NCLEX Reviewer Download about Pediatric Nursing (81-85)

NCLEX Reviewer Download about Pediatric Nursing

81. A nurse is caring for an infant with bronchiolitis is assessing for signs of dehydration. The nurse checks which of the following, knowing that it is the most reliable method of determining fluid loss?

a) weight
b) fontanels
c) intake and output
d) mucous membrane

82. An emergency room nurse is caring for a child diagnosed with epiglotitis. Assessing the child, the nurse monitors for which indication that the child may be experiencing airway obstruction?

a) the child exhibits nasal flaring and bradycardia
b) the child is leaning forward, with the chin thrust out
c) the child has low-grade fever and complains of sore throat
d) the child is leaning backward, supporting himself or herself with the hands and arms

83. A sweat test is performed on a child with a suspected diagnosis of cystic fibrosis. The nurse reviews the test results and determines that which of the following is a positive result for cystic fibrosis?

a) chloride level of 20 mEq/L
b) chloride level of 30 mEq/L
c) chloride level of 40 mEq/L
d) chloride level of 70 mEq/L

84. A student nurse is caring for a 2-year old child diagnosed with croup and the nursing instructor asks the student about the clinical manifestations associated with the illness. Which statement by the student indicates a need for further research?

a) the cough is harsh and brassy
b) inspiratory stridor and a low-grad fever may be present
c) symptoms usually worsen at night and are better during the day
d) symptoms usually worsen during the day and are relieved during sleep

85. A nurse receives a telephone call from the admitting office and is told that a child with rheumatic fever will be arriving in the nursing unit for admission. On admission, the nurse prepares to ask the mother which question to elicit assessment information specific to the development of rheumatic fever?

a) has the child complained of back pain?
b) has the child complained of headache
c) has the child had any nausea or vomiting?
d) did the child have a sore throat or fever within the last two months?





NCLEX Reviewer Download about Pediatric Nursing:
ANSWERS AND RATIONALE
81) A
- Weight is the most reliable method of measurement of body fluid loss or gain. A weight change of 1 kg represents 1 L of fluid loss or gain. Although options B, C, and D identify components of the assessment for dehydration, these are not the most reliable determinants, because they require more subjective interpretation than weight, which is more objectively determined.

82) B
- Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward while supported by arms, chin thrust out, mouth open), nasal flaring, tachycardia, a high fever, and a sore throat. Option D is an incorrect position. Options A and C are incorrect because epiglottitis causes a high fever and tachycardia.

83) D
- In a sweat test, sweating is stimulated on the child’s forearm with pilocarpine, the sample is collected on absorbent material, and the amounts of sodium and chloride are measured. A sample of at least 50 mg of sweat is required for accurate results. A chloride level higher than 60 mEq/L is considered to be a positive test result. A chloride level of 40 mEq/L suggests cystic fibrosis and requires a repeat test. A chloride level of less than 40 mEq/L indicates no cystic fibrosis.

84) D
- Croup often begins at night and may be preceded by several days of upper respiratory infection symptoms. Croup is characterized by a sudden onset of a harsh, brassy cough, sore throat, and inspiratory stridor. Symptoms usually worsen at night and are better in the day. Croup usually is accompanied by a low-grade fever, but occasionally the temperature may be as high as 104° F.

85) D
- Rheumatic fever characteristically presents 2 to 6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child had a sore throat or an unexplained fever within the past 2 months. Options A, B, and C are unrelated to rheumatic fever.



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