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Question
When assigned to the patient on complete bed rest for spinal fusion secondary to scoliosis, the nurse will want to intervene to prevent common complications of immobility. Nursing interventions will include:
Standard Text: Select all that apply.
1. Encouraging use of the spirometer every two hours while the child is awake.
2. Log-rolling the patient every two hours while awake.
3. Increasing intake of milk to maintain bone calcium.
4. Increasing fruit and grains in the diet.
5. Limiting fluid intake to reduce the need to void.
Answer
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Related questions
Q:
The nurse is planning postoperative care for an infant after a cleft lip repair. Which intervention should the nurse include in this infant's plan of care?
1. Suctioning with a tonsil tip (Yankauer) device
2. Using a pacifier to reduce straining the suture line with crying
3. Supine positioning
4. Frequent breast or bottle feeding
Q:
A three-year-old child is suspected of having Hirschsprung's disease. Which assessment factors would support such a medical diagnosis?
1. Clay-colored stools and dark urine
2. History of early passage of meconium in the newborn period
3. History of chronic, progressive constipation and failure to gain weight
4. Continual bouts of foul-smelling diarrhea
Q:
The 10-year-old boy is admitted to the pediatric neurologic unit with a suspected craniopharyngioma. The nurse will assess the child with which symptoms related to this brain tumor?
Standard Text: Select all that apply.
1. Evening nausea
2. Excessive urination leading to dehydration
3. Nystagmus
4. Headaches
5. Orbital ecchymosis
Q:
The ten-year-old child was diagnosed with a medulloblastoma; following surgery the child is started on chemotherapy by intrathecal injection. While preparing the family for the start of chemotherapy, the nurse will explain that intrathecal administration was chosen because:
1. It reduces side effects.
2. It does not require the child being "stuck."
3. Many chemotherapy drugs do not cross the blood-brain barrier.
4. Intrathecal administration is less expensive than intravenous administration.
Q:
Following diagnosis of osteosarcoma, a 14-year-old girl has a below-the-knee amputation. The girl has had trouble accepting the reality of her amputation. Which behavior, when observed by the nurse, indicates she is beginning to accept the amputation?
1. The girl complains of pain in the missing leg.
2. When physical therapy comes, she is willing to have her temporary prosthetic applied and attempts crutch training.
3. Prior to visiting hours, she asks to be helped to a wheelchair with a blanket over her legs.
4. When the nurses change the dressing on the stump, she watches the dressing change.
Q:
A child has been diagnosed with Ewing sarcoma and is being started on a chemotherapy protocol. The mother questions the nurse on why more than one drug is being used as it would seem that using fewer drugs would decrease the side effects. The best response by the nurse would include the information that:
1. The child's cancer is a severe form and needs additional drugs to remove the cancer.
2. A protocol is a proven means of treatment.
3. A protocol is used in children but not adults due to the chemotherapy's effect on growth.
4. A protocol involves a group of drugs that work in different modes and have different side effects.
Q:
The nurse is explaining to the mother that her child with cancer will receive chemotherapy daily for one month and then no treatments for six weeks. Following the period of rest, chemotherapy will be administered again for another month. The mother asks why the child can"t receive the medication for two months straight. The nurse would explain that the rest period:
1. Prevents the child from having side effects from the drugs.
2. Is due to the scheduling requirements of the infusion center.
3. Is necessary because receiving the medication for more than one month can cause heart failure.
4. Allows normal cells to repair themselves while the cancer cells die.
Q:
During rounds, the interdisciplinary team is discussing the care of a child with a newly diagnosed Wilms' tumor. The nurse describes the mother as being angry and upset that they are not caring properly for her child. What behavior probably is the cause of the mother's anger?
1. The mother is beginning the stages of grief over loss of her previously well child.
2. The mother is feeling guilty for not recognizing that the child was ill.
3. The nurses are negligent in providing safe care for the child.
4. The mother does not have adequate support from Social Services.
Q:
After years of treatment with chemotherapy and radiation, a child with a brain tumor is shown to be refractory to treatment, and a DNR (Do Not Resuscitate) has been obtained. The mother has reached the stage of acceptance; the father is angry that the medical and nursing team has not been able to "save" his child. How would the multidisciplinary team best support this family?
1. Tell the father that he should have brought his child in earlier for treatment.
2. Continue to include the family in planning care and assure them that the child will be kept comfortable in the days to come.
3. Initiate a Social Services referral.
4. Contact the on-call chaplain for consultation with the entire family and ask him to take the father aside for additional assistance.
Q:
The antiemetic drug ondansetron (Zofran) is being administered to a child receiving chemotherapy. It should be administered:
1. Only if the child experiences nausea.
2. Before chemotherapy administration, as a prophylactic measure.
3. After the chemotherapy has been administered.
4. Never; this antiemetic is not effective for controlling nausea and vomiting associated with chemotherapy.
Q:
The physician has ordered the child to receive a unit of packed red blood cells. In preparing to administer the blood, the nurse will initiate an intravenous line and hang what fluid?
1. D5W
2. D5LR
3. D5 1/4NS
4. NS
Q:
The nurse is preparing to administer a blood transfusion to a child with a severe anemia. Which type of transfusion reaction may be within the nurse's realm of prevention?
1. Allergic
2. Hemolytic
3. Febrile
4. Septic
Q:
A child who has undergone a hematopoietic stem cell transplantation (HSCT) is ready for discharge. Which concepts are important for the nurse to include in discharge education?
Standard Text: Select all that apply.
1. Keeping the child on a high-calcium diet
2. Practicing good hand washing
3. Avoiding live plants and fresh vegetables
4. Avoiding influenza vaccinations
5. Returning the child to school within six weeks
Q:
For which complication(s) should the nurse observe during administration of Factor VIII to a child with hemophilia?
1. Fever and chills
2. Fat emboli
3. Nausea and vomiting
4. Congestive heart failure
Q:
Which of the following parental demonstrations indicates that the parents understand the nurse's teaching with regard to prevention of iron-deficiency anemia?
1. The parents feed their infant with a formula that is not iron-fortified.
2. The child's vitamin C consumption is limited after one year of age.
3. The parents start iron-fortified infant cereal at four to six months of age.
4. Cow's milk is introduced into the child's diet at six months of age.
Q:
A two-month-old infant has been diagnosed with severe combined immunodeficiency disease (SCID). The physician talked with the parents about the planned treatment and prognosis for the infant. Which statement by the parents indicates the need for additional education?
1. "My child will receive intravenous immune globulins as a way to help him fight infection."
2. "Within days of receiving a stem cell transplant, my child will be cured."
3. "If my child needs a blood transfusion, it should be with irradiated blood cells."
4. "Antibiotics will be used as necessary to help my child fight infections."
Q:
The nurse is preparing the hospital room for admission of a child with multiple allergies including cow's milk, peanuts, and latex. The nurse's priority responsibility in preparing for this child would include:
1. Evaluating the hospital room for equipment containing latex.
2. Ordering an EpiPen for the child.
3. Notifying dietary of the milk and peanut allergy.
4. Placing a sign on the door which identifies all allergies.
Q:
The nurse is caring for a child with rheumatoid arthritis. Which is an appropriate nonpharmacologic measure to reduce the joint pain associated this disease?
1. Elevation of the extremity
2. Immobilization
3. Massage
4. Application of moist heat
Q:
The nurse has just finished a parent teaching session on preventing heat-related illnesses for children who exercise. Which statement by a parent indicates understanding of preventive techniques taught?
1. Wearing dark clothing during exercise is recommended
2. Water is the drink of choice to replenish fluids.
3. During activity, stop for fluids every 15 to 20 minutes.
4. Hydration should occur at the end of an exercise session.
Q:
There has been an outbreak of communicable diseases in the community. To reduce parental anxiety, the nurse presents information about disease at the school's Parent Teacher Association meeting. The nurse explains that children cannot acquire vector-borne diseases from other children. The nurse explains that vector-borne diseases include:
Standard Text: Select all that apply.
1. Measles (Rubeola).
2. Pertussis (whooping cough).
3. Rocky Mountain Spotted Fever.
4. West Nile Virus.
5. Lyme disease.
Q:
The nurse administers the flu vaccine to a school age child. After administering the vaccine, the nurse will document:
Standard Text: Select all that apply.
1. The date of the last flu vaccine.
2. The site of the vaccination.
3. The lot and serial number of the vaccine.
4. The date and time of administration.
5. Who assisted in restraining the child.
Q:
The clinic nurse is checking the potency of the vaccine. Which finding may have rendered the vaccine ineffective?
1. The vaccine was frozen as labeled.
2. The vaccines have been stored in a refrigerator where the temperature has been maintained between 35 to 46F.
3. The vaccine's expiration date expires within the next month.
4. The vaccine is stored in the door of the refrigerator.
Q:
The mother of an immunocompromised child brings her child to the clinic for a routine check-up and recommended immunizations. The mother expresses concern that her child will "catch" the disease from the vaccination. The nurse would explain that which of the following carry no risk of acquiring the infection?
Standard Text: Select all that apply.
1. Toxoid
2. Killed virus vaccine
3. Live virus vaccine
4. Attenuated vaccine
5. Immunoglobulins
Q:
The school nurse is trying to prevent the spread of a flu virus through the school. Infection-control strategies that could be employed include:
1. Sanitizing toys, telephones, and doorknobs to kill pathogens.
2. Teaching parents safe food preparation and storage.
3. Withholding immunizations for children with compromised immune systems.
4. Not separating children with infections from well children.
Q:
A parent reports that her five-year-old child, who has had all recommended immunizations, had a mild fever one week ago and now has bright red cheeks and a lacy red maculopapular rash on the trunk and arms. The nurse recognizes that this child might have:
1. Rubeola (measles).
2. German measles (rubella).
3. Chickenpox (varicella).
4. Fifth disease (erythema infectiosum).
Q:
The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis) immunization for a six-month-old infant. To administer this injection safely, the nurse chooses which of the following needles (size and length), injection type, and injection site?
1. 25-gauge, 5/8-inch needle; IM (intramuscular); anterolateral thigh
2. 25-gauge, 5/8-inch needle; ID (intradermal); deltoid
3. 22-gauge, 1/2-inch needle; IM (intramuscular); dorsogluteal
4. 25-gauge, 3/4-inch needle; SQ (subcutaneous); anterolateral thigh
Q:
The nurse is caring for a four-year-old child who is intellectually disabled and is scheduled for surgery tomorrow. The nurse wants to plan postoperative care and pain relief. The nurse will determine the best pain assessment tool by observing the child's:
Standard Text: Select all that apply.
1. Language skills.
2. Understanding of the concept of more and less or otherwise has the ability to quantify pain.
3. Ability to sit for a ten minute evaluation.
4. Ability to perceive pain.
5. Ability to understand pain.
Q:
A five-year-old child is being discharged from the outpatient surgical center. Which statement by the parent would indicate the need for further teaching?
1. "I will call the office tomorrow if the pain medicine is not relieving the pain."
2. "I can expect my child to have some pain for the next few days."
3. "Because my child just had surgery today, I can expect the pain level to be higher tomorrow."
4. "I will plan to give my child pain medicine around the clock for the next day or so."
Q:
A child who has chronic pain of long duration will exhibit which behavior?
1. Increased respiratory rate
2. Normal temperature
3. Normal heart rate
4. Decreased blood pressure
Q:
A six-year-old postoperative patient IV has infiltrated and has to be restarted immediately for medication. There is no time for placing local anesthetic cream on the skin. What other complementary therapies would be most helpful when placing this IV?
1. Restraints
2. Moderate sedation
3. Anesthesia
4. Distraction