pediatric hesi part 1 With Solutions 100%
Correct
A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic for a routine
evaluation. Which assessment finding suggests the presence of a common complication often
experienced by those with Down syndrome? Presence of a systoli...
A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic for a routine
evaluation. Which assessment finding suggests the presence of a common complication often
experienced by those with Down syndrome? Presence of a systolic murmur
Rationale: Congenital heart disease occurs in 40% to 50% of children with trisomy 21 (Down
syndrome). Defects of the atrial or ventricular septum that create systolic murmurs are the most
common heart defects associated with this congenital anomaly.
Which preoperative nursing intervention should be included in the plan of care for an infant with
pyloric stenosis? Observe for projectile vomiting.
Rationale: Projectile vomiting (D), the classic sign of pyloric stenosis, contributes to metabolic
alkalosis.
A 6-month-old male infant is admitted to the postanesthesia care unit with elbow restraints in
place. He has an endotracheal tube and is ventilator-dependent but will be extubated soon
following recovery from anesthesia. Which nursing intervention should be included in this
child's plan of care? Remove restraints one at a time and provide range-of-motion
exercises.
Rationale: Removing restraints one at a time is safer than simultaneously. The infant should have
the restrained extremities assessed frequently for signs of neurologic or vascular impairment, and
, pediatric hesi part 1 With Solutions 100%
Correct
range-of-motion exercises should be performed with these assessments. Under no circumstances
should restraints be applied to the client continuously. Documentation of assessment findings
regarding the restrained extremities must occur much more frequently than every 72 hours;
however, the reason for using restraints must be justified and should be stated in the medical
record.
The nurse notes that a 16-year-old male client is refusing visits from his classmates. Further
assessment reveals that he is concerned about his edematous facial features. Based on these
assessment findings, the nurse should plan interventions related to which nursing diagnosis?
Social isolation
Rationale: Peer acceptance and body image are significant issues in the growth and development
of adolescents. The answer addresses the problem of a lack of contact with peers stemming from
his desire to protect his ego.
Ampicillin, 75 mg/kg, is prescribed for a 22-lb child. It is available in a solution that contains
250 mg/5 mL. How many milliliters should the nurse administer in one dose? 15
Rationale: Take 22lbs / 2.2 = 10kg
10kg X 75mg/kg = 750mg
750/250 mg = 3mg X 5mL = 15
, pediatric hesi part 1 With Solutions 100%
Correct
A child comes to the school nurse complaining of itching. Further assessment reveals that the
child has impetigo. What action should the nurse take? Send the child home with the
parents to see the health care provider before returning to school.
Rationale: Impetigo is a staphylococcal infection and is transmitted by person-to-person contact.
The child should be sent home with a note to the parents explaining the condition
The nurse observes a 4-year-old boy in a day care setting. Which behavior should the nurse
expect this child to exhibit? Boasts aggressively when telling a story
Rationale: Four-year-old children are aggressive in their behavior and enjoy telling tales
During routine screening at a school clinic, an otoscope examination of a child's ear reveals a
tympanic membrane that is pearly gray, slightly bulging, and not movable. Based on these
findings, what action should the nurse take? Ask if the child has had a cold, runny nose, or
any ear pain lately.
Rationale: The tympanic membrane is normally pearly gray, not bulging, and moves when a
client blows against resistance or when a small puff of air is blown into the ear canal. Because
these findings are not completely normal, further assessment of history and related signs and
symptoms are needed to interpret the findings accurately.
, pediatric hesi part 1 With Solutions 100%
Correct
Following the administration of immunizations to a 6-month-old girl, the nurse provides the
family with home care instructions. Which statement by the mother indicates that further
teaching is needed? "I will give her a baby aspirin every 4 hours as needed for fever."
Rationale: Although fever may occur, non-aspirin-containing medications should be used
because of the risk of Reye's syndrome
A 7-month-old infant with a rotavirus causing severe diarrhea is admitted for treatment. Which
intervention should the nurse implement first? Insert an intravenous (IV) line and begin
IV fluids.
Rationale: An infant with severe diarrhea is at high risk for dehydration, so the nurse's priority is
to initiate IV fluids
The nurse is preparing a child with an intussusception for a prescribed barium enema. What is
the main purpose of conducting this procedure prior to surgical intervention? Reduce the
invaginated bowel segment.
Rationale: Intussusception, an invagination or telescoping of one portion of the intestine into
another, causes intestinal obstruction in children (usually occurs between 3 months and 5 years
of age). Nonsurgical treatment is attempted with hydrostatic pressure created by barium
instillation, which often reduces the area of bowel intussusception, thereby negating the need for
surgical intervention.
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