Which client on an acute care pediatric unit requires the nurse’s immediate attention?

An 18-month-old client who had a cleft palate repair and is crying in pain.

A 12-year-old client who had an appendectomy and refuses to ambulate.

An 8-year-old client who had a tonsillectomy and is swallowing frequently.

A 15-year-old client who has an IV infusion and reports pain at the insertion site.

Answer and Explanation

The Correct Answer is C

Choice A rationale
While pain management is important following a cleft palate repair, it does not typically require immediate attention. Pain can be managed with appropriate analgesics and does not typically present an immediate risk to the patient’s health.
Choice B rationale
A patient refusing to ambulate following an appendectomy does not typically require immediate attention. Encouraging mobility is important for recovery, but refusal to ambulate does not present an immediate risk to the patient’s health.
Choice C rationale
Frequent swallowing following a tonsillectomy could indicate post-operative bleeding, which requires immediate attention. Post-tonsillectomy hemorrhage can be a life-threatening condition that requires immediate intervention.
Choice D rationale
While pain at the site of an IV infusion should be addressed, it does not typically require immediate attention unless there are signs of infection or infiltration. It does not present an immediate risk to the patient’s health.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale
Pediculosis capitis, also known as head lice, is a common condition in children. One of the definitive indications of this condition is the presence of firmly attached white particles on the hair, which are the eggs or “nits” of the lice.
Choice B rationale
While itching and scratching of the head can be a symptom of pediculosis capitis, it is not a definitive indication as it can be caused by other conditions such as dandruff or dermatitis.
Choice C rationale
Patchy areas of hair loss are not typically associated with pediculosis capitis. They could indicate a different condition, such as alopecia areata or tinea capitis.
Choice D rationale
Thick yellow-crusted lesions on a red base are not a symptom of pediculosis capitis. This description is more consistent with impetigo, a bacterial skin infection.

A. Schedule the child for an abdominal ultrasound. B. Instruct the parent to avoid pressing on the abdominal area. C. Determine if the child is having pain. D. Obtain a urine specimen for a urinalysis.

Correct Answer is B

Explanation

The correct answer is choice B: Instruct the parent to avoid pressing on the abdominal area.

Rationale for each choice:

Choice A: Schedule the child for an abdominal ultrasound. While an ultrasound may be necessary for further diagnosis, it is not the immediate priority. The child’s symptoms suggest a possible Wilms’ tumor, a type of kidney cancer that primarily affects children. An ultrasound can help confirm this diagnosis, but it should not be the first action.
Choice B: Instruct the parent to avoid pressing on the abdominal area. This is the correct answer. If the child has a Wilms’ tumor, pressing on the abdominal area could potentially cause the cancer to spread. Therefore, it is crucial to avoid any unnecessary pressure on the abdomen until further medical evaluation can be performed.
Choice C: Determine if the child is having pain. While assessing for pain is an important part of nursing care, it is not the immediate priority in this situation. The child’s symptoms need urgent medical attention, and assessing for pain will not provide the necessary information to guide immediate care.
Choice D: Obtain a urine specimen for a urinalysis. Although a urinalysis can provide valuable information about a patient’s health, it is not the immediate priority in this situation. The child’s symptoms suggest a possible Wilms’ tumor, which requires immediate medical attention. A urinalysis may be part of the diagnostic process, but it should not be the first action taken.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which client on an acute care pediatric unit requires the nurse’s immediate attention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is checking a school-age child for pediculosis capitis. Which of the following findings is a definitive indication of this condition?

Correct Answer is A

Explanation

A nurse is caring for a toddler whose parent states that the child has a mass in his abdominal area and his urine is a pink color. Which of the following actions is the nurse’s priority?

Correct Answer is B

Explanation

A nurse is assisting with the admission of a 2-year-old toddler who has acute gastroenteritis. Which of the following actions should the nurse take first?

A nurse is providing teaching to a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates a need for additional teaching?

A nurse is planning care for a child who has severe diarrhea. Which of the following actions is the nurse’s priority?

A nurse is collecting data from a child and notes the presence of bruises on her arms and legs. Which of the following actions should the nurse take first?

A nurse is caring for a toddler who has intussusception. Which of the following manifestations should the nurse expect?

A nurse is gathering information from a 1-year-old child who has been diagnosed with Wilms’ tumor. Which of the following symptoms should the nurse anticipate?

How many mL of fluid intake should the nurse record for a client who consumed 1 cup of coffee, 4 oz of orange juice, 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3 oz of water during a 4-hour period? (Round the answer to the nearest whole number)

A nurse is caring for a child who has tinea pedis. The child’s parent asks the nurse what this infection is commonly called. The nurse should respond with which of the following common names?