1.The nurse is assessing a 9-year-old boy who has been admitted to the
hospital with possible acute post-streptococcal glomerulonephritis
(APSGN). In obtaining his history, what information is most significant?
ANS -a sore throat last week
2.The nurse is measuring the frontal occipital circumference (FOC) of a
3-months old infant, and notes that the FOC has increased 5 inches since
birth and the child's head appears large in relation to body size. Which action
is most important for the nurse to take next?
ANS -palpate the anterior fontanel for tension and bulging
3.a female infant recently admitted with vomiting and diarrhea now weighs
10kg. Her weight at a previous well-baby visit was 11kg. What is the
percentage of body weight loss for this infant?
ANS 9%
1/
21
,4.A male high school student with Type 1 diabetes tests his blood glucose
level before playing a game of soccer, and he obtains a reading of 180.
Based on this reading, which action should the nurse take?
ANS -tell him to eat a sandwich and fruit before beginning the game
5.A 7-year-old child is admitted to the hospital with a diagnosis of acute
rheumatic fever. In obtaining a health history from the child's mother,
the recent occurrence of which illness is most significant?
ANS -sore throat
6.A mother brings her 2 month old son to the clinic for a well baby exam.
During the assessment the nurse finds that the right testicle is not
descended into the scrotum but the left is palpable. Which action should the
nurse take?
ANS -ask if the right tests has been seen in the scrotum before.
7.The nurse is assessing a 6-month old infant. Which response
requires further evaluation by the nurse?
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21
, ANS -demonstrate startle reflex
8.A 4 year old girl returns to the pediatricians office for a post op visit
following hospitalization for minor surgery. When observing the child in
the waiting area, which behavior should the nurse consider normal for this
age child?
ANS -"talks" to an imaginary friend
9.A preschool aged child is experiencing respiratory distress is brought ti
the er by the parents. The child is anxious, has a temp of 102.8 and is
drooling from the mouth while leaning forward while sitting. Which action
should the nurse prepare for the child next?
ANS -obtain bedside trays for intubation or tracheostomy by the
healthcare provider.
10.The nurse is caring for a preschool aged child with a congenital heart
defect who is admitted with intermittent low grade fever, fatigue, and
weight loss. Further physical assessment findings include a new murmur,
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