmental norms In doing an infant's admission examination, the nurse notes all the following abnormal findings. Which one is the most common sign of heart disease the nurse should assess? Circumoral cyanosis. Hypertension. Diastolic murmur. Tachycardia. The majority of infants with CHD have tachycardia, or a heart rate above 160 beats/min; this is often the first sign of CHD that the nurse can assess. Circumoral cyanosis (Answer 1), hypertension (Answer 2), and diastolic murmur (Answer 3) all may or may not be present, depending on the type and severity of the defect. Note the use of the words "most common sign" in this question. Eliminate the three others that may not be present To "flood" the croupette with oxygen before placing a toddler in the tent, the nurse should initially adjust the oxygen flow rate to: 2-3 L/min. 4-5 L/min. 8-10 L/min. 15 L/min. To "flood" the croupette with oxygen means to raise the oxygen concentration to that level ordered by the physician; in general, the flow rate should be adjusted to 15 L/min, the tent should be closed and tucked in, and the nurse should wait about 15 minutes before checking the concentration and readjusting the flow. Lower flow rates (Answers 1, 2, 3) would result in lower-than-required oxygen concentrations. Note the use of the words "initially adjust" in this question A toddler is admitted to the hospital with acute bilateral otitis media, with a temperature of 103°F and tremors in arms and legs. In addition to a spinal tap to rule out bacterial meningitis, the doctor orders all the following. Which order should the nurse perform first? Respiratory isolation. IV 5% dextrose in 0.45 normal saline solution at 35 ml/hr. Tylenol 120 mg PO q4h. Seizure precautions. In caring for a patient with a potentially contagious condition such as meningitis, the first priority is protecting the nurse and other patients by observing appropriate infection control measures, in this case, respiratory isolation. All other nursing care measures would then follow in the appropriate order (Answers 2, 3, 4). Infection control is always a priority of care The doctor orders an IV to infuse at 35 mL/hr; a pediatric microdrip chamber is hanging. How many drops per minute should the nurse regulate the IV to infuse? 5-6. 7-8. 9-10. 35. With a pediatric microdrip chamber, the number of mL/hr = number of drops/min. Therefore, if the physician orders 35 mL/hr, the IV should infuse at 35 drops/min any other flow rate would be incorrect (Answers 1, 2, 3). The nurse must know how to calculate the rate of flow of IVs A 7-year-old who has had leukemia for 2 years was in primary remission for 18 months but recently experienced infections, epistaxis, and abdominal petechiae. The doctor suspects the child is no longer in remission and must be admitted to the hospital. In reviewing admitting blood work, the nurse notes all the following. Which finding should the nurse interpret as the probable cause of the infections? Anemia. Leukopenia. Neutropenia. Thrombocytopenia. Neutropenia is an abnormal decrease in the number of neutrophils, the specific type of WBC responsible for phagocytosis and bacterial destruction; as such, the infection in a patient with leukemia is most commonly related to neutropenia. These patients may also suffer from anemia (Answer 1), leukopenia (Answer 2), or thrombocytopenia (Answer 4), although these blood dyscrasias will result in other signs or symptoms of leukemia. Look for the cause that is directly related A school-age child with rheumatic fever develops heart failure and is placed on digoxin, Lasix, and potassium. The chief purpose for giving potassium is to: Enhance the cardiogenic effect of digoxin. Potentiate the diuretic action of Lasix. Prevent hypokalemia. Pharmacologically induce hyperkalemia. Patients receiving digoxin in addition to Lasix are particularly prone to developing hypokalemia, which can result in digoxin toxicity and potentially fatal cardiac dysrhythmias. Potassium supplements are frequently administered to avoid this problem rather than for any of the other reasons cited here (Answers 1,2,4). It logically follows that if K+ is given, the purpose is to replace K+ and therefore to avoid low K+ Two hospitalized school-age children complain that they are "bored." The nurse should offer them: A game of Monopoly or Life. Workbooks, paper, and pencils. Some books from the hospital library. A chance to stay up late and watch TV. School-age children are notoriously competitive, and they particularly enjoy the challenge of board games such as Monopoly or Life. Although schoolwork is important and should receive due consideration (Answer 2), it will not relieve their boredom. Likewise, books and TV (Answers 3, 4) are less effective diversions for the school-age child. Three options are passive, one is interactive. Remember that school-age children are highly competitive, enjoying interactive games with others A 12-year-old is admitted to the hospital in status asthmaticus, for the second time. In planning care for this child, the nurse must first assess: What she knows about asthma. How she usually cares for herself. What she knows about hospitalization. How she feels about becoming a teenager. In working with children in hospitals, the most important factor for the nurse to assess first is the child's experience with illness and hospitalization. This is of special importance with this child, who has been hospitalized previously. After this most important factor, the nurse would continue the admitting assessment by determining what she knows about asthma (Answer 1), how she usually cares for herself (Answer 2), and how she feels about becoming a teenager (Answer 4). A major principle of teaching-learning is to start where the client is When the nurse begins teaching a teenager with diabetes about insulin, which one fact should be stressed to this teen and the family? Properly controlled dietary management, along with hypoglycemic agents, may eventually be used. Exogenous insulin will be necessary for the rest of the child's life. Activity level, nutritional intake, and state of health will necessitate daily modifications in the insulin dose. Due to the need for insulin, the child should no longer participate in active sports. Because the beta cells of the islets of Langerhans of the pancreas will never again produce a sufficient quantity of insulin, this teenager will remain dependent on insulin injections (exogenous insulin) for the rest of his life. Patients with type 1 diabetes can never rely on hypoglycemic agents to control diabetes (Answer 1), because these drugs work by stimulating the pancreas, and in this case the stimulation would have absolutely no effect. Daily modifications would generally not be necessary (Answer 3), although periodic adjustments in insulin dosage would be needed as this teenager grows. The child can continue to participate in sports (Answer 4), but should be taught to take some extra foods on those days when actively participating in sports. To pick the most theoretically correct answer, pull apart the key points about a time element: eventually, for life, daily, never In doing a child's admission history, the nurse notes all the following signs of hemophilia. The hallmark, or classic sign, of hemophilia is: Excessive hematoma formation. Hemarthrosis. Prolonged bleeding from lacerations. Intracranial bleeding. Hemarthrosis, or bleeding into a joint either spontaneously or following an injury, is considered the hallmark, or most typical sign, of hemophilia. If hemarthrosis is not treated properly or adequately, permanent joint deformities may result. Other signs of hemophilia include prolonged bleeding from a relatively minor injury (Answer 3), excessive or unusual hematoma formation (Answer 1), and intracranial bleeding following a closed head injury (Answer 4). When all are correct, choose the one most associated with pain (a classic symptom of hemophilia), such as pain due to bleeding into a joint The nurse performs a Denver Developmental Screening Test (DDST) on a 3-year-old. Which behavior should the nurse expect this child to be capable of doing? Going up stairs on alternate feet. Pedaling a bicycle. Dressing without supervision, Tying shoelaces. Three-year-olds should be able to coordinate the brain and gross motor activity necessary to go up stairs using alternate feet. They should also be able to pedal a Big Wheel or a tricycle but not a bicycle (Answer 2). Three-year-olds should also be able to get dressed with supervision but not without it (Answer 3). They should not be ready to master tying shoelaces (Answer 4) for another year or two. Remember, three years = three wheels; a 3-year-old should be capable of pedaling a tricycle While admitting an infant, the nurse notes all the following abnormal findings. Which one is considered the classic sign of Hirschsprung's disease? Abdominal distention. Anorexia. Constipation. Vomitus flecked with feces. The classic sign of Hirschsprung's disease is obstinate constipation that persists despite all efforts at treatment. Other symptoms may also occur but are not generally considered specific to Hirschsprung's disease as much as they indicate in Testinal obstruction: abdominal distention (Answer 1), anorexia (Answer 2), and vomiting (Answer 4). Note the use of the words "classic sign" in this question, meaning specific to the condition The best way for a nurse to perform a test on a 9-month-old is to: Take the infant from the mother and ask her to wait in the child's room. Take the infant from the mother and ask her to come with them to the testing area. Briefly talk first with the mother, then take the infant to the testing area alone. Ask the infant's mother to carry the child to the testing area. The instruction manual of the DDST clearly states that the parent should accompany the child who is to have the DDST and that the examiner should do everything possible to establish rapport with the parent and the child. With a 9- month-old, this should include allowing the parent to hold the child rather than separating them for the purpose of Testing (Answers 1, 2, 3). Fear of strangers peaks at 8-9 months of age (i.e., keep the mother and baby together). Therefore, eliminate Answers 1, 3, and 4 For an infant with severe chronic CHF, the formula the nurse should plan to offer would be: Isomil. Lofenalac. Lonalac. Similac 27 with iron. An infant with severe chronic CHF should be on a low-sodium formula, Lonalac. Isomil (Answer 1) is a lactose-free formula that contains a normal amount of sodium. Lofenalac (Answer 2) is the formula used to treat infants with PKU and also contains a normal amount of sodium. Similac 27 with iron (Answer 4) is most frequently used for preterm infants and also contains a normal amount of sodium. Look at the name of the formula and try to think it through; lo = low, na = sodium, lac = sounds like similac. Thus, a low-sodium formula! The parents of a school-age child with leukemia tell the nurse that their daughter frequently has nightmares, and they wonder how to handle this. The nurse would be most correct in advising them to: Comfort her, but leave her in her own bed. Comfort her by bringing her into their bed. Consult a child psychologist to determine why she has recurring sleep disturbances. Encourage the child to keep a written record of her dreams and discuss them with her primary nurse during hospitalization. Most psychologists would recommend that a child be offered comfort in the form of a hug, kiss, or cuddle; however, the child should be left in his or her own bed to avoid overdependence on the parents or possible psychosexual conflicts caused by entering the parents' bed (Answer 2). For the school-age child, nightmares are a common occurrence and can be accepted as a normal part of 3; therefore, no professional intervention is necessary at this time (Answer 3). It could be very difficult for this child to keep written records of her dreams (Answer 4); in fact, such an expectation might lead to even more severe sleep disturbances for her. Focus on two options with "comfort," which are better than "consult" or "written record." As a general rule, children should sleep in their own beds, not with parents Before giving a child digoxin, which pulse would the nurse be most correct in assessing? Apical. Brachial. Pedal. Radial. Before administering digoxin to a child, the nurse should auscultate the apical pulse for a full minute to most accurately evaluate cardiac rate and rhythm. Other pulse sites (Answers 2, 3, 4) are less accurate in children. In this case, the key words "most correct" mean most accurate. Infants' and childrens' pulses should always be checked apically A 20-month-old is admitted to the pediatrics unit for the third and final, surgical procedure to correct his congenital hypospadias. When admitting this toddler to the hospital, the nurse should assess all of the following. Which information will be the most important to the nursing plan of care for this toddler? His developmental level. The parents' knowledge level regarding hypospadias, His previous experience with illness and hospitalization. The parents' plans for rooming-in. In working with children in hospitals, the most important factor for the nurse to assess first is what that child's experience with illness and hospitalization has been thus far. This is of special importance with this child, who has previously had two hospitalizations and surgeries; the nurse needs to know if these were positive experiences for this child and how he was able to cope with them. After this, the nurse would continue the admitting assessment by determining the child's developmental level (Answer 1), what the parents already know about hypospadias (Answer 2), and whether the child's parents plan to room-in with him (Answer 4). An important principle of teaching-learning is to always start with what the client already knows A hospitalized preschooler wakes up crying at 2 A.M. and says, "I want my mommy now." The nurse should: Pick the child up and rock the child for a little while. Talk softly to the child while rubbing the back, but leave the child in the crib. Gently but firmly tell the child to go back to sleep. Call the mother and ask her to come to the hospital. Hospitalized preschoolers often regress in their behavior and want "mommy," but this is obviously not practical all the time. The nurse should try to soothe the child back to sleep during the middle of the night. Calling the mother to come right in (Answer 4) would be inappropriate, because the family should not be called in the absence of a genuine emergency. The nurse should also not pick the child up (Answer 1), because hospitalized preschoolers frequently reject everyone except their "mommy." Simply insisting the child go back to sleep (Answer 3) is not enough, because the child needs some degree of comfort at this time. Look at the verbs: "pick ... rock," "talk softly... rubbing back," "firmly tell," "call... mother." Preschoolers will regress when stressed, and respond well to verbal and physical comfort ("talk softly. . . rubbing back.") The nurse does discharge teaching with the mother of a preschooler with epiglottitis before discharge. Which statement by the mother indicates that she has correctly understood the nurse's teaching? I'm so glad that my child is all better now. I will keep my child home from preschool for the rest of this month. I'm still worried that my child will get sick again when we get home. I will get a portable tank of oxygen for my child before he comes home. Although the abrupt onset and critical nature of this illness is very frightening for parents, the child is expected to make a total recovery before discharge. The parents should be aware of this very positive diagnosis. Although discharge instructions from the physician may include some rest at home, there is no need for the child to miss almost a month of school (Answer 2). The parents should not worry about the child's getting sick again (Answer 3) or having oxygen in the home again (Answer 4); the excellent prognosis should be stressed. Eliminate the incorrect statement first. Note the use of the words "correctly understood" in this question After flooding a croupette for 5 minutes, the nurse should readjust the flow rate of oxygen. To maintain an oxygen concentration of 35-40%, the nurse should now adjust the oxygen flow rate to: 2-3L/min. 4-5L/min. 8-10L/min. 15L/min. To maintain an oxygen concentration of 35-40%, the flow rate should now be adjusted to 8-10 L/min; this is the usual concentration ordered for a croup tent. Other flow rates would result in higher or lower concentrations (Answers 1, 2, 4). There is only one theoretically correct answer. Although respiratory therapy often sets up croupettes and other forms of oxygen therapy, the nurse should be thoroughly familiar with the usual rate of flow. In this case, pick the midrange response (not 2-5 or 15) A toddler tries to pull the IV out, and the nurse determines that the child must be restrained to maintain the IV site. Which restraint would the nurse be most correct in applying? Posey jacket. Elbow. Mummy. Clove-hitch. To restrain a toddler receiving IV therapy, clove-hitch restraint to two or more limbs is most effective in maintaining the IV site. A posey jacket (Answer 1) would allow the toddler use of hands with which to pull at the IV. Elbow restraints (Answer 2) would still allow the toddler to stand and twist at the IV tubing. A mummy restraint (Answer 3) would be unnecessarily restrictive for a toddler. Choose the option that is effective while not restraining, by visualizing what these various restraints do and where they are placed A lumbar puncture is performed on a child by the doctor. After the procedure, the nurse should position the child: Flat in bed, with no pillow. Flat in bed, with a small pillow. In semi-Fowler's position. Semiprone, with head to the side. The best position for patients who have had a spinal tap is perfectly flat in bed, with no pillow at all. Such patients are prone to headaches due to the loss of CSF during the spinal tap; until the fluid is naturally replaced by the body, a flat position will minimize cerebral irritation and minimize headache; thus, (Answer 2) is incorrect. Elevating the HOB (Answer 3) will increase headache and is not recommended. There is no need to place the child semiprone (Answer 4) at this time. Focus on two options that are "flat." "Flat" is "flat," meaning no pillow. Following a spinal tap, all patients should be flat in bed When the parents of a newborn with myelomeningocele visit the nursery for the first time, they make no comments about the baby's spinal sac. Instead, they offer many positive observations about size, color, hair, and appearance. The nurse would be most correct in interpreting the parents' behavior as: Attachment. Denial. Immaturity. Love. The usual response to the birth of a defective infant is denial, often manifest in the parents' "refusing" to acknowledge the problem; this is a normal response, at least initially. The parents' comments about their infant, in view of this serious defect, should not be interpreted as attachment (Answer 1), immaturity (Answer 3), or love (Answer 4). Denying (in this case, the obvious physical problem) is one of the most commonly seen defense mechanisms The pediatrician orders syrup of ipecac for a toddler who has ingested a harmful substance. Generally, the nurse should administer this medication only if the child is: Alert and reactive. Convulsing. Comatose. Known to have swallowed a corrosive substance. With a child who has suffered an ingestion, vomiting should be induced only if the child is fully alert and reactive. If the child has any alterations in level of consciousness, such as seizures (Answer 2) or coma (Answer 3), vomiting may cause an aspiration pneumonia. Further, if the child has swallowed a corrosive substance (Answer 4), the substance that burned once going down will burn a second time coming up if vomiting is induced. In this case, when one option (1) is different than two others (2 and 3 = not alert), choose the one that is different; note the use of the words "should administer," implying that you can eliminate three contraindicated situations (2, 3, 4) The mother of a toddler who will have his third, and final, surgical procedure to correct congenital hypospadias questions the need for another surgical procedure while he is still so young. The nurse should stress that: It is the mother's right to refuse surgery at any time. It is in her son's best interest to follow the doctor's recommendations. He can have this third, and final, surgery any time before the onset of puberty. This type of surgery is usually timed to take place between 6 and 18 months of age. The corrective surgery for hypospadias is usually timed to be completed before the child develops body image and castration anxiety, by 18 months of age. Developmental and psychological factors thus play a crucial role in the timing of this surgery, and other explanations (Answers 1, 2, 3) are either incorrect or inappropriate for this child. Note the two options with "time" (3, 4). Select the option that is age specific, not "anytime" (3) After the nurse completes preoperative teaching with a preschooler, which would be the best method for evaluating the effectiveness of the teaching? Ask him to draw a picture of what he will look like after surgery. Using puppets, ask him to show the nurse what he has learned about his surgery. Tell him that this is a test and he must repeat what he has learned about his operation. Suggest his parents check on their child's level of understanding and report back to the nurse. When doing preoperative teaching with preschoolers, the best method is to use puppets (doctor, nurse, hospital setup) to "act out" what the child can expect to happen. For evaluating the teaching, the nurse can then ask the child to use puppets to give a return demonstration of what was learned; this enables the nurse to clarify any misconceptions or answer any lingering questions the child might still have. Most preschoolers will not be able to accurately draw pictures regarding the factual information of preoperative teaching (Answer 1), although this might be a good way to get at feelings about the surgery or hospital. A preschooler probably has had limited experience with " Tests" (Answer 3). The nurse should not rely on the parents to evaluate the preoperative teaching (Answer 4), because they are not professionals and are most likely too involved emotionally. Preschoolers respond best to play— therapeutic, or medical The nurse should withhold a 6 year-old's digoxin and notify the physician if the child's pulse was below: 80 beats/min. 90 beats/min. 100 beats/min. 110 beats/min. The lower limit of a normal pulse rate for a 6-year-old is 75-80 beats/min; the nurse would be most correct in with holding the child's digoxin and notifying the physician if the pulse were below 80. A pulse rate of from 90 to 110 (Answers 2, 3, 4) would be considered within normal limits for a 6-year-old, and the nurse would be correct in administering the medication as ordered. The nurse should know approximate pulse rate norms for children of varying age groups. Key word is withhold with age-relevant norm for bradycardia An adolescent is admitted to the hospital in sickle cell crisis with severe pain in the legs and abdomen. The adolescent asks the nurse why the doctor ordered oxygen when there is no trouble breathing. The nurse would be most correct in stating that the main therapeutic effect of oxygen is to: Reverse sickling of RBCs. Prevent further sickling. Prevent respiratory complications. Increase the oxygen-carrying capacity of RBCs. Sickling of RBCs occurs under conditions of low oxygen tension; giving this adolescent oxygen will prevent further sickling of RBCs, but it will not reverse the sickling of cells that has already occurred (Answer 1). The oxygen is not given to prevent any respiratory complication (Answer 3), nor will the oxygen have an effect on the oxygen-carrying capacity of the RBCs (Answer 4). Focus on the two options with "prevent.” Then note that the word "sickle" is in both the stem and Answer 2 ("sickling") A child is admitted to the hospital with a second attack of rheumatic fever. In doing an admission assessment on this child, which group of symptoms would the nurse most likely find? Petechiae, malaise, and joint pain. Chorea, anemia, and hypertension. Tachycardia, erythema marginatum, and fever in late afternoon. Subcutaneous nodules, dependent edema, and conjunctivitis. The most common symptom in children with rheumatic fever is tachycardia due to cardiac involvement; in addition, these children may develop a rash, "erythema marginatum," and a characteristic fever, which spikes in the late afternoon. They do not usually have petechiae (Answer 1), hypertension (Answer 2), or conjunctivitis (Answer 4). Remember that cardiac symptoms are associated with rheumatic fever; therefore, choose the option with tachycardia A school-age child has leukemia. Considering the diagnosis and health-teaching needs, the nurse would be most correct in advising this child to: Skip brushing the teeth at this time. Brush the teeth with a soft toothbrush only. Brush the teeth with a firm toothbrush only. Rinse the mouth with an antiseptic solution instead of brushing the teeth. Children with leukemia often experience bleeding gums due to thrombocytopenia; in addition, chemotherapy may cause oral mucous membrane ulceration. Therefore, the nurse would be most correct in advising this child to use a soft toothbrush only. Using a firm toothbrush (Answer 3) might cause a break in the gums, leading to infection. Rinsing the mouth only (Answer 4) might also lead to infection, because this would not necessarily clean the gums and teeth adequately; likewise, infection might be caused by not brushing the teeth (Answer1). Narrow your choices to two contradictory options about brushes (soft vs. hard) and choose soft, due to bleeding The mother of a hospitalized 3-year-old tells the nurse that he is a very poor eater at home. The best recommendation the nurse can make to increase his nutritional intake would be to: Provide him with a child-size table. Use plastic cups and plates with cartoon characters he likes. Offer him small portions of his favorite foods. Allow him to feed himself. For a child just leaving the toddler period of autonomy and just entering the preschool period of initiative, the best suggestion to improve his nutritional intake would be to allow the child to feed himself. Other suggestions would supplement and enhance this primary consideration (Answers 1, 2, 3). The major developmental task of the toddler is autonomy; the major developmental task of the preschooler is initiative. Look at the verbs: "provide," "use," "offer," and "allow." Choose "allow." A 3-year-old with hemophilia is to be discharged, and the nurse has completed teaching with the child's parents. Which statement by the parents indicates they may have misunderstood the nurse's teaching regarding the care? If our child gets a fever, we will only give acetaminophen, not aspirin. We will be sure to supervise our child carefully so that our child doesn't experience another bleeding episode. I'll order a Medic Alert bracelet for our child as soon as we get home. It's a relief to know that our little daughter will not get this disease too. It would be impossible to supervise a child with hemophilia so carefully that any other bleeding episodes would be prevented; furthermore, to attempt to do so would cause the parents to restrict the child totally, resulting in extreme over-protection an acceptable alternative response would be to prevent "major" episodes of bleeding or to promptly recognize signs of a bleeding episode that would require medical intervention. The other statements (Answers 1, 3, 4) are all correct responses by the parents, indicating they have probably understood the nurse's teaching regarding the child's care. Note the use of the word "misunderstood" in this question, meaning look for the incorrect statement An infant with CHF takes 1.25 oz of formula in 20 minutes. The doctor ordered 2 oz of formula q3h. The best action for the nurse to take at this time would be to: Ask the mother to feed the infant when she arrives. Burp the infant and try to stimulate sucking. Continue feeding slowly, allowing as much time as the infant needs to finish. 4 Stop the feeding, and request an order for gavage feedings prn. Infants with CHF should be given about 15-20 minutes per feeding; if the infant is unable to finish the feeding, or if the infant becomes cyanotic or experiences respiratory distress during the feeding, gavage feeding should be used to avoid exhausting the infant and possibly precipitating an episode of apnea. No attempts should be made to continue the feeding (Answers 1, 2, 3). Three options continue the feeding and one option stops the feeding. In this case, choose the option that is different. The mother of a child with epiglottitis tells the nurse that she does not even know what epiglottitis is. The nurse would be most correct in telling her that it is: An infection of the upper respiratory tract related to allergy and excessive mucous production. A potentially life-threatening infection that requires prolonged intensive care. A mild form of croup that is usually treated at home. A swelling in the throat that can lead to total airway obstruction if not treated promptly. Epiglottitis is a bacterial infection of the epiglottis resulting in rapid airway swelling and obstruction; without prompt, aggressive treatment, it can progress rapidly, resulting in respiratory arrest within 6 to 8 hours of onset. Although this condition does require hospitalization and is potentially life-threatening, the ICU stay is usually short (Answers 2, 3). There is no allergic cause of epiglottitis (Answer 1). Of all the respiratory conditions of childhood, epiglottitis is the most rapidly progressive (i.e., quickly life threatening and quick to recover, hence short stay in ICU.) On admission, a preschooler is carrying a soiled and worn-looking stuffed animal. His mother states that this is his favorite toy. The most appropriate action for the nurse to take at this time is to: Offer him a choice of another stuffed animal from the hospital playroom. Place this stuffed animal somewhere in his room where he can see it but not touch it. Suggest his mother bring him a new stuffed animal. Tell him that he can keep this stuffed animal in the bed with him. When a preschooler has a favorite "security object," be it a blanket or a doll or a stuffed animal, that child should be allowed to keep the security object, even during hospitalization. This will promote the child's sense of trust and security, thus helping to make the hospitalization a more positive experience. Offering the child another toy (Answer 1), putting the toy where he can see it but not touch it (Answer 2), or giving him a new stuffed animal (Answer 3) will not take the place of the child's old but well-loved original stuffed animal. Preschoolers will regress when stressed. Note that two options allow the security object to remain-one at a distance and the other close by In reviewing a preschooler's admission history and laboratory results, the nurse should know that the two most common findings in children with nephrosis are: Generalized edema and proteinuria. Hyperlipidemia and periorbital edema. Hypertension and hematuria. Oliguria and anorexia. Nephrosis (nephrotic syndrome) is a chronic syndrome characterized by variable pathology and questionable prognosis. In general, most children with nephrosis have severe, total body edema and 4+ proteinuria, along with hypoproteinemia. Hypertension and hematuria (Answer 3), and hyperlipidemia and periorbital edema (Answer 2), are more common in acute glomerulonephritis. The child with nephrosis seldom has severe oliguria (Answer 4), although occasionally this may occur; anorexia (Answer 4) may or may not occur, depending on the severity of the exacerbation. Choose "generalized" edema over limited (periorbital) edema The number one priority during the nurse's admission assessment of a school-age child with rheumatic fever is the child's: Weight. Apical pulse rate. Developmental level. ESR Carditis is the only manifestation of rheumatic fever that can lead to permanent damage; the best way to evaluate a child for the presence of carditis is to monitor the apical pulse at least q4h. Growth and development (Answers 1, 3) and ESR (Answer 4) deserve secondary consideration after checking the apical pulse. When performing an assessment, priority always implies either heart or lungs In planning care for a teenager in sickle cell crisis, the nurse should base any actions on the knowledge that pain in vaso-occlusive crisis is primarily due to: Increased RBC destruction. Hepatosplenomegaly. Obstruction of small blood vessels. Sequestration of blood. The pain in vaso-occlusive crisis is due primarily to the clumping together of RBCs, which blocks small blood vessels, thus causing tissue ischemia, necrosis, and death. Although there may be increased RBC destruction (Answer 1) and hepatosplenomegaly (Answer 2), this is not the primary cause of this child's pain. Sequestration of blood does not normally occur with sickle cell anemia (Answer 4). Vaso-occlusive crisis implies a blockage (obstruction) in blood flow. Note the similarity of the term in the stem and in option 3 A teenager is preparing the first dose of insulin. The physician orders 14 U of NPH insulin; the teen draws up 13 U and shows it to the nurse. The nurse should base any response on the knowledge that: This is the first attempt and the teenager did come close to the exact dose. At this age, the teenager cannot be expected to make such fine discriminations in dosage. The teenager must draw up the exact amount before administration. Teenagers often antagonize adults subconsciously. From the very first attempt by a child to administer his or her own insulin, the nurse should stress the need to administer exact amounts as ordered by the physician. The child should learn from the start that "close" is not "correct" (Answer 1). A teenager can and should be capable of drawing up the exact amount (Answer 2). Drawing up an incorrect dose does not mean this teen is trying to antagonize the nurse, consciously or subconsciously (Answer 4). Any medication administered must be in the exact amount ordered Between feedings, the nurse should place an infant with CHF in which position? In an infant seat with head elevated. Prone with head turned to side. Supine with head slightly hyperextended. Side-lying with the head of the bed elevated 30 degrees. As with an adult with CHF, the infant should be positioned in a chair/infant seat, in semi-Fowler's position, to provide for maximum expansion of the lungs and to assist the heart placing the infant on the stomach (Answer 2) might be an acceptable second choice, providing the infant can tolerate this position. The infant should never be placed on the back (Answer 3), even with the head slightly hyperextended, because of the possibility of aspiration and other respiratory complications. A side-lying position (Answer 4) would not allow for maximum expansion of the lungs; an infant seat is more appropriate. Picture the various positions and eliminate options 2 and 3. Cardiac rest is best promoted by a semi-Fowler's (i.e., head elevated) position, regardless of the patient's age or condition The doctor attempts to shine a light through myelomeningocele sac and notes "no transillumination." The nurse should interpret this finding to mean that the sac: Can be easily repaired. Cannot be evaluated by this technique. Contains meninges and CSF. Contains meninges, CSF, and the spinal cord. Transillumination, or the procedure of shining a light through the sac, is the usual means for evaluating the contents of the sac. When there is "no transillumination" (the light cannot shine through the sac), this indicates the presence of solid material, or the spinal cord, within the sac. Thus Answers 2 and 3 are incorrect. Transillumination has no bearing on determining whether the sac can be easily repaired (Answer 1). Break up the word transillumination into its respective parts, trans and illumination, to derive its meaning. Choose the option that is most inclusive (3 is included in option 4) After administering syrup of ipecac to a toddler, the nurse should also give: Four ounces of warm milk. Activated charcoal powder. As much water as the child will drink. A slice of dry toast. Syrup of ipecac is an emetic used to induce vomiting following ingestion of a harmful substance; the usual dose in children is 10-15 mL PO followed by at least 200 mL of water. The water is thought to enhance the emetic effect of ipecac and stimulate emptying of the stomach, thus ridding the body of the harmful substance. Activated charcoal (Answer 2) will neutralize the emetic effect and should not be given with ipecac, although in some cases it may be given after vomiting has occurred. Milk or toast (Answers 1, 4) has little or no effect and will neither help nor harm; how ever, if the child does vomit, they may increase the risk of aspiration. Ipecac should always be administered with water After placing a toddler in a croup tent, the nurse should adjust the plastic canopy so that: The edges are tucked tightly under the linen. The edges are lying loosely on top of the linen. The crib rails are raised and the canopy edges are over them. The crib rails are lowered and the canopy edges are inside them. Because oxygen is heavier than room air, it will settle to the bottom of the croupette and leak out unless the edges are tucked in tightly. If the edges are lying loosely on top of the linens (Answer 2), the oxygen will escape, resulting in lower concentrations than ordered. The crib rails should be raised for safety, not lowered (Answer 4); and again the edges should be tucked in tightly, not draped over the rails (Answer 3). Focus on the two options about plastic canopy edges and select "tightly" over "loosely." In what position should the nurse place a child in status asthmaticus? Knee-chest. High Fowler's. Lateral Sims'. Supine, with neck hyperextended. The preferred position for a child with asthma is high Fowler's, or sitting up straight, which allows for maximum expansion of the lungs. Other positions would not allow for the maximum expansion of the lungs (Answers 1, 3, 4) and would only contribute to this child's hypoxia. A full upright position allows for maximum expansion of the lungs A teenager hospitalized with diabetes goes to the teen lounge and becomes very boisterous and aggressive, starting a fight with another teen. The first question the nurse should consider is: Should he be sent to his room? Did he eat breakfast today? What did the other teen do to him? Does he miss his own friends? Juveniles with diabetes (type 1 diabetes) are extremely brittle, or difficult to control, and prone to episodes of hypoglycemia or ketoacidosis. If this teenager were to experience a hypoglycemic episode, the earliest symptoms would often be behavioral: irritability, personality changes, etc. If this teen becomes disruptive, the nurse should first ask if he has eaten his breakfast, how much he ate, and when; other areas (Answers 1, 3, 4) would be appropriate to explore after this primary consideration. An underlying physiological cause to a patient's behavior should be explored first, before looking at behavioral considerations The nurse has completed discharge teaching with the parents of an infant with ventricular septal defect (VSD) and CHF. Which one statement by the mother would indicate the need for additional teaching by the nurse? I'll be sure to dress our baby in loose-fitting clothes. I'll try to keep my house as warm as 1 can for our baby. I'll be at the clinic in 3 days for the appointment. I'll put the baby in the playpen at least once a day. Extremes of temperatures, either too warm or too cold, should be avoided for infants with CHD, because this increases the body's demand for oxygen, thus increasing the workload of the heart. The mother would need no further teaching if she correctly stated that this infant should be dressed in loose-fitting clothing (Answer 1), should be brought back to the clinic for regularly scheduled appointments (Answer 3), and should be placed in a safe play area to stimulate development (Answer 4). Note the use of the phrase "need for additional teaching" in this question (i.e., look for the incorrect statement) A 7-month-old infant is admitted to the pediatrics unit with moderate dehydration secondary to acute gastroenteritis (AGE). The physician writes all the following orders for this infant. Which one should the nurse implement first? Contact precautions. IV of 5% dextrose in 1/3 normal saline solution at 25 mL/hr. Urine specific gravity stat and q4h. Stool culture every shift x 3. With a patient with a potentially contagious infection such as AGE, the first priority is protection of the nurse and other patients by observing appropriate infection control measures, including contact precautions. Other interventions can then be safely implemented without risk of cross contamination (Answers 2, 3, 4). Infection control is always a priority of care The best advice the nurse can give to parents to handle a toddler's temper tantrums would be to: Allow the toddler to make own choices. Ignore this behavior. Change the setting in which they occur. Give in to the toddler's demands, to nurture autonomy. The general recommendation to make to parents on how to handle temper tantrums is to ignore this behavior. If a parent allows a child to make a choice (Answer 1) and then does not follow through with this choice either because of personal preference or because the choice is unsafe, tantrums will increase. Changing settings (Answer 3) is often a catalyst for a tantrum as the child is moved from one area to another (e.g., from the park to home). Giving in to a toddler's demands (Answer 4) is unrealistic; parents should offer only allowable choices to their toddler and then allow the toddler to follow through with these choices. Paying attention to a temper tantrum will reinforce this behavior. A toddler is admitted to the hospital with classic hemophilia (factor VIII deficiency). Which admission procedure by the nurse will probably be the most frightening for this child? Blood pressure. Rectal temperature. Urine specimen. Weight. Toddlers typically fear those procedures that are "intrusive," that is, where something goes into their bodies. Therefore, a rectal temperature would most likely evoke the most anxiety in a toddler. Generally, a toddler would be relatively cooperative with getting weighed (Answer 4) and giving a urine specimen (Answer 3), although having blood pressure taken might also be somewhat threatening (Answer 1). Note the patterns in the answers: three options are nonintrusive procedures, one option is intrusive—and therefore most frightening In writing a nursing care plan for a child with leukemia, the nurse should include all of the following goals. Which goal is most important and should receive top priority? Maintain infection-free state. Prevent injury. Promote adequate nutrition. Meet developmental needs. The leading cause of morbidity and mortality in children with leukemia is infection; therefore, preventing infection is the most important nursing care plan goal. Preventing injury (Answer 2), promoting adequate nutrition (Answer 3), and meeting developmental needs (Answer 4) are less important goals for the child with leukemia. Infection control is top priority of care when the immune system is compromised (e.g., in leukemia) The physician orders sterile moist soaks to a myelomeningocele sac. The major reason for this treatment is to: Promote comfort. Prevent infection. Relieve pressure. Stimulate neural development. The chief purpose of the moist soaks is to prevent tears or leaks in the sac, which could lead to infection, the number one cause of death during the neonatal period. Promoting comfort (Answer 1) and relieving pressure (Answer 3) are not reasons for ordering moist soaks for this infant. It is not possible to stimulate neural development (Answer 4), which is permanently and irreversibly arrested before birth. Look at the verbs: "promote," "prevent," "relieve," and "stimulate." Choose "prevent." The night before surgery, as he is getting ready for bed, a preschooler asks his father to "check under the bed for monsters." The nurse would be most correct in advising his father to: Ask the child to talk more about these monsters. Leave a light on and let the child check for himself. Make a game of checking under his bed. Tell him that monsters are only make-believe. By making a game of "checking for monsters," a potentially frightening situation is relieved, and the child may even begin to realize that there "really" are no monsters asking the child to talk about his monsters (Answer 1) may make him believe they are real and that his father also believes in them. It would be too frightening to the child to have to look for these monsters by himself (Answer 2). Telling a preschooler that his fantasies are not real (Answer 4) would not be enough to convince him and might make him become even more convinced they are real. Preschoolers are in the age of fantasy or magical thinking; therefore choose option 3, "make a game." Following surgery to correct hypospadias, a toddler returns to the unit with a Foley catheter in place. The nurse should expect the drainage to have: A clear yellow appearance. Small clots of blood or mucus. Gross hematuria in moderate amounts. A brownish tinge. The surgical repair for hypospadias is done on the urethra primarily and also on the urethral meatus. Postoperatively, a urinary drainage apparatus (Foley or suprapubic) will be in place, and the urine is expected to have a clear yellow appearance. There should normally be no blood or mucus (Answers 2,3,4), which would indicate hemorrhage or infection if present. Choose the option that is different: three options indicate a problem, one says it is OK (yellow urine is normal) A child with cystic fibrosis is to receive replacement pancreatic enzymes several times daily. The best time for the nurse to plan to administer this medication is: After every meal or snack. Between meals and after every snack. Immediately before meals or snacks. With meals and before snacks. To be most effective, pancreatic enzymes should be administered immediately before every meal and every snack; this will facilitate the absorption of fats and proteins contained within the meal. The enzymes will have little or no therapeutic value if given at other times (Answers 1, 2,4). Key word is "replacement" of what is missing in CF; therefore, the best time to aid fat absorption is before eating In addition to administering oxygen, the nurse can also relieve the pain experienced by a teenager in sickle cell crisis by: Applying warm compresses. Applying cold compresses. Performing passive ROM exercises. Performing ADL as needed. Warmth causes vasodilation, thus relieving the occlusion of small vessels and preventing tissue damage. Cold (Answer 2) would never be used, because it causes vasoconstriction. Performing ROM exercises (Answer 3) or ADL (Answer 4) would not relieve pain. Focus on two options that are contradictory: warmth —> vasodilation; cold —> vasoconstriction. Occluded blood vessels need vasodilation measures The nurse observes a nursing student fastening an infant's diaper snugly around the abdomen; the infant has CHF. The nurse should: Ask the student to loosen the diaper. Do or say nothing, as this is expected behavior for a student. Loosen the diaper after the student leaves the room. Praise the student for outstanding attention to detail. An infant with CHF should wear loose-fitting clothes, including diapers, to avoid pressure on the abdominal organs, which could impinge on the diaphragm and impede respiratory effort. The nursing student should loosen the diaper and should know the rationale for this action as well. The nurse should not take care of this after the student leaves (Answer 3), because the student will repeat the mistake without the nurse's intervention; in addition, pinning the diaper snugly is inappropriate for an infant with CHF (Answers 2,4), and the nurse has the final responsibility for the care this infant receives. Any patient with CHF, regardless of age, should wear loose fitting clothes Which statement by the parents of a preschooler with nephrosis indicates that they have fully understood the nurse's teaching? We will keep him away from other children so he doesn't get a relapse. We're so glad this is all over and we don't have to worry any more. When we get home, we're going to find it hard to keep him in bed. We will watch him for any signs of this starting up again. Nephrosis is characterized by periods of exacerbations and remissions that occur throughout the childhood years. The child's parents should watch him closely for exacerbations, which should be reported promptly to the physician. The child should be encouraged to play with other children, not to stay away from them (Answer 1) to avoid feelings of social isolation. It is not "over" (Answer 2), and the child will need to be watched carefully for periods of exacerbation. Once the child is discharged, he will generally not need to remain in bed (Answer 3) but rather can convalesce at home with alternating periods of activity and rest. Note the use of the words "fully understood" in this question; therefore, use a true-false approach to eliminate the three false statements A child with leukemia is receiving vincristine. The nurse should observe this child closely for the side effect of: Diarrhea. Diplopia. Hemorrhagic cystitis. Peripheral neuropathy. Vincristine is an antineoplastic Vinca alkaloid, which causes numbness, tingling, footdrop, paresthesia, etc. In addition, vincristine may also cause constipation, not diarrhea (Answer 1). Hemorrhagic cystitis (Answer 3) may be caused by cyclophosphamide (Cytoxan), not vincristine. Vincristine does not cause visual changes (Answer 2). Know the major side effects of vincristine (peripheral neuropathy) A 6-year-old with cystic fibrosis refuses to swallow the replacement pancreatic enzyme tablets. The best course of action for the nurse would be to: Check with the doctor about discontinuing this medication. Crush the tablets and mix with 1 teaspoon of cold applesauce. Dissolve the tablets in 4 oz of warm milk. Offer the child a "special treat" for swallowing the tablets "like a big kid." Pancreatic enzymes are enzymes; as such, they breakdown whatever food or liquid they are mixed with. However, for maximum therapeutic effect, the enzymatic action should be delayed until the medication reaches the stomach. The best food to mix with pancreatic enzyme tablets is the cold applesauce. The applesauce should be cold because cold delays the enzymatic action, which is most effective at 98.6°F. Applesauce is used because of its high fiber content, which also delays the enzymatic action of the medication any other foods or liquids the pancreatic enzymes might be mixed with (Answer 3) would be less than ideal. Pancreatic enzyme tablets cannot simply be discontinued (Answer 1) because a child has difficulty swallowing them; this medication must be taken for the rest of the child's life. It is not appropriate to bribe a child (Answer 4) with a reward for desired behavior; children should never be bribed or threatened into taking medication. Focus on the two options with contradictory terms: cold vs. warm. Cold has the desired effect of delaying enzymatic action A school-age child experiences the following signs or symptoms of rheumatic fever. The nurse should plan any interventions based on the knowledge that the only one that may result in permanent damage is: Sydenham's chorea. Migratory polyarthritis. Carditis. Erythema marginatum. Carditis can lead to permanent, irreversible cardiac damage, specifically, mitral valvular stenosis. The other manifestations of rheumatic fever (Answers 1, 2, 4) are transient and do not leave any permanent effects. Key word is "permanent." Choose the option pertaining to the heart. The best roommate for a 9-year-old girl with rheumatic fever would be: An 8-year-old girl with impetigo. A 9-year-old girl with a tonsillectomy. A 10-year-old girl with a concussion. An 11-year-old girl with a fractured elbow in skeletal traction. A child with rheumatic fever will be in the hospital for a relatively longer time and will be confined to bed most of the time. The ideal roommate would be another child of the same sex and same developmental level who will also be in the hospital for some time and confined to bed. The best choice is the young girl with the fractured elbow, who will be in skeletal traction and also on bed rest. The child with a tonsillectomy (Answer 2) or the child with a concussion (Answer 3) will most likely be in the hospital for a very short time and will be out of bed. The child with impetigo, caused by streptococcus (Answer 1), would be a most unsatisfactory roommate for this child, because she might reinfect her with strep. The ideal roommate for any child is another child of the same sex and developmental level The nurse should be aware that the most important nursing diagnosis in caring for a child with diabetes is: Risk for injury related to insulin deficiency. Altered family processes related to situational crisis (child with chronic disease). Knowledge deficit related to care of a child with diabetes. Altered body image related to treatment of diabetes. The most important nursing diagnosis relates to physiological integrity (i.e., maintaining a normal blood-sugar level). Other diagnoses (Answers 2, 3, 4) would be correct but not necessarily of primary concern. Physiological integrity is always a priority of care An infant with myelomeningocele is scheduled to have surgery to close the sac. The mother asks the nurse if the baby will be able to move the legs following this operation. The best response for the nurse to make would be: Not usually, although we can always hope for a miracle. There is no way to predict. All we can do is watch the baby closely. No, the surgery is done mainly to prevent infection. Yes, the surgery will restore the ability to move the legs. Parents often hope that the surgery done to close the sac will also help the infant move the legs. Surgery will not enable the infant to regain motor or sensory functioning; surgery is done primarily to prevent infection. Parents should not be told the infant will move the legs after surgery (Answer 4) or offered false hope (Answers 1, 2). Myelomeningocele results in permanent, irreversible nerve damage The best method to prevent the spread of infection from an infant with AGE to other staff members or visitors would be: Double-bagging all linens. Obtaining stool cultures. Strict hand washing. Wearing disposable gloves. The best means to prevent any type of infection in any type of setting is good hand washing. Other techniques are secondary (Answers 1,2,4). Hand washing is the first line of defense in infection control At 7 months of age, an infant exhibits the following skills. The nurse should know that the most recently acquired skill is probably the ability to: Roll over. Sit up. Bear some weight on legs. Pick up objects with palmar grasp. At 7 months of age, an infant may either sit with some support or sit alone; either behavior is commonly acquired at this age. Rolling over (Answer 1) is usually found in infants around 3 to 4 months of age, whereas weight bearing (Answer 3) and the palmar grasp (Answer 4) are commonly found in infants between ages 4 and 6 months. Note the use of the phrase "most recently acquired skill" in this question The most appropriate person to administer a preoperative series of cleansing enemas to a 9-month-old with Hirschprung's disease would be the: Primary nurse. Mother. Nursing student. Nursing assistant. As a 9-month-old with a chronic bowel problem, this infant has probably become accustomed to mother's administering suppositories or enemas. In addition, fear of strangers is common in this age group. Considering these factors, this infant's mother should at least be offered the opportunity to administer or assist with the enemas. If this is not feasible, another qualified person could take her place. (Answers 1, 3,4). Look at the pattern of responses: three options are staff, one is the mother. Choose the one that is different, especially considering that fear of strangers peaks at 8—9 months On admission, the nurse would expect a toddler to demonstrate which two early signs of laryngotracheobronchitis (LTB)? Cyanosis and apnea. Hoarseness and croupy cough. Restlessness and tachypnea. Retractions and inspiratory stridor. LTB progresses through four distinct stages, with early symptoms in the first stage including fear, hoarseness, croupy cough, and inspiratory stridor only when disturbed. In the second stage, the stridor is constant and is accompanied by retractions (Answer 4). In the third stage, restlessness and tachypnea (Answer 3) are seen in addition to anxiety, pallor, and sweating. In the fourth and final stage, intermittent or constant cyanosis is followed by the cessation of breathing, or apnea (Answer 1). Note the use of the words "early signs" in this question A diagnosis of bacterial meningitis is confirmed, and the child assumes an opisthotonos position. In which position should the nurse now place this child? Prone. Supine. Side-lying. Trendelenburg. The opisthotonos position occurs in children with severe meningitis due to the pressure on the spinal cord; the child's head is drawn back and the spine is arched backward in an attempt to minimize pressure on the cord. When the child assumes this position, the nurse should place the child in a side-lying position for safety and comfort. Any other position would not work as well (Answers 1, 2, 4). Visualize the condition, and then visualize the options to identify the position for safety and comfort In planning a roommate for a hospitalized 12-year-old girl, the nurse should realize that a child of this developmental level will: Probably prefer another girl her own age. Most likely seek out opportunities to socialize with teenagers. Enjoy being with either a girl or boy, as long as they are the same age. Feel helpful if given the opportunity to look after a slightly younger child. Younger teenage girls in particular prefer the company of other young girls; they have a definite preference for same- sex, same-age companions as such, this child would not necessarily seek out older or younger children (Answers 2, 4), nor would she have "no preference" regarding the sex of her companion (Answer 3). Know age-relevant stages of psychosocial development. Young teenage girls generally prefer a same sex "best friend." In teaching a teenager how to prevent further episodes of sickle cell crisis, the nurse should stress the need to avoid: Moderate emotional stress. Cool weather. Swimming in public pools. Extra fluid consumption. Crises are precipitated by conditions of low oxygen tension; this may include infection, which could easily be picked up by swimming in public pools. Other sources of low oxygen tension might include severe emotional stress (Answer 1), extremely cold or windy weather (Answer 2), or dehydration (Answer 4), as well as high altitudes. Note the use of the word "avoid" in this question, and situations that may lead to infections If a child who was given syrup of ipecac has not vomited within 30 minutes, the nurse should: Stimulate the gag reflex using his or her fingers. Wait another 30 minutes before doing anything else. Assume the danger is past and no further treatment is needed at this time. Repeat the dose a second time. With children who have received a 10 mL dose of syrup of ipecac, if vomiting has not occurred within 30 minutes, the dose can and should be repeated once more. Although the first dose is generally effective in the majority of cases, a second dose is almost always 100% effective. If the child does not vomit after a second dose, manual stimulation of the gag reflex or gastric lavage must be promptly initiated to avoid toxic effects of ipecac. The nurse should never use fingers to stimulate the gag reflex (Answer 1), especially in a toddler, because of the danger of receiving a human bite. Ipecac works within 15—30 minutes, and waiting another 30 minutes will not be helpful (Answer 2). If the child does not vomit at all, thus not removing either the ipecac or the ingested substance(s), there is the danger of ipecac toxicity, as well as poisoning from the ingested substance (Answer 3). Eliminate 2 (do not wait) and 3 (there is a danger) because ipecac is cardiotoxic and can cause complete heart block The physician orders "increase activity as tolerated" for a school-age child with carditis associated with rheumatic fever. After getting the child up into an armchair, the nurse should monitor how well this increase in activity is tolerated by checking the: Apical pulse rate. Breath sounds. Degree of restlessness. Lips and nailbeds. Due to this child's carditis, the best means for the nurse to evaluate how well any increase in activity is tolerated would be by monitoring the apical pulse rate any increase in pulse rate over 15—20 beats/min would indicate that the increase in activity is not tolerated and would be an indication for returning the child to bed immediately any other method of evaluating tolerance of increasing activity would be less effective (Answers 2, 3, 4). Activity tolerance in heart conditions (carditis in rheumatic fever) is best measured by heart rate About a week after discharge, a teenager newly diagnosed with diabetes and his mother return to the clinic for a checkup. His mother states, "I'm worried he will make a mistake, so I've been giving him his insulin." The nurse should: Allow the teenager and his mother to work this out on their own. Assist his mother to understand that he must assume this responsibility. Encourage his mother to continue working closely with him. Realize that this is an appropriate response by the mother. The teenager who is newly diagnosed with diabetes must assume responsibility for his own care as soon as possible; diabetes is a chronic disease with no known cure that this teen will have to live with for the rest of his life. The nurse should discourage his mother from being overly protective of him or from assuming this responsibility (Answers 1, 3, 4). Self-care management is always a patient-centered goal The mother of a hospitalized infant with CHF asks the nurse why the baby is sucking on a pacifier. The nurse would be most correct in telling her: The baby seems to like it. Most infants prefer a pacifier to their thumb. This is to keep the baby from crying. We give all hospitalized infants a pacifier. The use of a pacifier for an infant with CHF will promote true psychological rest, thus reducing the body's demand for oxygen and reducing the workload of the heart. This is the most important reason that this infant should be offered the pacifier; although it may also be true that the infant seems to like the pacifier (Answer 1), this is not the main reason one should be given. Answers 2 and 4 are too generalized and not necessarily true. According to Freud, because infants are in the stage of oral gratification, a pacifier will reduce crying, which is medically significant in this case The first night in the hospital, a child with hemophilia suffers an episode of epistaxis. In which position should the nurse place this child? Prone, with head turned to side. Semi-Fowler's with two pillows. Sitting up with head tilted backward. Sitting up and leaning forward slightly. Contrary to popular belief, the best position for the nurse to place a child with a nosebleed in is sitting up and leaning forward slightly, with head remaining above the level of the heart; this position will allow the blood to drain freely from the nose and prevent aspiration. Sitting up with the head tilted backward (Answer 3) will predispose the child to swallowing or aspirating blood, as will a semi-Fowler's position (Answer 2). The prone position (Answer 1) might be an acceptable second choice if the child were too weak to sit up without assistance. Preventing aspiration and maintaining a patent airway is always a priority of care Nursing care for a toddler in the croupette includes which of the following? Giving a bald plastic doll. Removing the blanket and pajamas. Restraining the arms and legs. Restricting visitors to the immediate family. While in the croupette, toddlers should be allowed only those toys that can be dried off easily; all stuffed animals, dolls with hair, etc. are not allowed, because they will harbor moisture and bacteria. While in the croupette, the child and the linens will also get damp or wet, and the nurse should implement measures to prevent chilling. Pajamas and blankets should be changed q4h or prn (Answer 2). There is no need to restrain a child in the croupette (Answer 3), because all working parts are safely outside the croupette. There is no need to restrict visitors (Answer 4). Infection control is always a priority of care. Look at the verbs in the stem: "giving," "removing," "restraining," and "restricting." "Giving" is preferable; it sounds better than the 3 r’ s The mother of a child with cystic fibrosis tells the nurse that she is thinking of getting pregnant again but is worried that her next child might also have cystic fibrosis. Because her child does have this disease, the nurse should advise this mother that a second child: Could be even more severely affected than her first child. Might also have the disease. Should be "normal," or disease free. Would only carry the trait. Cystic fibrosis is inherited as an autosomal recessive disorder. The fact that these parents have a child with CF means that they are carriers of the trait, and each subsequent pregnancy might result in a child who also has CF. It would not be correct to advise the mother that a second child would only carry the trait (Answer 4) or would be normal (Answer 3), although there is a possibility these might occur; the parents should be fully advised of the odds of this happening. In addition, it would needlessly worry the parents to tell them a second child might be more severely affected (Answer 1), although this is also a possibility. Regardless of the genetics, having had one child with this disease, there is always a risk that subsequent children may also have this disease A child has had asthma since age 6. In reviewing this child's history, which one factor should the nurse realize may be related to the development of the asthma? Strep throat/tonsillitis at age 2. Eczema at age 31/2. Paternal death at age 5. Pneumonia at age 7. About half the children who have eczema during the toddler or preschool years develop asthma during the school-age or teenage years asthma seems to have little or no relation to strep throat or tonsilitis (Answer 1). The father's death undoubtedly would have affected this child, but it occurred 1 year before the onset of the asthma (Answer 3). The pneumonia experienced at age 4 might have been related to the asthma, but was not the cause of it (Answer 4). Although the etiology of asthma is multifactorial, there is thought to be an allergic predisposition Which one behavior should the nurse expect a 5-month-old with CHF to be capable of demonstrating? Rolling over from stomach to back. Sitting with support. Pincer grasp. Bearing some weight on legs. Considering this infant's diagnosis, the nurse should anticipate that the infant will most likely have at least some developmental delays; most infants would begin to roll over by 3 months of age, but at 5 months the baby should be doing this now. Sitting (Answer 2) is normally found around 6 months of age; this infant will most likely not be capable of this behavior at 5 months. A pincer grasp (Answer 3) is normally found at 9-12 months of age, and this infant will most likely not be capable of this behavior. Weight bearing (Answer 4) is typically noted in healthy infants at 4-6 months of age; considering this infant's diagnosis, however, this baby may or may not be capable of this more strenuous behavior. Infants learn to roll over at 3 months, sit at 6 months, and crawl at 9 months. Consider delayed development in congestive heart failure Following surgery to close the myelomeningocele sac, the nurse should place the infant on the: Abdomen, with head 10 degrees lower than hips. Abdomen, with head of bed elevated 30 degrees. Abdomen, with hips 10 degrees lower than head. Abdomen, flat in bed. The infant is placed on the abdomen postoperatively to prevent trauma or pressure to the sutured area on the back. In addition, the infant's head should be positioned 10 degrees lower than the hips to prevent the pressure of circulating CSF from affecting the suture line on the lower back an obvious contraindication to this position is the presence of increased intracranial pressure, in which case the infant would be positioned flat in bed (Answer 4). In general, the head is never higher than the hips (Answers 2,3) during the immediate postoperative period for this type of surgery. Visualize the positions; know postoperative objectives regarding preventing pressure to suture area Parents of an infant with Hirschsprung's disease ask the nurse how their baby got the disease. The nurse would be most correct in advising them that: Their baby was born with this condition. It is the result of the meconium ileus the baby experienced as a newborn. Their baby spontaneously developed this condition. It often occurs following the introduction of solid foods due to a genetically inherited metabolic defect. Hirschsprung’s disease is a congenital condition. It does not "develop spontaneously," although the diagnosis may not be made until symptoms have been present for several months and some attempts at conservative medical treatment (enemas, stool softeners, etc.) have been made (Answer 3). In the newborn with Hirschsprung’s disease, there may be an episode of meconium ileus (Answer 2), but this occurs as a result of the Hirschsprung’s disease rather than as the cause of it. There is no known metabolic defect (Answer 4). Narrow your option to the one that is different: congenital vs. acquired after birth As a toddler recovers from meningitis, the nurse should watch carefully for which long-term complication? Encephalitis. Hydrocephalus. Learning disabilities. Mental retardation. As healing of the pathways of the CSF occurs following an episode of meningitis, scar tissue naturally forms; this may lead to noncommunicating hydrocephalus. The hydrocephalus might then lead to learning disabilities (Answer 3) or mental retardation (Answer 4). Encephalitis (Answer 1) may occur in conjunction with the meningitis, but it is not a complication. Note the use of the term long-term complication in this question, and select the option that incorporates (leads to two other conditions) or is in conjunction with the other options In reviewing what he would do if he experienced a hypoglycemic episode, a teenager correctly states that he would eat a piece of candy or drink a glass of orange juice. The nurse should then instruct him to follow this concentrated sweet with: A blood glucose level. A urine dipstick for glucose. A glass of milk. 5 U of regular insulin. Because concentrated sweets will cause a rise in blood sugar, followed by a precipitous drop, the nurse should teach this patient that he should follow up this concentrated sweet with a complex carbohydrate such as a glass of milk any other action would be inappropriate at this time (Answers 1, 2, 4). The complex carbohydrate will help maintain a steady blood sugar level. Therefore, choose the only option that is not a diagnostic Test or pharmacological agent. The mother of a child hospitalized with asthma asks the nurse what causes asthma. The nurse would be most correct in telling her the cause is: Unknown. Allergies. Stress. Multiple factors. There are multiple factors involved in the etiology of asthma, including an allergic predisposition (Answer 2), precipitation by severe emotional or physical stress (Answer 3), and other factors yet to be determined (Answer 1). When more than one option looks correct, choose the more comprehensive answer (multiple answers = "multiple factors") Long-term follow-up care is being planned for a school-age child with rheumatic fever before discharge from the hospital. This must include: Indefinite antibiotic therapy. Immunization against future attacks. Cardiac rehabilitation program. Home-bound tutoring. Long-term follow-up care for children with rheumatic fever most frequently includes antibiotic therapy with penicillin or erythromycin on an exact schedule for an indefinite time. There is no way to immunize against future attacks (Answer 2). This child will be sent home on restricted activity, and cardiac rehabilitation programs are out of the question at this time (Answer 3). Home tutoring would be fine, but it is not a priority at this time (Answer 4). Medical prevention is the clue to the best choice A preschooler has been admitted with a tentative diagnosis of epiglottitis. A medical student wants to look down this child's throat to visualize the epiglottis. The nurse would be most correct in: Asking the child's mother if she objects to the medical student checking her child. Telling the medical student that this absolutely cannot be done. Promising the child a special treat for "opening real wide for the doctor." Helping restrain the child so the medical student can get a better look. In suspected cases of epiglottitis, the visualization of the epiglottis is strictly contraindicated, because it may precipitate laryngospasm and immediate respiratory arrest. It is a nursing responsibility to inform any less knowledgeable health care providers of this danger; any other action (Answers 1, 3, 4) would be inappropriate at this time. The nurse must always serve as a patient advocate. Also note that three responses allow the procedure, but one does not. Choose the one that is different from the others A preschooler with nephrosis is started on prednisone. If the prednisone is having the expected therapeutic effect, the nurse should expect that this child will: Experience mood swings. Have sugar in the urine. Gain weight. Feel better. There is no known cure for nephrosis; rather, treatment is aimed at providing symptomatic relief. To that effect, prednisone—an anti-inflammatory corticosteroid is given to relieve symptoms rather than effect a cure. If prednisone has the expected therapeutic effect, the patient should report "feeling better" as symptoms are relieved. Side effects of prednisone therapy may also include mood swings (Answer 1), glucosuria (Answer 2), and fluid retention with weight gain (Answer 3). Note the key words "expected therapeutic effects," not side effects A toddler who is being placed in a croupette cries and tries to cling to the mother. The mother asks the nurse if she can climb into the crib and lie in the tent with the toddler. The nurse's best response would be: Do you always let your child behave this way? I'll have to check with the doctor first. No, that would not be safe for you or the child. It may help the child calm down; let's give it a try. Toddlers will suffer the most if separated from their mothers; a croupette is a particularly frightening experience, because explanations are difficult. If the toddler will calm down with the mother in the croupette, this will decrease the body's need for oxygen. There is no need to check with the physician (Answer 2), nor would it be "unsafe" (Answer 3). Considering that the child is hospitalized and most likely frightened by the strange equipment, there is no reason to question the parent's handling of the situation (Answer 1). First, decide if this is OK or not OK. Recall that toddlers are at a peak age for separation anxiety, and choose an "OK" answer In a 2-week-old infant, the earliest sign of hydrocephalus that the nurse would observe is: Bulging anterior fontanel. Increasing head circumference. Shrill, high-pitched cry. Sunset eyes. In infants, the earliest sign of hydrocephalus is increasing head circumference, which occurs as the suture lines separate and the fontanels widen to accommodate the extra fluid within the skull. Later signs would indicate that no further accommodation can occur and brain tissue is being destroyed; these signs might include bulging anterior fontanel (Answer 1), shrill, high-pitched cry (Answer 3), and sunset eyes (Answer 4). Note the use of the term earliest sign in this question A child with leukemia who is receiving chemotherapy develops oral ulcers. Three of the following are appropriate nursing interventions; which one is inappropriate? Encourage the child to use viscous lidocaine (Xylocaine) before meals. Offer the child a bland, moist, soft diet. Use a soft tooth brush. Provide frequent normal saline mouth rinses. Viscous xylocaine is never recommended for children with mucosa ulcerations secondary to chemotherapy, because of the risk of a depressed gag reflex and aspiration. The other interventions (Answers 2, 3, 4) are, however, all appropriate nursing interventions. Note that this question is asking about an intervention that is not appropriate, meaning eliminate the correct statements A child with nephrosis has a swollen scrotal sac. Which nursing action would be most effective in relieving discomfort? Apply zinc oxide to scrotum qid. Cleanse scrotum with warm water only. Sprinkle medicated powder on scrotum. Support scrotum on folded diapers. As generalized edema progresses, in males the scrotal sac can become extremely swollen, tender, and painful. The best nursing intervention is to place soft, folded diapers under the scrotum while the child is lying in bed. Zinc oxide (Answer 1) or medicated powder (Answer 3) will have little beneficial effect because the problem is mechanical rather than on the skin itself. Cleansing the scrotum (Answer 2) is important to prevent infection, because all edematous tissue needs special care to prevent skin breakdown; however, this will not relieve the child's discomfort. Providing comfort is the priority of care The surgeon orders a preoperative series of cleansing enemas for an infant with Hirschsprung's disease. The nurse should expect the solution ordered for these enemas to be: Soapsuds enema (SSE). Normal saline. Pediatric Fleets. Tap water. The only solution that should be used in doing cleansing enemas for a child with Hirschsprung's disease is normal saline, because the child will retain some of this fluid, which will be absorbed through the bowel wall as an isotonic solution, normal saline will not alter the fluid balance, as a non-isotonic solution almost certainly would (Answers 1, 3, 4). The choice is between isotonic and non-isotonic solutions. Select the isotonic solution In doing the admission assessment, the nurse should expect to find which signs of dehydration in an infant? Fever and bradycardia. Irritability and sunken eyeballs. Hypotension and anuria. Dry mucous membranes and bulging anterior fontanel. Signs of dehydration in infants include irritability and sunken, dry eyeballs due to fluid loss. Fever may be present, and tachycardia, not bradycardia (Answer 1), is also common. Low blood pressure often results, followed by oliguria; anuria (Answer 3) is rare and would be an ominous sign of renal failure. The oral buccal mucosa may be quite dry, and the anterior fontanel may be sunken, not bulging (Answer 4). If part of an answer is right but part of it is wrong, the answer must be wrong If a toddler were to develop hydrocephalus, which would be the earliest sign(s) the nurse would most likely note? Irritability and poor feeding. Increasing head circumference. Headache and diplopia. Ruptured retinal vessels. If a toddler were to develop hydrocephalus, the first sign would most likely be irritability and poor feeding due to increased intracranial pressure. The head circumference would not increase (Answer 2), because the fontanels have closed. Headaches or double vision might occur (Answer 3), but a toddler is not likely to complain of them. Ruptured retinal vessels (Answer 4) are a later sign of increased intracranial pressure. Note the use of the word "toddler," not infant, in this question The mother of a child with cystic fibrosis asks the nurse if the child will be allowed to participate in any team sports now that he is starting school. The nurse would be most correct in advising her that the child can participate in: Softball. Tennis. Soccer. Swimming. The best exercise for a child with cystic fibrosis is swimming, which provides needed exercise at an activity level that is not overly taxing for the child. Softball, tennis, and soccer (Answers 1, 2, 3) arc all generally thought to be too strenuous for a child with CF. "Swimming" is the option that is different from the others, which all call for ball playing Parents of a child with sickle cell anemia both have the sickle cell trait. In counseling these parents about having another child, the nurse would be most correct in telling them that future pregnancies will have a: 1:4 chance of producing a child with sickle cell anemia. 1:2 chance of producing a child with sickle cell anemia. 1:4 chance of producing a child with sickle cell trait. 4:4 chance of producing a child with sickle cell anemia. Because sickle cell anemia is inherited as an autosomal recessive disorder, if both parents have the trait, any future pregnancies would have a 1:4 (not 4:4 as in Answer 4) chance of producing a child with sickle cell anemia answer 2 is incorrect because each pregnancy would have a 1:2 chance of producing a child with the trait answer 3 is incorrect there is a 1:4 chance of producing a normal child answer 4 is totally incorrect. Autosomal recessive disorders have a 1:4 chance of occurring when both parents are carriers of the trait A patient with hemophilia is to receive Factor VIII concentrate. During the infusion of this medication, the nurse should plan to observe this patient for which potential complications? Emboli formation. Fluid volume overload. Onset of AIDS. Transfusion reaction. Factor VIII concentrate is a blood product; a type and crossmatch may be ordered for the child before the IV administration of this medication. Given the relatively small volume of fluid to be administered, it would not usually cause fluid volume overload (Answer 2). Although there has been some discussion about administering multiple IV medications to a patient with hemophilia and the linkage to AIDS (Answer 3), this is not a concern during the actual administration of the medication but rather a long-term concern. Emboli formation (Answer 1) can occur with any IV administration and is not specific to cryoprecipitate, although the nurse would need to take the necessary precautions to prevent this possibility. Any patient receiving blood or blood products should be closely monitored for a possible transfusion reaction A preschooler with epiglottitis is admitted to the hospital and is to receive Solu-Cortef 100 mg IV q6h. The main purpose for this medication is to: Provide mild sedation. Reduce swelling. Relieve pain. Treat infection. Solu-Cortef is a corticosteroid/anti-inflammatory used in epiglottitis to relieve edema. Solu-Cortef does not provide sedation (Answer 1) or relieve pain (Answer 3), and the bacterial infection is treated with antibiotics (Answer 4). Recall that this is a steroid; recall its function and recall that edema is a main concern in this condition. Therefore, reduction of swelling to keep airway patent is a priority A child with leukemia is being discharged, and the doctor suggests an immediate return to school. The nurse should be sure to teach the parents to keep this child home if any classmates develop: Impetigo. Strep throat. Pneumonia. Chickenpox. Although any infection can be life-threatening to a child with leukemia, chickenpox presents a particular danger, because the child may develop encephalitis or sepsis. Infections such as impetigo (Answer 1), streptococcus (Answer 2), or pneumonia (Answer 3) are less specific dangers. Choose the option that can result in encephalitis, a specific danger In discharge teaching with the parents of an infant with VSD and CHF, which one visitor should the nurse discourage from touching or holding this infant? An aunt, who has lupus. A grandmother, who has a slight cold. The father, who is a drug addict. A 3-year-old sister, who is in nursery school. Because infants with VSD and CHF have a tendency toward respiratory infections, the infant should have limited contact with visitors with URIs, such as the grandmother with her slight cold. In fact, her slight cold might mean an episode of pneumonia for this infant. Lupus (Answer 1) in the aunt is not contagious, nor is the father's drug addiction (Answer 3). The sister (Answer 4) should be allowed to see and touch the infant, unless she herself is sick. Respiratory infection control is the priority of care In monitoring a toddler for response to syrup of ipecac, the nurse should base any actions on the knowledge that ipecac is potentially: Cardiotoxic. Hepatotoxic. Nephrotoxic. Neurotoxic. The chief danger of ipecac's being absorbed into the body is that it can cause cardiac arrhythmias, atrial fibrillation, or severe heart block. There is minimal effect on the liver (Answer 2), kidneys (Answer 3), or CNS (Answer 4). Ipecac can cause cardiotoxicity A mother who lost her first-born to SIDS tells the nurse that she plans to breastfeed her second baby to prevent this from happening again. The nurse should base any response on the knowledge that: The risk of SIDS is the same, however infants are fed. Breastfeeding does seem to prevent SIDS. SIDS occurs less frequently in infants who are bottlefed. Breastfeeding is contraindicated for siblings of infants who died from SIDS. The most recent research indicates that infants who are breastfed do have a lower incidence of SIDS than bottle-fed infants. It is not true that bottle-fed infants have a lower risk of SIDS (Answer 3), nor is it true that the risk of SIDS is the same (Answer 1) however infants are fed. Breast feeding is not contraindicated for siblings of infants who died from SIDS (Answer 4); in fact, breastfeeding in this instance is recommended. Breastfeeding is generally recommended for all infants whose mothers express an interest and willingness to do so Normally, an infant's birth weight doubles by age 6 months and triples by age 1 year. By what age should the nurse expect the birth weight to quadruple? 18 months. 2 years. 2'/2 years. 3 years. Generally, infants who weigh 7 lb at birth will weigh 28 lb, or quadruple their birthweight, by 21/2 years of age. Consequently the other listed ages are incorrect (Answers 1, 2, 4). Know 3 milestones to choose the only correct answer A mother asks the nurse how tall her child will be when grown up. What answer should the nurse offer? This is virtually impossible to predict. It will be double the child's height at 2 years of age. It will be triple the child's height at 18 months of age. Add 2 feet to the child's height at 4 years of age. The general rule of thumb to predict a child's height as an adult is to double the child's height at 2 years of age. The other answers (Answers 1, 3,4) are incorrect. Know developmental milestones to pick the only correct answer In teaching principles of poison control to a group of mothers, the nurse would be most correct in stressing that the age group most likely to suffer from accidental ingestions is: 6-18 mo. 12 mo-2 1/2 yr. 2-4 yr. 3-5 yr. Poisoning is most common in toddlers, who have the motor skills necessary to reach the poisons yet lack the intelligence to know not to ingest the poison. The other answers (Answers 1, 3, 4) are, therefore, incorrect. Know age-relevant safely concerns In deciding which one type of accident prevention to discuss first with the parents of a toddler, the nurse should base the choice on the knowledge that most deaths in children under age 3 are caused by: Aspiration/suffocation. Falls. Motor vehicles. Poisonings. In children under 3 years, most accidental deaths are related to motor vehicles in which the child is a passenger; other types of accidents are not as common or not as likely to result in death (Answers 1,2,4). Know age-typical cause of accidental death The following four children are patients in the pediatrics unit. Which one should the nurse anticipate will he most affected by separation from parents? A 6-week-old with pyloric stenosis. A 19-month-old with salicylate poisoning. A 3'/2-year-old with hypospadias. A 5-year-old with hemophilia. Toddlers always suffer when separated from their parents, more so than any other age group (Answers 1,3,4). In fact, the years between ages 1 and 3 are when children are most likely to suffer separation anxiety. It is the age, not the condition. Toddlers are at the peak age for separation anxiety In assessing the development of a 5-year-old, the nurse would not expect the child to be able to: Name primary colors. Count to 100. Know the days of the week. Give telephone number and address. Five-year-olds may count up to 20 or 2b, but seldom beyond this. They should be able to name colors such as red, green, and blue (Answer 1). In addition, they should be able to give their phone number and address (Answer 4) and have a better sense of temporal relationships, as evidenced by their ability to name days of the week, months of the year, and seasons (Answer 3). The stem asks for what this child is not expected to do. The nurse should be familiar with developmental norms found in the DDST An RN from the telemetry unit is floated to the pediatrics unit. The charge nurse must assign three patients to her. Which patient should not be assigned to the telemetry nurse? A 5-month-old with Kawasaki disease. A 9-year-old with rheumatic fever. A 4-year-old with VSD after cardiac catheterization. A 3-week-old after pyloromyotomy. The RN floated from the telemetry unit would be least prepared to care for a young infant who has just had GI surgery and requires a specific feeding regimen answer 1 is incorrect because the RN floated from the telemetry unit should be experienced in caring for patients with cardiac arrhythmias, a common complication of Kawasaki disease answer 2 is incorrect because the RN floated from the telemetry unit should be experienced in caring for patients with carditis or congestive heart failure, common complications of patients with rheumatic fever answer 3 is incorrect because the RN floated from the telemetry unit should be experienced in caring for patients who are post-cardiac catheterization. "Least prepared" implies skills and knowledge that are not directly transferable. Look for the option that is different; in this question, the infant who is post-op pyloromyotomy is the only patient who does not have any cardiac involvement The nurse in the emergency department triage area must decide which of the following children should be examined first by the pediatrician. Which child requires immediate attention? A 3-year-old who fell off his bicycle and has several lower extremity lacerations requiring sutures. A 2-year-old with laryngotracheobronchitis who has wheezing on auscultation and a respiratory rate of 28 breaths per minute. A 6-month-old who fell from the sofa onto a carpeted floor, hitting her head. A 4-year-old with asthma who has diminished wheezing and is very irritable. Diminished wheezing in a child with asthma indicates possible worsening of respiratory obstruction, especially when coupled with irritability, which is a sign of air hunger answer 1 is incorrect because lacerations requiring sutures would not be a priority unless there was arterial hemorrhage answer 2 is incorrect because these symptoms are consistent with a fairly mild case of laryngotracheobronchitis answer 3 is incorrect because this type of fall onto a padded surface does not usually result in severe head trauma. Note the use of the words "immediate attention" in this question, meaning potentially life threatening. Therefore, narrow the options to the two respiratory conditions The RN is supervising a nurse's aide who is caring for a child with a multidrug-resistant respiratory infection. Which action by the aide would be unsafe and would require the nurse's immediate attention? The aide wears a gown and gloves when entering the child's room. The aide removes the gown and gloves before leaving the child's room. The aide leaves the sphygmomanometer, thermometer, and stethoscope in the child's room, out of the child's reach. The aide washes her hands after removing her gloves, and then leaves the child's room to care for another child in the next room. In addition to removing gown and gloves, the aide should wash her hands before leaving the child's room answers 1,3, and 4 are incorrect because these actions arc appropriate and would not require the nurse's immediate attention. Key word: "unsafe." Use a true-or-false approach to rule out the three approaches that are OK The RN assigns an LPN/LVN to care for a child with Hirschsprung's disease; the child's abdomen is grossly distended. The RN directs the LPN/LVN to measure the child's abdominal girth. Which action by the LPN/LVN would require the RN's intervention and further direction? The LPN/LVN: Uses a cloth tape to measure the child's abdominal girth. Leaves the tape in place after measuring the child's abdominal girth. Measures the child's abdominal girth at the umbilicus. Pulls the tape snug, but not tight, around the abdomen when measuring girth. Cloth tape can stretch over time, eventually resulting in inaccurate measurements. The RN should intervene and direct the LPN/LVN to use paper tape instead of cloth tape answers 2,3, and 4 are incorrect because these actions are appropriate and would not require intervention and further direction. Key words: "intervention and further direction," implying that the best answer is the incorrect action A child with a diagnosis of "rule out meningitis" is admitted to the pediatrics unit. The RN assigns this child to an LPN/LVN. Admitting orders include the following: bed rest with vital signs q2h; CBC with chemistry and electrolytes; gentamicin 80 mg IVPB q8h; liquid diet as tolerated; nasopharyngeal culture; and droplet precautions. In what sequence should the RN instruct the LPN/LVN to implement these orders? Put the child to bed and check vitals, take culture, draw blood, start antibiotics, initiate droplet precautions, order diet. Offer fluids, draw blood, take culture, put the child to bed and check vitals, start antibiotics, initiate droplet precautions. Initiate droplet precautions, put child to bed and check vitals, take a culture, start antibiotics, draw blood, order diet. Draw blood, start antibiotics, initiate droplet precautions, take culture, offer fluids, put child to bed and check vitals. The nurse should always initiate infection control measures, such as droplet precautions, before administering any other care, in order to protect the nurse, other health care workers, and other patients and their families answers 1, 2, and 4 are not correct because the nurse is not initiating infection control measures first, but is checking vitals or offering fluids or drawing blood first. Infection control is always a priority of care The nursing student is teaching a newly diagnosed diabetic adolescent about the disease and its treatment. Which statement by the student would require the RN's intervention? When you use the vial of insulin marked 'U80,' it means that there are 80 units of insulin in that vial. Be sure to check in with your doctor right away if you develop a fever or have an infection. You could develop a complication called ketoacidosis. When you are getting ready to give yourself insulin, first draw up the short-acting insulin and then draw up the intermediate-acting insulin. You should check your blood sugar four times a day, just like the MD ordered. The supplies are easily transportable and can go with you wherever you go. U80 means that there are 80 units of insulin per milliliter, not 80 units of insulin in the vial answers 2, 3, and 4 are incorrect because these statements are true and do not require the RN's intervention. "U" (units) followed by a number always refers to the number of units of insulin per milliliter The RN instructs the aide to give a child with eczema her bath. Which action by the aide would require the RN to provide additional supervision? The aide: Adds bath oil to the water. Bathes the child for 15 to 20 minutes. Provides toys for water play. Applies Lubriderm to the skin immediately after the bath. The child with eczema should be bathed in plain water, with no oils or soaps, to avoid further damage to the skin answers 2, 3, and 4 are incorrect because these actions are appropriate and require no additional supervision. Note the use of the words "require . . . additional supervision" in this question, meaning incorrect, or not OK The nurse is caring for all of the following patients. Which patient should the nurse recognize is at the highest risk for fluid and electrolyte imbalance? Infant with acute gastroenteritis. Toddler with lead poisoning. Preschooler with leukemia. School-age child with multiple trauma. Infants have the greatest percentage of fluid per pound of body weight than any other age group and are at highest risk for fluid and electrolyte imbalance answers 2, 3, and 4 are incorrect because none of the other conditions is at the highest risk for fluid and electrolyte imbalance. It is not an age variable but the condition that is at risk The RN should instruct the LPN/LVN or UAP caring for a child with PKU to be sure not to give this child: Green grapes. Diet soda. Cheerios. Cranberry apple juice. Diet soda contains aspartame (NutraSweet), which metabolizes into phenylalanine answers 1, 3, and 4 are incorrect because these food items are allowed on a low-phenylalanine diet that this child is undoubtedly on. Products containing aspartame (NutraSweet) should not be given to any patient with PKU. The stem calls for an elimination approach to what is OK to offer and what is not OK. An RN can safely delegate three of the following tasks to an LPN/LVN caring for a child with Down syndrome. Which one task should the RN perform personally and not delegate to an LPN/LVN? Transporting the child to the cardiac catheterization lab. Taking the child's vital signs, including blood pressure. Listening to the child's breath sounds bilaterally. Assisting the child to eat meals and snacks. This activity, auscultation of breath sounds, involves assessment skills. Patient transport (Answer 1), taking vital signs (Answer 2), and helping with activities of daily living (Answer 4) do not involve assessment and can therefore be safely delegated to an LPN/LVN. Key concept in delegation: patient assessments can be done only by the RN. During a routine physical examination, a healthy, well-nourished 16-year-old male tells the nurse that he feels like killing his girlfriend because she broke up with him. He then laughs, and asks the nurse to keep this a secret just between the two of them. The nurse reviews his chart and notes that there is no previous history of violence or psychiatric illness. All other findings are within normal limits. The best action for the nurse to take at this time would be to: Regard the comment seriously and notify the teen's primary health care provider and parents. Recall that teenage boys often say things they really do not mean, and ignore the comment. Suggest the teen meet with a counselor to discuss his feelings about the breakup with his girlfriend. Tell the teen that his feelings are normal, and recommend that he find another girlfriend to take his mind off the problem. Any threat to the safety of oneself or other should always be taken seriously and never disregarded by the nurse answer 2 is incorrect because the nurse should never ignore threatening comments answer 3 is incorrect because simply suggesting a meeting with a counselor at some vague point in time would not be sufficient swer 4 is incorrect because this action is theoretically incorrect. To narrow the choices, note two contradicting options: not OK (1) vs. OK (2). Choose the option in which safety is an issue. Safety is always a priority of care A nurse's aide is working with a group of children in the playroom. Which action by the aide would require the RN to intervene? The aide offers a pacifier to an infant who is NPO. The aide opens a can of Play-Doh and gives it to a toddler. The aide stops a preschooler with terminal cancer from pulling on the braids of another child who is ready to be discharged. The aide tells a school-age child that he is too big to be crying for his parents. No child or patient should be told not to express his or her feelings. Crying when upset is normal and healthy for any patient, regardless of age answers 1, 2, and 3 are incorrect because these actions are age and condition appropriate, and do not require the nurse to intervene. Concept: therapeutic interventions/ communication calls for encouraging patients to express their feelings A nursing student has been assigned to plan the prehospitalization teaching for a group of preschoolers having elective surgery. The preceptor should correct the teaching plan if it included which of the following? Make a list of the things the children could bring from home. Show the children a video describing activities that will take place during their hospital stay. Provide a detailed explanation to the children of what they will experience during preadmission testing. Give the children a tour of the ambulatory surgery unit, followed by a light snack and a chance to talk with the staff Preschoolers, who are at an age of fears and fantasies, should not be given detailed explanations of treatments answers 1, 2, and 4 are incorrect because these actions are age appropriate and do not require the preceptor to correct the teaching plan. The concept here is an age-appropriate activity. Preschoolers should be given a simple and brief explanation, shortly before the intervention Which of the following tasks could the RN safely delegate to a UAP? Give an oatmeal bath to a 1-year-old with eczema. Monitor the I&O of a comatose 3-year-old with salicylate poisoning. Perform a complete bed bath on a 2-year-old with multiple injuries from a serious multivehicle accident. Check the IV of a 4-year-old with Kawasaki disease. Bathing a child with eczema can be safely delegated to an aide, who should be competent in performing this basic task answer 2 is incorrect because only an RN can monitor an I&O, which is critical in a case of acute poisoning with an unpredictable outcome answer 3 is incorrect because an RN should be caring for a child with major trauma answer 4 is incorrect because only an RN can make an assessment. Look for non-assessment, predictable outcome, stable condition, noncomplex care A child with severe pain asks for pain medication. The team caring for this child includes an RN, an LPN/LVN, and a UAP. After assessing the child, the RN administers the pain medication. Who should subsequently evaluate the effectiveness of the pain medication? The RN only. The RN and the LPN/LVN. The LPN/LVN and the UAP. All of the members of the team caring for this child. Only the RN should evaluate the efficacy of pain medication or other treatments/medications answers 2,3, and 4 are incorrect because the LPN/LVN and the UAP are not legally responsible for evaluating the efficacy of pain medication. Recall that the concept of delegation sets responsibility for assessment/evaluation with the RN, not other assistive personnel A 9-year-old child with a brain tumor refuses to take chemotherapy. Both parents are present and insist that the RN administer the chemotherapy. The RN should: Administer the medication as ordered. Hold the medication and discuss this as soon as possible with the charge nurse and the MD. Offer distraction and then proceed to put the medication into the child's IV line. Leave the parents and child alone for awhile, to discuss this important issue privately. A 9-year-old child is within the age of reason, and his or her wishes regarding treatment must be considered by the health care team. The nurse, as part of the team, should consult with other team members before administering chemotherapy that the child refuses answers 1 and 3 are incorrect because the nurse should not administer chemotherapy against the child's wishes answer 4 is incorrect because the family should not make this important decision without the support and input of the health care team. The best option involves the concept of patients' rights: patients have the right to refuse medication or treatment An RN from the obstetrics unit is floated to the pediatrics unit. Which patients could the charge nurse safely assign to this float nurse? A child who has had a nephrectomy for Wilms' tumor. A child receiving IV chelating therapy for lead poisoning. A child with Kawaski disease and cardiac complications. A child who suffered a closed head injury in a 10 ft fall from a tree. The RN floated from the obstetrics unit should be able to safely care for a patient with major abdominal surgery, because this nurse has cared for patients with cesarean births answer 2 is incorrect because the RN floated from the obstetrics unit probably has not cared for patients receiving chemotherapy answer 3 is incorrect because the RN floated from the obstetrics unit probably has limited experience with cardiac problems answer 4 is incorrect because the RN floated from the obstetrics unit probably has limited experience with neurological injuries. Look for the implied experience and skills that are applicable from one clinical area to another A child with diabetes experiences a hypoglycemic episode while hospitalized. The RN instructs the UAP to give the child a glass of orange juice. The RN should then instruct the UAP to: Include this amount of liquid on the child's I&o sheet. Offer the child a choice of Jell-O or pudding. Bring the child several small cups of a variety of juices to keep at the bedside. Provide the child with a snack of peanut butter and crackers. After administering a concentrated sugar to a patient with hypoglycemia, the nurse should be sure the child receives a complex carbohydrate, which will help maintain a steady blood sugar level answer 1 is incorrect because simply adding this amount to the I&O is not sufficient answers 2 and 3 are incorrect because offering more concentrated sweets will likely result in an unstable blood sugar level. When two options are very similar (2, 3), neither option can be correct A 2-year-old patient has had an open reduction for a fractured femur; his current weight is 25 lb 7 oz. He is in skeletal traction, and the physician has ordered meperidine (Demerol) 50 mg IM q6h prn for severe pain and muscle spasms. The nurse should recognize that: This dose of Demerol is excessive for a child of this age and weight. This dose of Demerol is appropriate for a child of this age and weight. 2-year-old children usually do not require pain medication, and this order should be questioned. 2-year-old children usually do not require pain medication, but if the doctor ordered this drug for him, the nurse should give it as ordered. Although the nurse may not know the recommended dose, the nurse should recognize that 50 mg of Demerol is a normal adult dose. This would clearly be unsafe and inappropriate for a 2-year-old answer 2 is incorrect because this is a normal adult dose and is not appropriate answer 3 is incorrect because any patient may require pain medication, regardless of age answer 4 is incorrect because the nurse should never administer medication simply because the doctor ordered it. Narrow the choice to two contradicting options: in this situation, OK (2) vs. not OK (1), meaning it is excessive for a child An LPN/LVN is caring for a child who is postop and complaining of pain; the child asks for pain medication at 5 p.m. The LPN/LVN notes that the last dose was given at 11:30 a.m. The MD's order is for Demerol 25 mg IM q4-6h prn for pain. The RN supervising this LPN/LVN should expect the LPN/LVN to: Administer the Demerol as ordered and then ask the RN to monitor the child for pain relief. Report these findings to the RN. Notify the MD that the child may be developing a dependence on Demerol. Administer the Demerol as ordered, and then chart whether or not pain relief is noted. The LPN/LVN should never give a prn medication unless the RN has completed an assessment of the patient to determine if it is safe and appropriate answers 1 and 4 are incorrect because the LPN/LVN should never give a prn medication unless the RN has completed an assessment of the patient to determine if it is safe and appropriate answer 3 is incorrect because the LPN/LVN should not contact the MD; this is the RN's responsibility. Notice the pattern in the responses: two options give the drug, while two report/notify. Knowing role/responsibilities about assessment, eliminate the options that give the drug. Next, apply the lines of authority concept to arrive at the best answer When administering an IM injection to a young child, the nursing student aspirates before injecting and notices blood in the syringe. The RN should instruct the student to: Inject the drug and then complete an incident report. Withdraw, change needles, and inject the drug in another site. Inject the drug slowly, over a 2-minute interval, and watch for possible adverse reactions. Withdraw the needle one-quarter inch and aspirate again; if no further blood is obtained, inject the medication. Whenever the nurse aspirates blood when pulling back in giving an injection, the nurse must withdraw the needle and change it for another sterile needle. The nurse should then inject the medication in another site answers 1,3, and 4 are incorrect because it is unsafe to inject when the nurse has aspirated blood; there is always the possibility of injecting the drug directly into the bloodstream. Note the pattern in the responses: two options give the injection as is, and two do not. You must identify this as a problem and not OK to give this injection. Next, apply the concept of sterile technique to choose the best option The LPN/LVN is assigned to administer both an aerosol bronchodilator and an aerosol steroid to a child with asthma. The RN should instruct the LPN/LVN to administer: Both inhalers simultaneously. The bronchodilator first and the steroid second. The steroid first and the bronchodilator second. Neither; the RN should question these orders with the MD. By giving the bronchodilator first, this will help the air passages to open more fully. This enables the steroid to reach as deeply as possible into the bronchi, for maximum benefit to the patient answers 1 and 3 are incorrect because the bronchodilator should be given first answer 4 is incorrect because these medications can be given close to one another. Remember: bronchodilator first, steroid second The RN instructs the UAP to collect a routine urine specimen on an infant. Which action by the UAP would require the nurse's intervention and further direction? The UAP washes her hands and puts on gloves. The UAP cleanses and dries the infant's genital area. The UAP applies the bag directly to the infant's skin, with the urethral meatus in the center of the opening. The UAP leaves the bag in place until it is full of urine. Leaving the bag in place until it is full may cause tissue damage, as well as increase the likelihood of the bag pulling off and the specimen being lost answers 1,2, and 3 are incorrect because these actions are appropriate and would not require the nurses' intervention and further direction. The question is asking which action is not OK, not safe. The RN assigns an LPN/LVN to care for a child who just had a spinal tap to rule out meningitis. Which observation(s), if reported by the LPN/LVN within the first hour after the tap, should the RN follow up on? The child refuses fluids after the tap. The child denies having a headache. The child is lying flat in bed and states that he does not have a headache. The child is resting quietly and vital signs are within normal limits. After a spinal tap, patients should be encouraged to drink fluids to replace the circulating cerebrospinal fluid (CSF) and prevent a spinal headache answers 2, 3, and 4 are incorrect because these findings are within normal limits and require no follow-up. Intervention is usually required for abnormal findings, not normal findings The parents of a 12-year-old child call the clinic early one morning because they are concerned about their son. They report that he is refusing to go to school because he has a severe headache; he vomited once and the parents say that there has been a virus going around his class. The best advice for the clinic nurse to offer them over the phone should be: Bring your son into the clinic as soon as you can. Offer your son Tylenol or ibuprofen, and then drive him to school about an hour later. Give your son Tylenol or ibuprofen every 4 hours and monitor for fever; keep him home today. These symptoms are most likely due to the virus and should improve within 24 hours. Be sure he gets plenty of rest and fluids. These symptoms may indicate a potentially life-threatening infection such as bacterial meningitis, and the child should be evaluated promptly and thoroughly answers 2 and 3 are incorrect because they would only cover up the symptoms answer 4 is incorrect because this statement can not be safely made on the basis of the information the parents have offered without first seeing the child. When two answers (2,3) are very similar, neither answer can be correct The RN caring for a child with acute lymphocytic leukemia is called to the phone to speak with a caller who claims to be the child's aunt and godmother and who lives in another country. The woman is clearly upset, and tearfully asks the nurse whether the child's leukemia has relapsed. From report, the nurse is aware that the child is out of remission and that chemotherapy was started within the past hour. The nurse should tell the caller: Yes, unfortunately the child just began chemotherapy again. I just came on duty and have not had a chance to review the child's chart yet. I'm sorry, but I cannot give out that information over the phone. You really need to speak with the doctor about the child's condition and treatment. Confidentiality precludes the nurse from giving this kind of information over the phone answer 1 is incorrect because this is a breach of confidentiality answer 2 is incorrect because it defers addressing the issue of confidentiality answer 4 is incorrect because it disregards the caller's obvious distress. After directly answering the woman's question, the nurse might consider this as a possible follow-up statement. The concept of confidentiality and nurse-appropriate role points to the best answer