Home Care Measures for Various Child Health Conditions, Exams of Nursing

Download Home Care Measures for Various Child Health Conditions and more Exams Nursing in PDF only on Docsity! 1 Focus on Child Health Exam 1. An HIV-positive woman delivers an infant. The pediatrician prescribes testing for the newborn, and the nurse prepares for which action? A. Ask the laboratory to perform virologic testing Correct B. Obtain blood from the umbilical cord to send to the laboratory C. Perform a heelstick to obtain a specimen for a Western blot assay D. Perform a fingerstick to obtain a specimen for an enzyme-linked immunosorbent assay (ELISA) accurate in infants younger than 18 months because of the persistence of maternal antibodies. Because of the potential for maternal contamination during delivery, umbilical cord blood should not be used for testing. HIV-exposed infants should undergo virologic testing within 48 hours of birth and follow-up testing, depending on the initial results. Test-Taking Strategy: Focus on the subject, newborn infant exposed to HIV. Recalling that the ELISA and Western blot assay are not accurate in an infant younger than 18 months will assist you in eliminating these options. Next eliminate the option involving cord blood, knowing that such blood could be contaminated. Review: tests for HIV in newborn Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Infectious Diseases Giddens Concepts: Immunity, Infection HESI Concepts: Immunity, Infection Awarded 98.0 points out of 98.0 possible points. 2. A nurse providing home care instructions to a mother of a HIV-positive child discusses measures to prevent transmission of the virus. Which statement by the mother indicates a need for further instruction? A. “I won’t let my children share toothbrushes.” B. “I’ll wash up blood spills with soap and hot water and allow them to air dry.” Correct C. “I’ll wash my hands with soap and water if I touch any blood from my child.” D. “I’ll rinse bloodstained clothing with hydrogen peroxide and then wash it as usual.” Rationale: The correct method of cleaning up blood spills is to wash the area with soap and water, rinse with bleach, and let the area air dry. The remaining statements by the mother reflect correct measures to prevent transmission of the virus. Test-Taking Strategy: Focus on the subject, transmission of HIV virus. Note the strategic words “need for further instruction,” which indicates a negative event query and the need to select the incorrect statement. Recalling that blood spills must be cleaned with a 1:10 Rationale: Traditional HIV antibody measurement by ELISA or Western-blot assay is not 2 bleach/water solution will direct you to the correct option. Review: home care measures for HIV Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Child Health—Infectious Diseases Giddens Concepts: Client Education, Infection HESI Concepts: Infection, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points. 3. A child has been in the hospital for several days for treatment of severe vomiting related to his HIV-positive status. Which assessment finding is the best indication that the child’s condition is improving? A. No lesions in the mouth and throat B. Weight increase of 1 lb (0.45 kg) over 3 days Correct C. Temperature change from 100.2° F to 99.2° F (37.3°C) D. Capillary refill slowing from 2 seconds to 3 seconds Rationale: Vomiting results in fluid volume deficit. The most accurate method of evaluating fluid volume increase (the desired outcome) is weight. A temperature decrease is not reflective of fluid volume increase. Increasing capillary refill time is indicative of a fluid volume decrease, not an increase. The absence of mouth ulcers would allow the child to drink without pain but does not reflect a fluid volume increase. Test-Taking Strategy: Note the data in the question and the strategic word best, and remember that the child is experiencing severe vomiting. Use the process of elimination and focus on the subject, an assessment finding indicating fluid volume increase. The correct option is the only one related to fluid volume. Review: child with HIV and severe vomiting Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Child Health—Infectious Diseases Giddens Concepts: Fluid and Electrolytes, Evidence HESI Concepts: Evidence-Based Practice/Evidence, Fluids and Electrolytes Awarded 98.0 points out of 98.0 possible points. 4. A girl with systemic lupus erythematosus (SLE) wants to go to the beach with her friends on the day after their junior prom. The girl asks the nurse for guidance regarding sun exposure. The nurse should provide which information to the girl? A. She cannot be exposed to any sunlight at all B. She must bring a beach umbrella and remain under it all day C. Waterproof sunscreen with a minimum sun protection factor (SPF) of 15 is a necessity Correct 5 Rationale: Rectal temperatures are avoided in the child with diarrhea because inserting a the pathophysiology of dehydration will direct you to the correct option. Review: child with dehydration Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fluids & Electrolytes Giddens Concepts: Clinical Judgment, Fluid and Electrolytes HESI Concepts: Clinical Decision-Making/Clinical Judgment, Fluid and Electrolytes Awarded 98.0 points out of 98.0 possible points. 8. A nurse is assigned to care for a child with diarrhea. Which intervention should the nurse avoid in caring for the child? A. Wearing clean gloves B. Turning the child every 2 hours C. Using protective moisture barriers D. Taking a rectal temperature every 4 hours Correct thermometer in the rectum stimulates peristalsis and may damage excoriated tissue. Gloves are worn when caring for the child. Clean gloves are sufficient; sterile gloves are not necessary in this situation. The child is turned every 2 hours to reduce pressure on irritated skin and to prevent skin breakdown. Protective moisture barriers, such as creams or ointments, are useful in protecting the skin from diarrhea stools. Test-Taking Strategy: Note the strategic word “avoid,” which indicates a negative event query and the need to select the incorrect intervention. Focusing on the child’s diagnosis and recalling that peristalsis would aggravate the condition will direct you to the correct option. Review: child with diarrhea Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Gastrointestinal Giddens Concepts: Clinical Judgment, Elimination HESI Concepts: Clinical Decision-Making/Clinical Judgment, Elimination Awarded 98.0 points out of 98.0 possible points. 9. A nurse is providing home care instructions to the mother of a child who has undergone cleft lip repair. Which statements by the mother indicate an understanding of these instructions? Select all that apply. A. “I should put her on her stomach to sleep.” B. “I shouldn’t brush her teeth for 1 to 2 weeks.” Correct C. “I should rinse her mouth with water after feeding her.” Correct D. “I should watch for signs/symptoms of infection like drainage or fever.” Correct E. “I should never use a bulb syringe to clear secretions from her mouth.” 6 Rationale: “I shouldn’t brush her teeth for 1 to 2 weeks,” “I should rinse her mouth with water after feeding her,” and “I should watch for signs/symptoms of infection like drainage or fever” are all accurate statements. Gentle aspiration of oral secretions may be needed to prevent respiratory complications, and bulb syringes are often sent home with the family for removal of these secretions. After cleft lip repair the child should be kept supine, on the side opposite the repair, or in an infant seat. The prone position could result in contact of the suture line with the bed linens, leading to disruption of the suture line. Test-Taking Strategy: Focus on the subject, an understanding of home care measures. Consider the safety issues related to oral surgery and positioning and wound care. Visualize each of the options to answer correctly. Review: cleft lip repair Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Child Health—Gastrointestinal Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points. 10. A newborn is found to have esophageal atresia (EA) with tracheoesophageal fistula (TEF). In which position does the nurse immediatelyplace the infant? A. Trendelenburg B. Flat and side-lying C. Prone, with the head of the bed flat D. Supine, with the head of the bed elevated Correct Rationale: EA and TEF are congenital malformations in which the esophagus terminates before it reaches the stomach, a fistula forms an unnatural connection with the trachea, or both. Keeping the infant supine, with the head of the bed elevated, decreases the likelihood that gastric secretions will enter the lungs. Placing the child in the Trendelenburg position, flat and side-lying, or prone with the head of the bed flat is incorrect; any of these positions could result in the aspiration of gastric secretions. Test-Taking Strategy: Focus on the subject, infant with EA and TEF. Note the strategic word, “immediately” and recall the pathophysiology of this disorder. Recalling that the primary concern is aspiration of gastric secretions will direct you to the correct option. Review: infant with EA and TEF Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Gastrointestinal Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Awarded 98.0 points out of 98.0 possible points. 11. 7 A nurse is assigned to care for an infant with congenital diaphragmatic hernia (CDH). Which clinical finding supports this diagnosis? A. Presence of an anal membrane B. Failure to pass meconium stool C. Viscera located outside the abdominal cavity D. Auscultation of cardiac sounds on the right side of the chest Correct Rationale: CDH is an opening in the diaphragm through which abdominal contents herniate into the thoracic cavity during prenatal development. Clinical findings depend on the severity of the defect but may include the presence of abdominal organs in the chest (revealed by fetal ultrasonography), diminished breath sounds or an absence of such sounds on the affected side, auscultation of bowel sounds over the chest, auscultation of cardiac sounds on the right side of the chest, respiratory distress, and a scaphoid abdomen. The presence of an anal membrane and failure to pass meconium stool are findings noted in imperforate anus. The presence of viscera outside the abdominal cavity is noted in gastroschisis. Test-Taking Strategy: Focus on the subject, child with CDH. Eliminate first the options that are comparable or alike in that they are related to an imperforate anus. To select from the remaining options, focus on the name of the disorder and use your knowledge of the pathophysiology of CDH to find the correct option. Review: CDH Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Gastrointestinal Giddens Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based Practice/Evidence Awarded 98.0 points out of 98.0 possible points. 12. A nurse provides home care instructions to the mother of an infant with gastroesophageal reflux disease (GERD). Which statement by the mother indicates a need for further instruction? A. “I shouldn’t give the baby a pacifier.” Correct B. “I should thicken feedings with rice cereal.” C. “I should put the baby on her right side with her head raised.” D. “I need to give the baby small, frequent feedings and use a predigested formula.” Rationale: The use of a pacifier allows the infant to practice swallowing. Pacifier use also decreases the incidence of crying and reflux episodes and may increase clearance of reflux stomach contents. Small, frequent feedings of a predigested formula will reduce the amount of formula in the stomach, ease distension, and minimize reflux. These smaller, more frequent feedings with frequent burping are often tried as the first line of treatment. Thickened feedings tend to decrease the chances of reflux, vomiting, and aspiration. Placing the affected infant in a 30- degree head-elevated prone or right-side–lying position helps prevent reflux. Test-Taking Strategy: Focus on the subject, infant with GERD. Note the strategic words “need for further instruction.” These words indicate a negative event query and the 10 A. Fever B. Profuse diarrhea C. Alternating constipation and diarrhea and fecal impaction D. Olive-shaped mass palpated in the right upper abdominal quadrant Correct Rationale: The nurse would expect to see documented a movable, palpable, firm, olive-shaped mass felt in the right upper quadrant. This mass is most easily palpated when the stomach is empty and the infant is relaxed. Progressive non-bilious projectile vomiting in a previously healthy infant is a major sign/synptom of pyloric stenosis. The vomitus may become blood- tinged if esophageal irritation occurs. Deep gastric peristaltic waves from the left upper quadrant to the right upper quadrant may be visible immediately before vomiting commences. If the condition progresses, the infant may become dehydrated and experience metabolic alkalosis. Fever, profuse diarrhea, and alternating constipation and diarrhea and fecal impaction are not manifestations of this disorder. Test-Taking Strategy: Focus on the subject, manifestations of hypertrophic pyloric stenosis. First, eliminate the options that involve diarrhea. To select from the remaining options, note that the diagnosis involves the gastrointestinal system; this will direct you to the correct option. Review: hypertrophic pyloric stenosis Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Gastrointestinal Giddens Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based Practice/Evidence Awarded 98.0 points out of 98.0 possible points. 17. A nurse is caring for an infant scheduled for a pyloromyotomy. In which position should the nurse place the infant for the preoperative period? A. Prone B. Supine C. Head elevated Correct D. Trendelenburg Rationale: In the preoperative period, the infant’s head of the bed is elevated to reduce the risk of aspiration. The nurse would use blankets or towel rolls to maintain this position. Prone, supine, and Trendelenburg are incorrect positions because they increase the risk of aspiration. Test-Taking Strategy: First eliminate the options that are comparable or alike in that the head of the bed is flat. Next, recall that aspiration is a concern; this will direct you to the correct option. Review: pyloromyotomy Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Gastrointestinal 11 Awarded 98.0 points out of 98.0 possible points. 18. Hydrostatic reduction is performed in a hospitalized child with a diagnosis of intussusception. Which outcome indicates that the procedure was successful? A. Passage of barium in the stool B. Passage of stool without blood Correct C. Visible peristalsis across the abdomen D. Presence of a sausage-shaped abdominal mass Rationale: The passage of stool without blood is a successful outcome for a child who has had a hydrostateic reduction. Intussusception is an invagination of a section of the intestines into the distal bowel that results in bowel obstruction. In children, this condition most often occurs as a section of the terminal ileum telescopes into the ascending colon through the ileocecal valve. The goal of treatment is to restore the bowel to its normal position and function as quickly as possible. In children who do not show symptoms of shock or sepsis, attempts at hydrostatic reduction are made with the use of a barium or air enema until a free flow of barium into the terminal ileum is evident. The nurse watches for the passage of barium after this procedure, but it does not indicate a successful procedure. Visible peristalsis across the abdomen is a manifestation of Hirschprung’s disease. Presence of a sausage-shaped abdominal mass is a sign of intussusception. Test-Taking Strategy: Focus on the subject, “a successful outcome.” Recalling the signs/symptoms of intussusception and the purpose of hydrostatic reduction will direct you to the correct option. Review: hydrostatic reduction Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Child Health—Gastrointestinal Giddens Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based Practice/Evidence Awarded 98.0 points out of 98.0 possible points. 19. A nurse is providing information to the parents of a child with suspected Hirschsprung’s disease. The nurse informs the parents that diagnosis is definitively confirmed by the findings of which action? A. Blood tests B. Rectal biopsy Correct C. Barium enema D. Rectal examination Preoperative interventions HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Giddens Concepts: Clinical Judgment, Safety 12 Hirschsprung’s disease. Blood tests are not used to diagnose the disease. A barium enema and a rectal examination will detect significant characteristics of the disease but will not confirm the diagnosis. Test-Taking Strategy: Focus on the subject, confirming the diagnosis. Recalling the pathophysiology of this disease and remembering that a biopsy will identify the characteristics of tissues will direct you to the correct option. Review: Hirschsprung’s disease Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Gastrointestinal Giddens Concepts: Elimination, Evidence HESI Concepts: Elimination, Evidence-Based Practice/Evidence Awarded 98.0 points out of 98.0 possible points. 20. A nurse is caring for an infant with Hirschsprung’s disease. Which manifestation of the disease should the nurse expect to note? A. Non-bilious projectile vomiting B. Foul-smelling, ribbon-like stools Correct C. A sausage-shaped abdominal mass D. Bloody, mucousy “currant jelly” stools Rationale: The child with Hirschsprung’s disease will have constipation that has been present since the neonatal period and the frequent passage of foul-smelling, ribbon-like or pellet stools. Non-bilious projectile vomiting is a manifestation of pyloric stenosis. Bloody, mucousy “currant jelly” stools and a sausage-shaped abdominal mass are manifestations of intussusception. Test-Taking Strategy: Focus on the subject, the manifestations of Hirschsprung’s disease. Recalling that Hirschsprung’s disease is characterized by the absence of ganglionic cells will direct you to the correct option. Review: manifestations of Hirschsprung’s disease Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Gastrointestinal Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. p. 1074). St Louis: Mosby. Giddens Concepts: Clinical Judgment, Elimination HESI Concepts: Clinical Decision-Making/Clinical Judgment, Elimination Awarded 98.0 points out of 98.0 possible points. 21. mucosa is removed. Absence of ganglionic cells in the sample confirms the diagnosis of biopsy. During biopsy, a small core or punch sample that contains all layers of the bowel Rationale: The definitive diagnosis of Hirschsprung’s disease is made by means of rectal 15 pajamas that contains a moisture-sensitive alarm. As the child starts to void, the alarm goes off, awakening the child. Kegel or pelvic muscle exercises may be helpful for daytime enuresis but are not useful in preventing nocturnal enuresis. Test-Taking Strategy: Focus on the subject, managing primary nocturnal enuresis. Read each option carefully. Remembering that fluid intake is not normally limited in children because dehydration is likely to develop and understanding that performing Kegel or pelvic muscle exercises 24 hours a day will disrupt sleep will assist you in answering correctly. Review: primary nocturnal enuresis Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Child Health—Renal Giddens Concepts: Client Education, Elimination HESI Concepts: Elimination, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points. 25. What instruction should the nurse provide to a parent regarding the prevention of urinary tract infection in his child? A. Wrap the diaper tightly on the child B. Avoid giving the child bubble baths Correct C. Use underwear made of a synthetic fabric D. Encourage the child to hold the urine to avoid frequent voiding Rationale: Bubble baths should be avoided because they may irritate the urinary tract and lead to urinary tract infections. Tight clothing or diapers are avoided, and cotton underwear, rather than a synthetic fabric, should be used to prevent irritation that could lead to infection. The child should be encouraged to avoid holding urine and to urinate at least four times per day, emptying the bladder completely. Test-Taking Strategy: Focusing on the subject, preventing a urinary tract infection, and recalling the causes of a urinary tract infection will direct you to the correct option. Review: urinary tract infections Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health—Renal Giddens Concepts: Client Education, Infection HESI Concepts: Infection, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points. 26. A nurse is caring for an infant with hypospadias. What does the nurse make a priority when assessing the infant? A. Blood pressure B. Urinary output Correct C. Level of consciousness 16 Rationale: Hypospadias is a congenital anomaly in which the actual opening of the urethral D. Gastrointestinal function priority of assessing urinary function in the infant. Blood pressure, level of consciousness, and gastrointestinal function are unrelated to this disorder. Test-Taking Strategy: Focus on the subject, infant with hypospadias. Note the strategic word, “priority”. This indicates the first and most important assessment by the nurse. Recalling the pathophysiology of hypospadias will direct you to the correct option. Review: hypospadias Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Renal Giddens Concepts: Clinical Judgment, Elimination HESI Concepts: Clinical Decision-Making/Clinical Judgment, Elimination Awarded 98.0 points out of 98.0 possible points. 27. A nurse is performing an assessment of a school-age child admitted with acute poststreptococcal glomerulonephritis. Which question would help determine the cause of this acute condition? A. “Have you fallen off your bicycle recently?” B. “Did you have a sore throat a few weeks ago?” Correct C. “Have you had chickenpox in the last 2 months?” D. “Have you eaten any shrimp or crab in the last 7 to 10 days?” Rationale: Acute poststreptococcal glomerulonephritis occurs as an immune reaction to a group A beta-hemolytic streptococcal infection of the throat or skin. Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Acute poststreptococcal glomerulonephritis, the most common type, is characterized by hematuria, proteinuria, edema, and renal insufficiency. Falling off a bicycle, contracting chickenpox, and eating shellfish are not causes of acute glomerulonephritis. Test-Taking Strategy: Focus on the subject, the origin of this disorder. Note the relationship between the word “poststreptococcal” in the client’s diagnosis and the correct option. Review: glomerulonephritis Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Renal Giddens Concepts: Clinical Judgment, Infection HESI Concepts: Clinical Decision-Making/Clinical Judgment, Infection Awarded 98.0 points out of 98.0 possible points. 28. Which laboratory result would the nurse expect to see in a child admitted to the hospital with acute glomerulonephritis? meatus is below the normal placement on the glans of the penis. The nurse would make a 17 Rationale: History, presenting signs/symptoms, and laboratory results can establish the A. Hematocrit of 38% B. 2+ protein in the urine Correct C. Serum potassium of 3.8 mEq/L (3.8 mmol/L)mg/dL D. White blood cell (WBC) count of 9800 cells/mm3 (9.8 x 109/L) microscopic hematuria with red cast cells, which indicate glomerular injury. Proteinuria is also present. Blood chemistry values are usually within the normal ranges. If renal insufficiency is severe, however, the blood urea nitrogen and creatinine levels are increased. The complete blood count usually demonstrates normal a WBC count and mild anemia. The lower hemoglobin and hematocrit values reflect the dilutional effect of extra fluid in the blood, a result of decreased glomerular filtration. Electrolyte disturbances such as a high serum potassium level and low serum bicarbonate level may result from inadequate glomerular filtration. All laboratory values identified in the options are normal, with the exception of the urinary protein level. Test-Taking Strategy: Focus on the subject, laboratory findings in acute glomerulonephritis. Recalling the pathophysiology of acute glomerulonephritis and recalling normal laboratory findings will direct you to the correct option. Review: laboratory findings of acute glomerulonephritis Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Renal Giddens Concepts: Cellular Regulation, Infection HESI Concepts: Cellular Regulation, Infection Awarded 98.0 points out of 98.0 possible points. 29. A nurse is performing an assessment of a child with nephrotic syndrome. Which manifestation would the nurse most likely note? A. Periorbital edema Correct B. Weight loss of 1.5 kg C. Temperature of 99.2° F (37.3°C) D. Blood pressure of 128/86 mm Hg Rationale: The manifestation the nurse would most likely note is edema (primarily noted in the periorbital spaces and dependent areas of the body). Other signs/symptoms include anorexia, fatigue, abdominal pain, respiratory infection, and increased weight. Nephrotic syndrome is a kidney disorder characterized by proteinuria, hypoalbuminemia, and edema. The child with nephrotic syndrome usually has a normal blood pressure. Fever may occur if an infection is present. Test-Taking Strategy: Focus on the subject, nephrotic syndrome. Note the strategic words “most likely.” Recalling that nephrotic syndrome is a kidney disorder characterized by proteinuria, hypoalbuminemia, and edema will direct you to the correct option. Review: nephrotic syndrome diagnosis of acute poststreptococcal glomerulonephritis. Urinalysis reveals macroscopic or 20 B. “I need to call the doctor if the tubes fall out.” C. “I need to keep his/her ears dry while he’s taking a bath.” D. “I should keep him/her from blowing his nose for 7 to 10 days.” Rationale: The mother’s statement that indicates a need for further instruction is “A fever is normal after this procedure.” The mother should be instructed to report any fever or increased pain, which could indicate a postoperative infection. It is not an emergency if the tubes fall out, but the surgeon should be notified. Nose-blowing should be avoided for 7 to 10 days after the procedure. The child’s ears need to be kept dry during baths and showers. The usual recommendation is to place ear plugs or cotton balls covered with petroleum jelly in the ears during baths and showers. Test-Taking Strategy: Focus on the subject, myringotomy with insertion of tympanostomy tube. Note the strategic words “need for further instruction,” which indicate a negative event query and the need to select the incorrect statement. Recalling that fever is an indication of an infection will direct you to the correct option. Review: homecare after myringotomy Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health—Ear Giddens Concepts: Client Education, Infection HESI Concepts: Infection, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points. 34. The mother of a child who underwent myringotomy with the insertion of tympanostomy tubes 1 day ago calls the surgeon’s office and reports to the nurse that the child has a small amount of reddish drainage coming from the ears. What information should the nurse provide to the mother? A. Irrigate the ears gently with warm water B. Bring the child to the surgeon’s office to be checked C. Carefully push the tubes a little farther into the ear canal D. Continue to monitor the drainage, because this is a normal finding Correct Rationale: Information the nurse should provide to the mother is to continue to monitor the drainage, because this is a normal fidning. After myringotomy with insertion of tympanostomy tubes, the child is monitored for ear drainage. A small amount of reddish drainage is normal for the first few days after surgery, but the mother should report any heavier bleeding or bleeding that occurs after 3 days. Having the surgeon check the child is unnecessary. Irrigating the ears with warm water and pushing the tubes further into the ear canal are inappropriate and could cause harm to the child. Test-Taking Strategy: Focus on the subject, myringotomy performed on a child. Focusing on the type of surgical procedure identified in the question will assist you in eliminating the options that involve irrigating the ear and pushing the tubes farther in. To select from the remaining options, note the strategic words “small amount” in the question, which should direct you to the correct option. 21 Rationale: Although signs/symptoms differ between viral and bacterial pharyngitis, Review: findings after myringotomy Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Ear Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points. 35. A child has been found to have pharyngitis. The most reliable method of determining whether the infection is bacterial or viral in origin is by which method? A. Throat culture Correct B. The rapid streptococcal antigen test C. Monitoring for complaints of a sore throat D. Collecting data regarding the child’s signs and symptoms origin is a throat culture. Not all children with pharyngitis complain of a sore throat, particularly if they are of preschool age. Instead, the child may complain of a stomachache or simply refuse to eat. Although a rapid streptococcal antigen test can be used to screen for group A streptococcal infection, it is not the most reliable means of determining whether a case of pharyngitis is viral or bacterial in origin. This test has an approximately 20% incidence of false- negative results. Test-Taking Strategy: Focus on the subject, difference between viral and bacterial pharyngitis. Eliminate the options that are comparable or alike in that they involve signs/symptoms. To select from the remaining options, note the strategic words “most reliable method.” This indicates the best method to differentiate between the two conditions, and direct you to the correct option. Review: tests for pharyngitis Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Throat and Respiratory Giddens Concepts: Evidence, Infection HESI Concepts: Evidence-Based Practice/Evidence, Infection Awarded 98.0 points out of 98.0 possible points. 36. A nurse is caring for a child scheduled for a tonsillectomy. To reduce the risk of aspiration during surgery the nurse should assess the child for which? A. Loose teeth Correct B. Throat redness C. Signs of active infection D. Exudate in the tonsillar area the most reliable means of determining whether a case of pharyngitis is viral or bacterial in 22 Rationale: In the preoperative period, the child is checked for loose teeth to reduce the risk of aspiration during surgery. Throat redness and exudate in the tonsillar area are signs/symptoms of active infection. Other signs/symptoms of active infection include fever and an increased white blood cell count. Test-Taking Strategy: Focus on the subject, reducing the risk of aspiration. Note the options that are comparable or alike. Throat redness and exudate in the tonsillar area are signs/symptoms of active infection. Review: preoperative tonsillectomy care of child Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Throat and Respiratory Giddens Concepts: Gas Exchange, Safety HESI Concepts: Oxygenation/Gas Exchange, Safety Awarded 98.0 points out of 98.0 possible points. 37. A nurse is assessing a child after tonsillectomy. Which finding is indicative of postoperative bleeding? A. Slowed pulse rate B. Frequent swallowing Correct C. Complaints of throat pain D. An increase in blood pressure Rationale: Monitoring the child for postoperative bleeding is most important. Because the operative site in this procedure is not as readily visible as other surgical sites, the nurse must be alert to excessive or frequent swallowing, an increased pulse and decreasing blood pressure, signs/symptoms of fresh bleeding in the back of the throat, vomiting of bright-red blood, and restlessness that does not seem to be associated with pain. Pain is not an indication of postoperative bleeding. Test-Taking Strategy: Focus on the subject, signs/symptoms of postoperative bleeding. Throat pain would be expected in the postoperative period, so eliminate this option. Thinking about the physiological response that occurs with blood loss will assist you in eliminating a slowed pulse rate and an increased blood pressure. Review: bleeding after tonsillectomy Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Throat and Respiratory Giddens Concepts: Clinical Judgment, Clotting HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion/Clotting Awarded 98.0 points out of 98.0 possible points. 38. In order to facilitate drainage, which position should the nurse place the child who has just undergone a tonsillectomy? 25 Rationale: A change in the child’s normal behavior is an important early sign/symptom of Review: RSV Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Child Health—Infectious diseases Giddens Concepts: Client Education, Infection HESI Concepts: Infection, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points. 42. A nurse is monitoring a child who sustained a head injury. Which assessment finding is an early sign/symptom of increased intracranial pressure (ICP)? A. Bradycardia B. Change in behavior Correct C. Widened pulse pressure D. Change in respiratory rate and pattern increased ICP. The Cushing response — which consists of an increased systolic blood pressure with widening pulse pressure, bradycardia, and a change in respiratory rate and pattern, usually apparent just before or at the time of brainstem herniation —is a late sign of increased ICP. Test-Taking Strategy: Focus on the subject, early sign/symptom of ICP. Note the strategic word “early.” This indicates the sign/symptom that initially occurs. Eliminate the options that are comparable or alike in that they involve vital signs. Review: early signs of increased ICP Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Neurological Giddens Concepts: Clinical Judgment, Intracranial Regulation HESI Concepts: Clinical Decision-Making/Clinical Judgment, Intracranial Regulation Awarded 98.0 points out of 98.0 possible points. 43. A nurse provides information to new parents about measures to reduce the risk of sudden infant death syndrome (SIDS). Which measure should the nurse tell the parents to implement? A. Obtain a soft crib mattress and soft bedding B. Place the infant in a supine position for sleep Correct C. Place the infant in a face-down position for sleep D. Be sure that the infant sleeps in a crib in the parent’s room until the age of 12 months Rationale: As a means of reducing the risk of SIDS, the infant should be positioned on his or her back rather than in the prone (face-down) position to sleep. The use of soft bedding is also a risk factor. Infants may suffocate by rebreathing carbon dioxide–laden expired air when sleeping face down on soft bedding. SIDS occurs most frequently between the second and fourth months of life, with most of cases occurring before the age of 2 to 3 months. 26 Test-Taking Strategy: Focus on the subject, measures to reduce the risk of sudden infant death syndrome (SIDS). Think about the risk factors associated with SIDS and visualize each of the options. This will direct you to the correct option. Review: risk factors of SIDS Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health – Throat and Respiratory Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points. 44. A child with severe respiratory distress is seen in the emergency department and treated for an acute asthmatic episode. Which assessment finding indicates that the child’s condition is improving? A. Stridor B. Shortness of breath C. Increased wheezing Correct D. Dyspnea on exertion Rationale: A child in severe respiratory distress may not demonstrate wheezing during an acute asthma attack because of decreased air movement. Decreased wheezing in a child who is not improving clinically may signal an inability to move air. This is referred to as a "silent chest" and is an ominous sign during an asthma episode. With treatment, increased wheezing may actually signal that the child’s condition is improving. Shortness of breath, dyspnea on exertion, and stridor are manifestations of an asthmatic episode that indicate airway obstruction. Test-Taking Strategy: Focus on the subject, a finding that indicates that the child’s condition is improving. Recalling the pathophysiology of an asthma episode will direct you to the correct option. Review: findings after treatment for asthma episode Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Child Health—Throat and Respiratory Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas Exchange Awarded 98.0 points out of 98.0 possible points. 45. A child who is experiencing wheezing during an acute asthma episode is brought to the emergency department by the parents. Which intervention does the nurse prepare to implement first? A. A chest x-ray B. Administration of a corticosteroid C. Administration of a bronchodilator Correct 27 D. Insertion of an intravenous (IV) catheter Rationale: A child who is experiencing an episode of wheezing along with other signs/symptoms of an acute asthma attack will first receive a bronchodilator by way of nebulizer or metered-dose inhaler. If the signs/symptoms do not improve, a dose of an oral corticosteroid is usually prescribed. If the child’s condition still does not improve, hospitalization may be necessary. Once the child is hospitalized, humidified oxygen is administered to keep the oxygen saturation at 95% or greater. An IV line is initiated to deliver fluids and provide venous access for parenteral medications as prescribed. Chest radiography, arterial blood gas determinations, or pulse oximetry may be performed as a means of further evaluating the child’s oxygenation status. Test-Taking Strategy: Focus on he subject, interventions for acute asthma episode. Note the strategic word “first.” Use your knowledge of the ABCs (airway, breathing, and circulation). This will direct you to the correct option. Remember, a bronchodilator will dilate the airways. Review: immediate care of child with asthma experiencing wheezing Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Throat and Respiratory Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas Exchange Awarded 98.0 points out of 98.0 possible points. 46. A nurse provides instruction to an adolescent client with exercise-induced asthma. Which statement by the adolescent indicates a need for further instruction? A. “I should use the bronchodilator after I finish working out.” Correct B. “The signs/symptoms usually begin after 5 to 10 minutes of exercise.” C. “I should use progressive muscle-relaxation techniques to keep from hyperventilating.” D. “When I exercise in cold weather, I should cover my nose and mouth with a scarf to warm up the air I’m breathing.” Rationale: The statement, “I should use the bronchodilator after I finish working out” indicates a need for further instruction. Exercise-induced asthma may be triggered by the rapid breathing of large volumes of cool, dry air, such as that taken in with mouth breathing during exercise. The signs/symptoms of exercise-induced asthma usually begin after 5 to 10 minutes of exercise and often last 30 to 60 minutes. Measures to prevent exercise-induced asthma include warming the air by breathing through the nose or covering the mouth and nose with a scarf when exercising in cold weather, using an inhaled bronchodilator before exercise, and practicing techniques to decrease hyperventilation, such as progressive muscle relaxation and diaphragmatic breathing. Test-Taking Strategy: Note the strategic words “need for further instruction,” which indicate a negative event query and the need to select the incorrect statement. Note the subject, exercise-induced asthma, as well as the words “after I finish working out” in the correct 30 Rationale: Pancreatic enzyme preparations are administered with every meal and snack to Awarded 98.0 points out of 98.0 possible points. 50. A pancreatic enzyme preparation is prescribed for a child with cystic fibrosis (CF). The nurse instructs the child’s mother to administer the pancreatic enzyme in what way? A. At noon only B. With meals and snacks Correct C. 2 hours after breakfast and dinner D. At bedtime and in the morning when the child awakens supplement and replace pancreatic enzymes and aid digestion. They are administered to ease the steatorrhea that occurs in CF as a result of digestive system involvement. Test-Taking Strategy: Eliminate the option containing the closed-ended word “only.” To select from the remaining options, recall the purpose of administering these preparations, which should direct you to the correct option. Review: administration of pancreatic enzyme preparations Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology Giddens Concepts: Client Education, Nutrition HESI Concepts: Teaching and Learning/Patient Education, Metabolism – Nutrition Awarded 98.0 points out of 98.0 possible points. 51. A nurse provides instructions to the mother of a child with cystic fibrosis (CF) on the correct procedure for administering pancrelipase. The nurse tells the child’s mother that the medication may be administered with which item? A. Oatmeal B. Hot milk C. Applesauce Correct D. Mashed potatoes Rationale: Pancrelipase is a pancreatic enzyme preparation used to reduce fat in the stool and to aid the digestion of protein, carbohydrates, and fat. Because these enzymes may be inactivated by heat, the preparation should not be administered with hot foods. Test-Taking Strategy: Focus on the subject, what food to administer pancrealipase with. Eliminate first the option containing the word “hot.” Next eliminate the options that are comparable or alike in that they are they are prepared and served with a warm or hot temperature. Review: administering pancrelipase Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Practice/Evidence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based 31 Awarded 98.0 points out of 98.0 possible points. 52. Which test result specifically indicates that a child with an immunosuppressive condition has been exposed to tuberculosis? A. A positive ELISA result B. A positive result on the Western blot immunoassay C. A white blood cell (WBC) count of 13.5 × 103/μL (13.5 × 109/L) D. A 7-mm area of induration after administration of a tuberculinskin test Correct Rationale: The tuberculin skin test is administered as a screen for tuberculosis. Purified protein derivative (PPD) is administered by way of intradermal injection and the skin reaction is read by a professional 48 to 72 hours after administration. An induration measuring 5 mm or larger is considered a positive finding in the highest-risk groups, such as children with immunosuppressive conditions or HIV infection. The ELISA and Western blot are used to diagnose HIV. An increased WBC count occurs with infections in general but is not specific to tuberculosis. Test-Taking Strategy: Focus on the subject, exposure to tuberculosis. Eliminate the ELISA and Western blot, which are comparable or alike in that both are used to diagnose HIV. To select from the remaining options, note that the child has an immunosuppressive condition to find the correct option. Review: procedure for interpreting results of tuberculin skin test Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Infectious Disease Giddens Concepts: Immunity, Infection HESI Concepts: Immunity, Infection Awarded 98.0 points out of 98.0 possible points. 53. A cardiac catheterization is performed on an infant. After the procedure, what should the nurse tell the mother about the infant? A. Needs to remain in the crib for 6 hours B. Can be held in a prone position on the mother’s lap Correct C. Needs to have the affected leg restrained for 8 hours D. Will have to remain in a 20-degree head-elevated position for several hours Rationale: After cardiac catheterization, the affected leg is kept straight for 4 to 6 hours. Keeping the infant in the crib does not ensure that the affected leg will remain in a straight position. The infant may be held prone on a parent’s lap. Older children remain in bed, with the head of the bed raised just 20 degrees. Test-Taking Strategy: Focus on the subject, cardiac catheterization in an infant. Visualize each of the options and recall that the affected leg must remain straight. This will direct you to the HESI Concepts: Teaching and Learning/Patient Education, Metabolism – Nutrition Giddens Concepts: Client Education, Nutrition Content Area: Pharmacology 32 Rationale: The parents are instructed to keep the child from engaging in strenuous exercise correct option. Review: cardiac catheterization on an infant Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Cardiovascular Giddens Concepts: Client Education, Clotting HESI Concepts: Teaching and Learning/Patient Education, Perfusion/Clotting Awarded 98.0 points out of 98.0 possible points. 54. What discharge instructions are important to provide the parents after their child undergoes cardiac catheterization? Select all that apply. A. A fever is normal after the procedure. B. Some bleeding from the catheter insertion site is expected. C. The child may play in a tub bath 1 day after the procedure. D. Contact sports should be avoided for 1 week after the procedure. Correct E. Acetaminophen or ibuprofen may be given to ease pain or discomfort. Correct (e.g., climbing trees, swimming, contact sports) for 1 week after the procedure. Acetaminophen or ibuprofen is recommended for mild pain as needed. The parents are instructed that the primary health care provider must be notified if a fever higher than 38° C (101° F) develops, if bleeding or drainage (pus) from the catheter insertion site is noted, or if the child exhibits pallor, coolness, or numbness of the affected extremity. Bathing should be limited to a shower, sponge bath, or brief tub bath (no soaking) for the first 1 to 3 days. Test-Taking Strategy: Focus on the subject, that the child has undergone cardiac catheterization and read each option carefully. Thinking about the procedure and recalling the complications that may occur after this procedure will direct you to the correct options. Review: home care instructions for child following cardiac catheterization Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health—Cardiovascular Giddens Concepts: Client Education, Perfusion HESI Concepts: Teaching and Learning/Patient Education, Perfusion/Clotting Awarded 98.0 points out of 98.0 possible points. 55. A nurse is reviewing the results of an infant’s serum digoxin test. The digoxin level is 0.6 ng/mL (0.77 nmol/L). In light of this finding, which action should the nurse take? A. Administering the prescribed dose because the level is within the therapeutic range Correct B. Calling the primary healthcare provider with the results and asking for further prescriptions 35 child. A blunt chest injury is not associated with rheumatic fever. A swollen knee joint and loss of appetite may be manifestations of this disorder but are not the cause. Test-Taking Strategy: Focus on the subject, the origin of rheumatic fever. Because a swollen knee joint and loss of appetite may be manifestations, rather than causes, of this disorder, these options are eliminated first. To select from the remaining options, note the name of the disorder, which will assist you in identifying the correct option. Review: cause of rheumatic fever Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Cardiovascular Giddens Concepts: Clinical Judgment, Infection HESI Concepts: Clinical Decision-Making/Clinical Judgment, Infection Awarded 98.0 points out of 98.0 possible points. 59. A nurse is planning diversional activities for a school-age child hospitalized with acute febrile rheumatic fever. Which activity is appropriate? A. Board games Correct B. Twice-daily visits to the playroom C. Frequent visits from the child’s friends D. Visits from other children who are hospitalized Rationale: A child with rheumatic fever requires bed rest during the acute febrile stage of the illness. When the child’s activities are restricted, the nurse and family should limit visitors and arrange for quiet yet enjoyable activities based on the child’s age and developmental level. Visits to the playroom are also restricted during the acute stage of the illness. Board and computer games, movies, puzzles, and crafts are all appropriate for the school-age child. Test-Taking Strategy: Focus on the subject, school-age child hospitalized with acute febrile rheumatic fever. Note the strategic word “acute” in the diagnosis. Eliminate the options that are comparable or alike in that they are stimulating activities. Review: child with acute febrile rheumatic fever Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Child Health—Cardiovascular Giddens Concepts: Development, Infection HESI Concepts: Developmental, Infection Awarded 98.0 points out of 98.0 possible points. 60. The mother of a child admitted to the hospital with Kawasaki disease asks the nurse about the disease. What does the nurse respond that it is characterized by? A. It is a common communicable disease B. It is caused by exposure to an individual with rheumatic fever C. It is a disease that affects the smooth muscle cells of the vascular walls Correct 36 D. It is a disease that most often occurs in the summer after swimming in a lake Rationale: Kawasaki disease, is a generalized immune response that affects the smooth muscle cells of the vascular walls. It is also called mucocutaneous lymph node syndrome, and results as an acute febrile exanthematous illness of children with a generalized vasculitis of unknown origin. It is not a communicable disease and is not caused by exposure to an individual with rheumatic fever. Kawasaki disease is diagnosed most often in late winter and early spring. It is not associated with swimming. Test-Taking Strategy: Focus on the subject, child with Kawasaki disease. Eliminate the options that are comparable or alike in that they indicate that Kawasaki disease is communicable. To select from the remaining options it is necessary to know that the disease affects the smooth muscle cells of the vascular walls. Review: Kawasaki disease Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Cardiovascular Giddens Concepts: Immunity, Perfusion HESI Concepts: Immunity, Perfusion/Clotting Awarded 98.0 points out of 98.0 possible points. 61. A nurse is monitoring a child for complications after spinal fusion for scoliosis. The nurse suspects the presence of superior mesenteric artery syndrome if the child exhibits which sign/symptom? A. Becomes lethargic B. Complains of pain C. Complains of a headache and has a fever D. Vomits and exhibits abdominal distension Correct Rationale: One complication of the surgical treatment of scoliosis is superior mesenteric artery syndrome, the result of mechanical changes in the position of the client’s abdominal contents caused by lengthening of the body. It results in a syndrome of emesis and abdominal distention. Therefore postoperative vomiting warrants attention. Lethargy and headache with fever are not signs/symptoms of superior mesenteric artery syndrome. The nurse would need more information about the client’s pain to determine whether it is the result of superior mesenteric artery syndrome. Additionally, pain is expected in the postoperative period. Test-Taking Strategy: Focus on the subject, superior mesenteric artery syndrome. Recalling the location of the superior mesenteric artery (peritoneum) will direct you to the correct option. Review: superior mesenteric artery syndrome and scoliosis Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Child Health—Neurological Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety 37 Awarded 98.0 points out of 98.0 possible points. 62. A nurse reviews the prescriptions for a child with Kawasaki disease and notes that the primary health care provider has prescribed intravenous immune globulin (IVIG). The nurse should tell the child’s mother that this medication has been prescribed for which purpose? A. Reduce the child’s fever B. Prevent coronary artery damage Correct C. Alleviate pain from joint inflammation D. Prevent the transmission of the infection to others Rationale: Therapeutic management of Kawasaki disease is directed at preventing or reducing the coronary artery damage that may occur. High-dose IVIG has been shown to reduce the prevalence of coronary artery abnormalities when given within 10 days of fever onset. IVIG is not specifically administered to reduce a fever or to alleviate pain. Kawasaki disease is not communicable. Test-Taking Strategy: Focus on the subject, the purpose of administering intravenous immune globulin (IVIG). Recalling that this disease affects the smooth muscle cells of the vascular walls will direct you to the correct option. Review: administering IVIG to the child with Kawasaki disease Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Cardiovascular Giddens Concepts: Immunity, Perfusion HESI Concepts: Immunity, Perfusion/Clotting Awarded 98.0 points out of 98.0 possible points. 63. A nurse is conducting an assessment of a 12-year-old with Osgood-Schlatter disease. Which question does the nurse ask the child to elicit data regarding the cause of the disease? A. “Do you participate in sports?” Correct B. “Did you fall off your bicycle?” C. “Have you ever fallen and hit your head?” D. “Does anyone else in your family have this disease?” Rationale: Osgood-Schlatter disease is believed to result from repetitive stress in sports, combined with overuse of immature muscles and tendons over an extended period, and an imbalance in the strength of the quadriceps muscle during adolescent growth. The classic picture is bilateral knee pain that is exacerbated by running, jumping, or climbing stairs in a very active boy or girl who is involved in sports. The child will point to the tibial tubercle as the site of pain. The disease occurs in boys and girls between the ages of 8 and 16 years, although it is more common in boys. Usually both knees are involved. The assessment questions noted in the remaining options are unrelated to the cause of this disease. Test-Taking Strategy: Focus on the subject, 12-year-old child with Osgood-Schlatter disease. Eliminate the options that are comparable or alike in that the child is asked about sustaining an injury (i.e., fall off the bicycle, hitting the head in a fall). To select from the remaining options, 40 Awarded 98.0 points out of 98.0 possible points. 67. The primary health care provider prescribes oral amoxicillin 60 mg 3 times daily for a child who weighs 12.5 lb. The safe pediatric dosage is 20 to 40 mg/kg/day in 3 equal doses. The medication label reads, "Amoxicillin 125 mg/5 mL." How many milliliters will the nurse administer per dose? Correct Correct Responses 2.4 .//assessment[15]/question[32]/question_correct_feedback/text() Awarded 98.0 points out of 98.0 possible points. 68. A child with a history of sickle cell disease is seen in the emergency department where acute sequestration crisis is diagnosed. The nurse should immediately prepare to take which action? A. Administer pain medication B. Start an intravenous (IV) line Correct C. Obtain informed consent for a splenectomy D. Place a cold pack on the abdomen over the area of the spleen Rationale: Acute sequestration crisis is a life-threatening condition if hypovolemic shock occurs. Emergency treatment involves inserting an IV line immediately to restore circulating blood volume with a crystalloid and colloid (blood) infusion. Acute sequestration crisis is a complication of sickle cell disease. It is characterized by pooling of blood in the spleen, resulting in splenic enlargement. Pain is not a priority concern with this type of crisis. Splenectomy may be necessary in cases in which the condition recurs frequently. Placing a cold pack on the abdomen over the area of the spleen will not stop the pooling of blood and might cause more discomfort for the child, so this is not an appropriate measure. Test-Taking Strategy: Focus on the subject, child with acute sequestration crisis. Note the strategic word “immediately.” This indicates a quick action by the nurse. Focus on the name of the crisis and recall that this type of crisis can lead to hypovolemic shock. This will direct you to the correct option. Review: treatment for acute sequestration crisis Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Hematological Giddens Concepts: Clinical Judgment, Clotting HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion/Clotting Awarded 98.0 points out of 98.0 possible points. 69. 41 A pediatric community health nurse is conducting a screening program to identify children at risk for a hematologic disorder. The nurse determines that the child at most risk for beta- thalassemia is which child? A. Of Mediterranean descent Correct B. Whose dietary intake of iron is poor C. Who has a known factor VIII deficiency D. Whose parent is known to have abnormal hemoglobin S (HbS) Rationale: The thalassemias are a group of inherited disorders characterized by an abnormality in hemoglobin synthesis that results from a reduction in or absence of one of the chains found in normal hemoglobin. They are primarily found among people of Mediterranean descent. Beta- thalassemia, also known as thalassemia major or Cooley’s anemia, is the most common and severe form of thalassemia. Poor dietary intake of iron is associated with iron-deficiency anemia. Factor VIII deficiency is associated with hemophilia. An abnormal HbS trait is associated with sickle cell disease. Test-Taking Strategy: Focus on the subject, those at risk for beta-thalassemia. Use knowledge regarding the various types of anemias to assist in directing you to the correct option. Review: characteristics of beta- thalassemia Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Hematological Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Assessment, Clinical Decision-Making/Clinical Judgment Awarded 98.0 points out of 98.0 possible points. 70. Hemosiderosis develops in a child with beta-thalassemia as a result of long-term transfusion therapy. The child is being treated with deferoxamine. What does the nurse monitor to determine the effectiveness of this therapy? A. Lung sounds B. Blood pressure C. Serum iron level Correct D. Serum erythrocyte level Rationale: The nurse would assess the effectiveness of therapy by monitoring the serum iron level. One major complication of long-term transfusion therapy is hemosiderosis, the deposition of hemosiderin, an iron-containing pigment, in the organs. As a means of preventing iron overload–induced organ damage, chelation therapy with deferoxamine (administered subcutaneously or intravenously) is instituted. Therapy is continued until the iron level returns to an acceptable level. Lung sounds, blood pressure, and the serum erythrocyte levels are not indicators of the effectiveness of this therapy. Test-Taking Strategy: Focus on the subject, hemosiderosis in a child with beta-thalassemia due to long-term transfusion therapy. Note the strategic word, “effectiveness”. This indicates how well the client is responding to the treatment. Recalling that hemosiderosis is the deposition of an iron-containing pigment in body organs will direct you to the correct option. 42 Review: purpose of deferoxamine Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Child Health—Hematological Giddens Concepts: Evidence, Perfusion HESI Concepts: Evidence-Based Practice/Evidence, Perfusion/Clotting Awarded 98.0 points out of 98.0 possible points. 71. The mother of a child with hemophilia calls the clinic nurse and reports that her child has hit his knee on the corner of a coffee table and that the joint appears swollen. The nurse should tell the mother immediately to take which action? A. Immobilize the affected joint Correct B. Take the child to the emergency department C. Elevate the affected joint and apply a heating pad D. Bring the child to his primary healthcare provider Rationale: If a muscle or joint injury occurs in the child with hemophilia, the affected part is immediately immobilized, elevated, and treated with ice and compression. Initial immobilization will help prevent further injury until the bleeding resolves. There is no information in the question indicating that bringing the child to the emergency department is necessary. Heat will increase circulation to the site and increase bleeding. The physician should be notified if a blunt injury, especially that involving a joint, occurs, but it is not necessary to immediately bring the child to the primary healthcare provider. Test-Taking Strategy: Focus on the subject, child with hemophilia with a knee injury. Note the strategic word “immediately.” This indicates the most important action the mother is told to take. Focusing on the data in the question will assist you in eliminating the options that are comparable or alike (i.e., bringing the child to the emergency department or primary healthcare provider). To select from the remaining options, recall the effects of heat, which will help you eliminate this option. Review: child with hemophilia Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Hematological Giddens Concepts: Clinical Judgment, Clotting HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion/Clotting Awarded 98.0 points out of 98.0 possible points. 72. A nurse is conducting an assessment on a child admitted with suspected von Willebrand’s disease (VWD). Which question does the nurse ask to elicit information specific to the manifestations associated with this disease? A. “Does it hurt to urinate?” B. “Are you always thirsty?” 45 diphenhydramine and Maalox, may be recommended. Viscous lidocaine is not recommended for young children, because it may depress the gag reflex and increase the risk of aspiration. Favorite foods should not be given to a child who is nauseated, because the child will associate these foods with being sick. Test-Taking Strategy: Focus on the subject, 3-year old child with leukemia. Note the data in the question “not eating and losing weight”. Also, note that the child is experiencing nausea and mucositis. Read each option carefully and think about the effect of the intervention on the client’s problems. This will help you answer correctly. Review: child with leukemia with nausea and mucositis Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Giddens Concepts: Cellular Regulation, Nutrition HESI Concepts: Cellular Regulation, Metabolism – Nutrition Awarded 98.0 points out of 98.0 possible points. 76. A nurse is reviewing the chart of a child with a brain tumor. Which signs/symptom(s) would the nurse expect to note in the history and physical? A. Nausea that occurs at bedtime B. Fatigue that occurs after activity C. Dizziness that occurs late in the day D. Headache and morning vomiting related to the child's getting out of bed Correct Rationale: Manifestations of brain tumors vary with tumor location and the age and development of the child, but the hallmark signs/symptoms of a brain tumor in a child are headache and morning vomiting related to the child's getting out of bed. The sudden increase in intracranial pressure that occurs with the change of position causes the vomiting. Nausea at bedtime, dizziness that occurs late in the day, and fatigue after activity are not signs/symptoms specifically associated with brain tumors. Test-Taking Strategy: Focus on the subject, signs/symptoms of a brain tumor. Note the relationship of the client’s diagnosis, “brain tumor,” and the word “headache” in the correct option. Review: manifestations of a brain tumor Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Neurological Giddens Concepts: Clinical Judgment, Intracranial Regulation HESI Concepts: Assessment, Intracranial Regulation Awarded 98.0 points out of 98.0 possible points. 77. A child is admitted to the hospital, where Wilms’ tumor is diagnosed. Which is the primary nursing intervention? 46 Rationale: The nurse’s primary intervention is to place a sign in the child’s room warning A. Keeping the room dark and avoiding overstimulation B. Posting a sign over the bed reading, “Do not palpate abdomen” Correct C. Take the blood pressure once per day to avoid irritating the child D. Maintaining the client in a high Fowler position when she is not sleeping against palpating the abdomen. Wilms’ tumor, or nephroblastoma, is the most common renal tumor in children. The most common clinical presentation is an asymptomatic, mobile abdominal mass. The tumor mass should not be palpated because of the high risk of rupturing the protective capsule. Excessive manipulation may result in seeding of the tumor. Hypertension may occur as a result of increased production of renin by the kidneys; therefore the blood pressure needs to be checked regularly (more frequently than once a day). Placing the child in a high Fowler position and keeping the room dark are not interventions specific to Wilms’ tumor. Test-Taking Strategy: Focus on the subject, child with Wilms’ tumor. Note the strategic word, “primary”. Recalling that this type of tumor presents as an abdominal mass and involves the kidney will direct you to the correct option. Review: child with Wilms’ tumor Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Renal Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Awarded 98.0 points out of 98.0 possible points. 78. Oral nystatin suspension is prescribed for an infant with thrush (oral candidiasis). Which instruction should the nurse provide to the mother? A. Avoid breastfeeding the infant B. Apply the suspension before feeding the infant C. Apply the suspension with a cotton-tipped applicator D. Rub the suspension onto the mucous membranes with a gloved finger Correct Rationale: An effective method of administration of oral nystatin suspension is to rub the suspension onto the mucous membranes, using a gloved finger. Thrush is a superficial fungal infection of the oral mucous membranes. It occurs as a result of overgrowth of Candida albicans. Cotton-tipped applicators tend to absorb the medication. To increase the amount of time the medication is in contact with the mucous membranes, nystatin should be applied after feedings. Breastfeeding does not need to be avoided. If the infant is breastfed, the mother’s breasts should also be treated with nystatin. Test-Taking Strategy: Focus on the subject, the procedure for applying oral nystatin suspension. Note the diagnosis and think about the intended effect of the medication. This will direct you to the correct option. Review: applying oral nystatin suspension Level of Cognitive Ability: Applying 47 Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Pharmacology Giddens Concepts: Client Education, Infection HESI Concepts: Infection, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points. 79. A nurse provides home care instructions to the mother of a child with pediculosis capitis (head lice). Which statement by the mother indicates a need for further instruction? A. “I need to wash her clothes and bedding in hot water and dry them on a hot setting.” B. “I need to use an antilice spray on her and on anything that she’s been in contact with.” Correct C. “I need to boil or soak her combs and brushes in antilice shampoo or hot water for at least 10 minutes.” D. “I can get the lice and nits off her eyelashes by applying petrolatum to the eyelashes twice a day for 8 days.” Rationale: Antilice sprays should be used on furniture and other environmental objects but are never used on a child. Also, floors, play areas, and furniture should be vacuumed to remove any hairs carrying live nits. The child’s clothing and bedding should be washed in hot water and dried on a hot setting. Items that cannot be washed should be dry cleaned or sealed in plastic bags and kept in a warm place for 2 to 3 weeks. Combs and brushes must be boiled or soaked in antilice shampoo or hot water for at least 10 minutes. Lice and nits may be removed from the child’s eyelashes with the application of petrolatum to the eyelashes twice a day for 8 days. Test-Taking Strategy: Focus on the subject, child with pediculosis capitis. Note the strategic words “need for further instruction.” This indicates a negative event query and the need to select the incorrect statement. Recall that antilice sprays should never be sprayed on the child. This will direct you to the correct option. Review: home care instructions for the child with lice. Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Child Health—Infectious Disease Giddens Concepts: Client Education, Infection HESI Concepts: Infection, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points. 80. The nurse is planning care for a child admitted to the emergency Department (ED) who sustained a severe burn injury at home. While reviewing the paramedic’s documentation, what actions does the nurse note were conducted at the scene? Select all that apply. A. Child initially rolled in blanket including covering face and head B. After flames are extinguished, burn area covered with clean cloth Correct C. Child placed in vertical position to stop burning process and smother flames 50 D. Rationale: The most serious complication associated with skeletal traction is osteomyelitis, an infection involving the bone. The child in skeletal traction should be monitored most closely for osteomyelitis. Organisms gain access to the bone systemically or through the opening created by the metal pins or wires used for traction. Osteomyelitis may occur with any open fracture. Clinical manifestations include localized pain, swelling, warmth, tenderness, and unusual odor. An increased temperature may accompany the signs/symptoms. Balanced suspension traction may be used with or without skin and skeletal traction. When it is used with skeletal traction, however, the client is at risk for osteomyelitis. Buck’s extension and Russell traction are types of skin traction. Crutchfield tongs are inserted in the skull and as a result are less likely to give rise to osteomyelitis. Test-Taking Strategy: Focus on the subject, signs/symptoms of osteomyelitis. Recall that osteomyelitis is an infection of the bone. From this point, use the process of elimination and note the words “skeletal traction” in the correct option. Review: types of traction Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Musculoskeletal Giddens Concepts: Infection, Tissue Integrity HESI Concepts: Infection, Tissue Integrity Awarded 98.0 points out of 98.0 possible points. 83. A nurse is conducting a neurovascular assessment of a child who has just had a cast applied to her leg. The nurse notes that the capillary refill time distal to the cast is 4 seconds. In light of this finding, which action by the nurse is most appropriate? A. Documenting the findings B. Contacting the primary health care provider Correct C. Removing any pillows that were placed under the leg D. Continuing neurovascular assessments every 1 to 2 hours Rationale: To assess capillary refill time, the nurse would apply pressure to the child’s nail bed and count how long it takes for the color to return (should be no longer than 2 seconds). A sluggish capillary refill time indicates neurovascular impairment; if such impairment is suspected, the primary health care provider is notified. Although the nurse would document the findings and continue the assessments, it would be mostappropriate to contact the primary 51 health care provider. Elevation of the extremity on pillows helps prevent edema at the fracture site and subsequent neurovascular impairment. Test-Taking Strategy: Focus on the subject, child with cast on left leg. Note the data in the question related to capillary refill time. Recalling that the normal capillary refill time is 2 seconds or less and that a sluggish capillary refill indicates neurovascular impairment will direct you to the correct option. Review: signs/symptoms of neurovascular impairment Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Musculoskeletal Giddens Concepts: Clotting, Tissue Integrity HESI Concepts: Perfusion/Clotting, Tissue Integrity Awarded 98.0 points out of 98.0 possible points. 84. The use of a Pavlik harness has been prescribed for an infant with developmental dysplasia of the hip, and the nurse provides instructions to the mother about the use of the harness. Which statement by the mother indicates the need for further instruction? A. “The diaper is put on under the harness.” B. “The harness is placed against the skin to provide support.” Correct C. “I need to support her hips and buttocks when the harness is off.” D. “The harness straps should be secure enough to keep her hips flexed but not tight.” Rationale: When the infant is in a Pavlik harness, the skin under the harness must be protected. The parents are instructed to place a shirt and socks on the infant under the harness to reduce rubbing. The diaper should go on under the harness as well. The harness straps should be secure enough to keep the child’s hips flexed but not tight. The harness should be worn 23 hours a day and should be removed only in accordance with the primary health care provider’s recommendation. The infant’s hips and buttocks should be carefully supported whenever the infant is out of the harness. Test-Taking Strategy: Focus on the subject, infant in a Pavlik harness. Note the strategic words “need for further instruction,” which indicate a negative event query and the need to select the incorrect intervention. Note the words “placed against the skin” in the correct option for this question. Review: home care instructions for infant in Pavlik harness Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health—Musculoskeletal Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points. 85. 52 A nurse is providing home care instructions to the mother of a child with juvenile idiopathic arthritis. Which action should the nurse tell the parents to take during a painful exacerbation? A. Splinting the painful joints and avoiding any joint movement B. Encouraging the child to perform simple isometric exercises Correct C. Alternating splinting of the painful joints with joint exercises every hour D. Encouraging the child to perform the prescribed joint exercises to maintain muscle and joint integrity painful joint, but such inactivity could lead to muscle wasting and flexion deformity. Therefore it is important for the child to perform simple isometric exercises. These exercises are appropriate during exacerbations of the disease because they do not involve joint movement. Exercises that involve joint movement are avoided during an exacerbation of the disease. Test-Taking Strategy: Focus on the subject, exercise during an acute exacerbation of juvenile idiopathic arthritis. Eliminate the option using the words “avoiding any joint movement”. To select from the remaining options, note the word “simple” in the correct one. Review: painful exacerbations of juvenile idiopathic arthritis Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health—Musculoskeletal Giddens Concepts: Functional Ability, Pain HESI Concepts: Functional Ability, Pain Awarded 98.0 points out of 98.0 possible points. 86. A 9-year-old is found to have type 1 diabetes mellitus. The nurse discusses with the child’s parents the self-care tasks that may be delegated to the child. In light of the developmental characteristics of the school-age child, which task does the nurse tell the mother may be delegated to the child as long as the child is supervised? A. Drawing up insulin B. Recognizing when to test for ketones C. Looking for patterns in the blood glucose level D. Choosing the injection site in accordance with the rotation schedule Correct Rationale: The school-age child is beginning to develop a self-concept. Appropriate self-care tasks include choosing the injection site in accordance with a rotation schedule, performing fingersticks and blood glucose testing, pushing the plunger on the insulin syringe after the needle has been inserted by a parent or administering one's own injection, and performing ketone testing. Drawing up insulin is a task appropriate for a client in early adolescence. Recognizing when to test for ketones and looking for patterns in the blood glucose level are also tasks for the adolescent. Test-Taking Strategy: Focus on the subject, the concepts of growth and development. Focusing on the client of the question, a 9-year old, will direct you to the correct option. Review: characteristics of school-age child Level of Cognitive Ability: Analyzing Rationale: During an exacerbation of the disease, the child’s natural reaction is to rest the 55 Test-Taking Strategy: Focus on the subject, child with suspected meningitis. Recalling the purpose of each diagnostic test will direct you to the correct options. Review: tests for meningitis Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health-Neurological Giddens Concepts: Clinical Judgment, Intracranial Regulation HESI Concepts: Assessment, Intracranial Regulation Awarded 65.333333 points out of 98.0 possible points. 90. A nurse is developing a plan of care for a child at risk for seizures. Which interventions should be carried out if a seizure occurs? Select all that apply. a. Turning the child on her side Correct b. Monitoring the child’s movements Correct c. Restraining the child’s arms and legs d. Loosening the clothing around the child’s neck Correct e. Gently inserting a padded tongue blade between the child’s upper and lower teeth Rationale: When a seizure begins, it is important to note the child’s movements and keep track how long the seizure lasts. This information will help the primary health care provider treat the seizure. Positioning the child on the side will help prevent aspiration because saliva will drain from the child’s mouth. Clothing around the child’s neck is loosened to help maintain a patent airway. The nurse would not restrain the child’s arms or legs, because this could cause injury. The nurse would not insert any object into the child’s mouth. Forcing an object into the child’s mouth may cause injury to the child’s mouth, gums, or teeth. Test-Taking Strategy: Focus on the subject, actions to be taken during a seizure. Visualize this occurrence to answer correctly. Also, read each option carefully and eliminate those that could cause harm to the child. Remember, do not restrain the child experiencing a seizure or place anything in the child’s mouth. Review: nursing interventions during a seizure Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Child Health—Neurological Giddens Concepts: Caregiving, Intracranial Regulation HESI Concepts: Caregiving, Intracranial Regulation Awarded 98.0 points out of 98.0 possible points. 91. The nurse should contact the primary health care provider with concerns about a prescription for valproic acid for an adolescent who has a history of which disorder? a. Hepatitis Correct b. Diabetes mellitus 56 Rationale: Valproic acid, an anticonvulsant used to treat seizures, is principally used as an c. Migraine headaches d. Tonic-clonic seizures headaches. Valproic acid is contraindicated in hepatic disease and used with caution in persons with a history of hepatic disease or bleeding abnormalities. It is not contraindicated in clients with diabetes mellitus. Test-Taking Strategy: Focus on the subject, a contraindication for valproic acid. This question involves a negative event query and the need to select the incorrect disorder. Recalling that this medication is an anticonvulsant will help you eliminate tonic-clonic seizures. To select from the remaining options, recall that valproic acid is hepatotoxic, which will help you answer correctly. Review: valproic acid Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Giddens Concepts: Collaboration, Safety HESI Concepts: Collaboration/Managing Care, Safety Awarded 98.0 points out of 98.0 possible points. 92. A child being seen in the clinic is found to have rubeola (measles), and the father asks the nurse how to care for the child. The nurse should provide which instruction to the father? a. Keep the child in a room with dim lights Correct b. Give the child warm baths to help prevent itching c. Allow the child to play outdoors, because sunlight will help heal the rash d. Take the child's temperature every 4 hours and administer 1 baby aspirin for fever Rationale: One nursing consideration in rubeola is eye care. The affected child usually has photophobia, so the nurse should suggest that the parent keep the child out of brightly lit areas. Children with viral infections are not to be given aspirin because of the risk of Reye syndrome. Warm baths and sunlight will aggravate itching. Additionally, the child needs rest. Test-Taking Strategy: Focus on the subject, instructions to care for a child with rubeola. Eliminate the options that involve warmth, which will aggravate the condition. Recalling that aspirin should not be administered will help you answer correctly. To select from the remaining options, recall that photophobia may develop in children with rubeola. Review: child with rubeola Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Child Health—Infectious Diseases adjunct to other anticonvulsant agents. It is also used as prophylaxis against migraine 57 Awarded 98.0 points out of 98.0 possible points. 93. A nurse is providing home care instructions to the mother of an infant who has just been found to have hemophilia. The nurse should tell the mother to take which action? a. Pad crib rails and table corners Correct b. Use baby aspirin for pain relief c. Use a soft toothbrush for dental hygiene d. Use a generous amount of lubricant when taking the child’s temperature rectally Rationale: Establishment of an age-appropriate safe environment is of paramount importance for the hemophiliac client. Providing a safe environment for an infant includes padding table corners and crib rails, providing extra joint padding in clothes, and keeping items that could be pulled down onto the infant out of reach. The use of a soft toothbrush is an appropriate measure for a child with hemophilia but is not typically necessary for an infant. Rectal temperature measurements and the use of aspirin are contraindicated in hemophilia because of the risk of bleeding. Test-Taking Strategy: Focus on the subject, an infant with hemophilia. Remembering that a toothbrush is not needed for an infant will help you eliminate this option. Recalling that aspirin should not be administered will assist you in eliminating this option. Rectal temperature measurements are contraindicated in hemophilia, so this option may easily be eliminated as well. Additionally, the words "generous amount" should serve as a clue that this is an incorrect option. Review: infant with hemophilia Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Child Health—Hematological Giddens Concepts: Client Education, Clotting HESI Concepts: Teaching and Learning/Patient Education, Perfusion/Clotting Awarded 98.0 points out of 98.0 possible points. 94. A nurse is providing home care instructions to the parents of a child with bacterial conjunctivitis. The nurse should provide which information to the parents? a. That the child may attend school if antibiotics have been started b. To save any unused eye medication in case a sibling gets the eye infection c. That the child's towels and washcloths should not be used by other members of the household Correct d. To wipe any crusted material from the eye with a cotton ball soaked in warm water, starting at the outer aspect of the eye and moving toward the inner aspect HESI Concepts: Infection, Teaching and Learning/Patient Education Giddens Concepts: Client Education, Infection