Question

A nurse is reviewing data for four children. Which of the following children should the nurse assess first?

Answer 1

Correct Answers:

A 10-year-old child who has sickle cell anemia who reports severe chest pain

Rationale :

💔 In a child with sickle cell anemia, severe chest pain may indicate acute chest syndrome, a life-threatening complication characterized by pulmonary infiltrates, hypoxia, and infection or infarction of lung tissue.

💔 It can rapidly progress to respiratory failure if not addressed immediately. This condition requires urgent assessment, oxygen, pain control, hydration, and often antibiotics.

💔 While other choices show concerning findings, this child presents the most immediate risk of deterioration.

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Answer 2

Correct Answers:

"Placing your child on her back when sleeping will decrease the risk of SIDS"

Rationale :

🛏️ The most evidence-based and effective measure to reduce the risk of Sudden Infant Death Syndrome (SIDS) is placing infants on their backs to sleep, as recommended by the AAP's "Back to Sleep" campaign.

🛏️ This position keeps the airway open and reduces the risk of suffocation or positional asphyxia.

🛏️ The incidence of SIDS has decreased significantly since this recommendation was widely adopted.

🛏️ Safe sleep practices also include a firm mattress, no soft bedding or toys, and room-sharing without bed-sharing.

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Answer 3

Correct Answers:

"This is a normal, expected reaction for a child of this age:

Rationale :

👶 Around 6 to 9 months of age, infants begin to experience separation anxiety, a developmental milestone linked to increasing object permanence.

👶 It is a healthy emotional response that shows strong attachment to the caregiver and growing awareness of their environment.

👶 While distressing to parents, it is temporary and can be managed with reassurance and consistent caregiver routines.

👶 Nurses can support parents by explaining that this behavior is normal and age-appropriate.

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Answer 4

Correct Answers:

Frequent swallowing

Rationale :

🩸 In a post-tonsillectomy child, frequent swallowing, especially when not eating or drinking, is often a silent sign of bleeding.

🩸 Blood trickles down the throat and is swallowed, making it difficult to detect overt bleeding early.

🩸 This warrants immediate assessment, as hemorrhage is a life-threatening post-op complication in tonsillectomy patients.

🩸 Nurses should also monitor for restlessness, tachycardia, or vomiting blood.

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Answer 5

Correct Answers:

Initiate droplet precautions.

Rationale :

😷 Mumps is a viral illness transmitted via respiratory droplets, so droplet precautions are essential to prevent spread.

😷 This includes wearing a mask within 3 feet of the patient, placing the patient in a private room, and limiting visitors and staff exposure.

😷 Mumps presents with parotid gland swelling, fever, and malaise, and is highly contagious in school and daycare settings.

😷 It’s preventable via the MMR vaccine, which is part of routine immunization schedules.

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Answer 6

Correct Answers:

Give with orange juice_

Rationale :

🍊 Ferrous sulfate is best absorbed in an acidic environment, and vitamin C in orange juice enhances iron absorption in the gastrointestinal tract.

🍊 Milk, antacids, and tea inhibit absorption, so these should be avoided during administration.

🍊 It should ideally be given between meals unless it causes GI upset.

🍊 Parents should be warned that stools may become dark or greenish-black, which is normal.

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Answer 7

Correct Answers:

Offer the child a choice of taking the medication with juice or water-

Rationale :

🧃 Giving preschoolers a sense of control by offering simple, limited choices helps encourage cooperation without compromising medical treatment.

🧃 This supports autonomy while maintaining nurse authority.

🧃 It avoids the power struggle that often triggers resistance at this age.

🧃 Avoid deception or force, as it may erode trust and create long-term fear of medications.

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Answer 8

Correct Answers:

Body weight

Rationale :

⚖️ In infants, body weight is the most accurate and sensitive indicator of fluid loss or gain.

⚖️ A loss of 1 kg = 1 liter of fluid, which can represent a significant percentage of total body fluid in a small child.

⚖️ Monitoring daily weights allows early detection of dehydration or fluid overload, often before other signs appear.

⚖️ It’s part of routine care in any child at risk for fluid imbalance.

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Answer 9

Correct Answers:

Regression

Rationale :

🧸 Regression is a common reaction in hospitalized toddlers, especially after prolonged stays and separation from caregivers.

🧸 Behaviors like thumb-sucking, clinginess, withdrawal, and even toilet training reversal reflect stress and emotional coping.

🧸 These are age-appropriate defense mechanisms, not signs of pathology.

🧸 Nurses should reassure parents and provide comfort without punishment or pressure to return to prior behaviors immediately.

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Answer 10

Correct Answers:

"It is not your fault that this happened.'

Rationale :

🛡️ The priority in responding to a child who has experienced abuse is validation and reassurance that they are not to blame.

🛡️ Children often internalize abuse as being their fault, especially if the abuser is a trusted adult.

🛡️ The nurse must use a nonjudgmental, empathetic approach while ensuring mandatory reporting to appropriate authorities.

🛡️ The child’s emotional safety must be preserved while building trust for further disclosure and healing.

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QLexNursing

1 :
A nurse is reviewing data for four children. Which of the following children should the nurse assess first?

2 :
A nurse is caring for a newborn whose mother voices concems about sudden infant death syndrome (SIDS). The nurse should include which of the following statements in a discussion with the mother?

3 :
A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, "l don't understand why my child is so upset. I've never seen my child act this way around others before." Which of the following statements should the nurse make?

4 :
A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings is a manifestation of hemorrhage?

5 :
A nurse is planning care for a child who has mumps. Which of the following instructions should the nurse include in the plan?

6 :
A nurse in a pediatric clinic is caring for a child who has iron deficiency anemia and a new prescription for ferrous sulfate tablets. Which of the following instructions should the nurse provide the parents regarding administration of this medication?

7 :
A nurse is caring for a 4-year-old child who is resistant to taking medication. Which of the following strategies should the nurse use to elicit the child's cooperation?

8 :
A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

10 :
A nurse is caring for a child who has been physically abused by a family member. Which of the following statements should the nurse say to the child?

QLexNursing

1 : A nurse is reviewing data for four children. Which of the following children should the nurse assess first?

2 : A nurse is caring for a newborn whose mother voices concems about sudden infant death syndrome (SIDS). The nurse should include which of the following statements in a discussion with the mother?

3 : A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, "l don't understand why my child is so upset. I've never seen my child act this way around others before." Which of the following statements should the nurse make?

4 : A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings is a manifestation of hemorrhage?

5 : A nurse is planning care for a child who has mumps. Which of the following instructions should the nurse include in the plan?

6 : A nurse in a pediatric clinic is caring for a child who has iron deficiency anemia and a new prescription for ferrous sulfate tablets. Which of the following instructions should the nurse provide the parents regarding administration of this medication?

7 : A nurse is caring for a 4-year-old child who is resistant to taking medication. Which of the following strategies should the nurse use to elicit the child's cooperation?

8 : A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

10 : A nurse is caring for a child who has been physically abused by a family member. Which of the following statements should the nurse say to the child?

1 :
A nurse is reviewing data for four children. Which of the following children should the nurse assess first?

2 :
A nurse is caring for a newborn whose mother voices concems about sudden infant death syndrome (SIDS). The nurse should include which of the following statements in a discussion with the mother?

3 :
A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, "l don't understand why my child is so upset. I've never seen my child act this way around others before." Which of the following statements should the nurse make?

4 :
A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings is a manifestation of hemorrhage?

5 :
A nurse is planning care for a child who has mumps. Which of the following instructions should the nurse include in the plan?

6 :
A nurse in a pediatric clinic is caring for a child who has iron deficiency anemia and a new prescription for ferrous sulfate tablets. Which of the following instructions should the nurse provide the parents regarding administration of this medication?

7 :
A nurse is caring for a 4-year-old child who is resistant to taking medication. Which of the following strategies should the nurse use to elicit the child's cooperation?

8 :
A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

10 :
A nurse is caring for a child who has been physically abused by a family member. Which of the following statements should the nurse say to the child?