HESI PN NURSING CARE OF CHILDREN PROCTORED EXAM
VERSION 1
A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction?
- Laryngeal edema
- Flank pain
- Distended neck veins
- Muscular weakness
Answer- b. Flank pain. The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion.A- Laryngeal edema is an indication of an allergic reaction to the blood transfusion.C- Distended neck veins are an indication of circulatory overload, which is a complication of a blood transfusion.D- Muscle weakness is an indication of an electrolyte disturbance, which is a complication of a blood transfusion.
A community health nurse is assessing an 18-month-old toddler in a community day care. Which of the following findings should the nurse identify as a potential indication of physical neglect?
- Resists having an axillary temperature taken
- Exhibits withdrawal behaviors when her parent leaves
- Has multiple bruises on her knees
- Poor personal hygiene
Answer- d. Poor personal hygiene. Poor personal hygiene in a toddler is a potential indication of physical neglect. Because toddlers are still dependent on their parents for help with hygiene needs, poor personal hygiene indicates a lack of supervision.A- The toddler has begun to develop a sense of body image and boundaries and can be resistant to intrusive assessments such as assessing the mouth or ears, or taking an axillary temperature. Therefore, this finding is not an indication of physical neglect.B- Separation anxiety is an expected finding for a toddler. The child of this age can become fearful and exhibit regressive behaviors when left alone with strangers and separated from her parents; therefore, this finding is not an indication of physical neglect.C- The 18-month-old toddler has accomplished the gross motor skills of standing and walking and has begun to try to run but falls easily and can have bruises on her knees. Therefore, this finding is not an indication of physical neglect.
A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take?
- Use surgical asepsis when providing routine care for the child.
- Administer the measles, mumps, rubella (MMR) vaccine to the child.
- Screen the child's visitors for indications of infection.
- Infuse packed RBCs.
Answer- c. Screen the child's visitors for indications of infection. The child who is severely immunocompromised is unable to adequately respond to infectious organisms resulting in the potential for overwhelming infection; therefore, the nurse should screen the child's visitors for indications of infection.Nursing Care Of Children HESI PN Test Bank Proctored (3000+ Questions and Answers) - Brand New Q&As Latest 2023 1 / 4
A- It is not necessary for the nurse to use surgical asepsis when providing direct care. Strict hand washing and medical asepsis are recommended to prevent the spread of infection.B- It is contraindicated for a child who is severely immunocompromised to receive the MMR vaccine because it is a live virus vaccine and the child may not be able to build adequate antibodies to prevent infection with the organism.D- A child who is immunocompromised as a result of chemotherapy will have a decreased neutrophil count. The nurse should plan to infuse packed RBCs to the child who is anemic. However, packed RBCs will not increase the child’s neutrophil count.
A nurse is teaching a school-age child who has a severe allergy to bee venom and his parent about epinephrine. Which of the following instructions should the nurse include in the teaching?
- Use a second dose if the first dose of epinephrine does not completely reverse the symptoms.
- Store unused epinephrine syringes in the refrigerator.
- Shake the epinephrine syringe prior to use to dissolve the precipitate.
- Administer the medication subcutaneously in the back of the arm.
Answer- a. Use a second dose if the first dose of epinephrine does not completely reverse the symptoms. A biphasic response, in which the child will appear to recover and then experience a recurrence of symptoms, is possible with some allergic reactions. The nurse should instruct the parent and child to use a second dose if the first dose does not resolve all the symptoms.B- The nurse should instruct the parent and child to store epinephrine in a dark area at room temperature. Refrigeration of an epinephrine syringe can result in failure of the injection mechanism to work.C- The nurse should instruct the child and his parent that the formation of precipitate or a brown coloration to the solution is an indication that the medication should be replaced and not used.D- The nurse should instruct the child and his parent to inject the medication intramuscularly into the anterolateral aspect of the middle thigh.
A nurse is assessing a school-age child who has appendicitis with possible perforation. The nurse should identify which of the following as a manifestation of peritonitis?
- Hyperactive bowel sounds
- Abdominal distention
- Bradycardia
- Polyuria
Answer- b. Abdominal distention. The nurse should recognize that abdominal distention is a manifestation of peritonitis. Peritonitis is an inflammation of the lining of the abdominal wall. This inflammation in the abdomen, along with the ileus that develops, causes abdominal distention.A- Hypoactive bowel sounds are a manifestation of peritonitis. The peritoneal inflammation caused by the feces and bacteria released from the perforated appendix results in the development of an ileus, and a decrease in bowel motility.C- Tachycardia is a manifestation of peritonitis resulting from infection and fluid shifts within the abdomen, which causes hypovolemia.D- Polyuria occurs with an elevated glucose level and is not a manifestation of peritonitis.
A nurse is reviewing the laboratory report of a 6-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?
- Hgb 8.5 g/dL
- WBC 9,500/mm3
- Prealbumin18 mg/dL
- Platelets 300,000/mm3
Answer- a. Hgb 8.5 g/dL. The child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range for a 6-year-old child and should be reported to the
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provider.B- The child receiving chemotherapy is at risk for infection due to the myelosuppressing effects of the medication used to treat the cancer. The presence of infection can be evaluated through body temperature, redness, edema, warmth, or drainage of wound or IV sites, as well as through measurements of WBC and absolute neutrophil counts. A WBC count of 9,500/mm3 is within the expected reference range for a 6-year-old child.C- The child receiving chemotherapy is at risk for malnutrition as a result of nausea and vomiting, stomatitis, and pain. Nutritional status can be evaluated through prealbumin, albumin, and transferrin levels. A prealbumin level 0f 18 mg/dL is within the expected reference range for a 6- year-old child.D- The child receiving chemotherapy is at risk for hemorrhage due to the thrombocytopenic effects of the medications used to treat cancer. The development of thrombocytopenia is diagnosed through laboratory testing of platelet levels. A platelet count of 300,000/mm3 is within the expected reference range for a 6-year-old child.
A nurse is caring for a school-age child who is receiving a cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first?
- Prednisone
- Epinephrine
- Diphenhydramine
- Albuterol
Answer- b. Epinephrine. This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs.A- Prednisone is an anti-inflammatory agent that can treat severe inflammation Although it will benefit a child who is having an anaphylactic reaction, it is not the first medication the nurse should administer.C- Even though histamines are not the major mediators of an anaphylactic reaction, administering an antihistamine such as diphenhydramine can help to decrease the allergic reaction. However, it is not the first medication the nurse should administer.D- Albuterol is a beta adrenergic agonist that can treat acute bronchospasms. Although albuterol will improve the child's breathing, it is not the first medication the nurse should administer.
A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect?
- Deep respirations of 32/min
- Shallow respirations of 10/min
- Paradoxic respirations of 26/min
- Periods of apnea lasting for 20 seconds
Answer- a. Deep respirations of 32/min. The nurse should expect deep and rapid respirations in a child who has diabetic ketoacidosis. This respiratory rhythm is the body's attempt to blow off excess carbon dioxide and achieve a state of homeostasis.B- The nurse should expect shallow respirations in a child who has respiratory depression related to opioid administration. However, shallow respirations are not an expected finding in a child who has ketoacidosis.C- The nurse should expect paradoxic respirations in a child who has flail chest. However, paradoxic respirations are not an expected finding in a child who has ketoacidosis.D- The nurse should expect periods of apnea in a child who has obstructive sleep apnea. However, periods of apnea are not an expected finding in a child who has ketoacidosis.
A nurse is caring for a newly-admitted school-age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to recommend to the parents for treating the child's condition?
- Desmopressin
- Luteinizing hormone-releasing hormone
- Recombinant growth hormone
- Levothyroxine 3 / 4
Answer- c. Recombinant growth hormone. Recombinant growth hormone injections are used to treat hypopituitarism, which inhibits cell growth and results in growth failure. The nurse should expect the provider to recommend this treatment to the child's parents. The nurse's role is to provide emotional support for the parents as they make a decision about the treatment they feel is best for their child.A- Desmopressin is used to treat hyposecretion of antidiuretic hormones.B- Luteinizing hormone-releasing hormone is used in the treatment of precocious puberty to slow prepubertal growth in children and in the treatment of advanced prostate cancer in adult clients.D- Levothyroxine is used to treat various hypothyroid conditions.
A nurse is preparing to administer a hepatitis B vaccine to a 1-month-old infant. The nurse should plan to inject the medication at which of the following locations?Vastus lateralis A is incorrect. The nurse should recognize that the deltoid muscle is used for intramuscular injections in infants age 18 months or older. The disadvantages associated with this site include the limited amount of medication that can be administered, as well as possible radial nerve damage.B is incorrect. The nurse should realize that the abdomen is used for subcutaneous, rather than intramuscular, injections.C is correct. The nurse should prepare to inject the vaccine into the vastus lateralis or anterolateral thigh muscle because this is a well-developed muscle in an infant and is linked with an improvement in immune response in comparison to other acceptable sites.
A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler?
- Apple juice
- Peanut butter
- Chicken broth
- Oral rehydration solution
Answer- d. Oral rehydration solution. A toddler who has acute diarrhea should consume an oral rehydration solution to replace electrolytes and water and promote recovery from dehydration.A- A toddler who has acute diarrhea should not drink apple juice because it is high in carbohydrates and osmolarity and low in electrolytes.B- A toddler who has acute diarrhea should not eat peanut butter because it is high in carbohydrates and fiber. The high sugar content can result in prolonging the diarrhea and worsening of the dehydration, as water is pulled into the bowel lumen in response to the increased osmolality caused by the sugar. The fiber content further stimulates the bowel, worsening the diarrhea.C- A toddler who has acute diarrhea should not consume chicken broth because it is high in sodium and is not nutrient-dense.
A nurse is teaching the parent of an infant who has a Pack harness to treat developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parents indicates an understandings of the teaching?
- "I should remove the harness at night to allow my infant to stretch her legs."
- "I will need to adjust the straps on the harness once each week."
- "I should apply baby powder to my infant's skin twice daily."
- "I will place my infant's diapers under the harness straps."
Answer- d. "I will place my infant's diapers under the harness straps.". To prevent soiling of the harness the parent should apply the infant's diaper under the straps.A- The harness is to be worn continuously until the hip is stable, which usually occurs within 6 to 12 weeks. Removing the harness frequently or for long periods of time will reduce the effectiveness of the treatment.B- The Pavlik harness is designed to maintain the infant's hips in a position of flexion and abduction. The nurse should instruct the parents not to adjust the harness in any way to avoid complications.C- The use of powders and lotions should be avoided during treatment with the Pavlik harness because these products in combination with the harness can cause skin irritation and breakdown.
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