a 2 year old is admitted to the hospital with possible encephalitis and a lumbar puncture is scheduled which information should the nurse provide this
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Nursing Elites

HESI RN

HESI Pediatric Practice Exam

1. A 2-year-old is admitted to the hospital with possible encephalitis, and a lumbar puncture is scheduled. Which information should the nurse provide this child concerning the procedure?

Correct answer: A

Rationale: Children, especially young ones, benefit from knowing what position they will be in during a procedure as it helps them understand and feel more in control. Describing the side-lying, knees-to-chest position can reduce anxiety and promote cooperation during the lumbar puncture. Choice B is incorrect because the question is about preparing the child for the procedure, not about pre-procedure fasting requirements. Choice C is incorrect because there may be restrictions on activity after the procedure. Choice D is incorrect because mentioning loud clicking noises may increase the child's anxiety and fear.

2. A 2-year-old child with a history of frequent ear infections is brought to the clinic by the parents who are concerned about the child’s hearing. What should the nurse do first?

Correct answer: C

Rationale: The most appropriate initial action for the nurse to take is to inspect the child's ears for drainage. This step can provide immediate information on the presence of infection or fluid, which could be impacting the child's hearing. By assessing for drainage, the nurse can gather valuable initial data to determine the next course of action, such as further evaluation or treatment. Asking about speech development or referring to an audiologist would be secondary steps after assessing the physical condition of the ears. Performing a hearing test would also be premature without first examining the ears for any visible issues.

3. A 9-year-old child is brought to the clinic with complaints of fatigue, pallor, and shortness of breath. The nurse notes that the child has a history of iron-deficiency anemia. What is the nurse’s priority action?

Correct answer: A

Rationale: In a child with a history of iron-deficiency anemia presenting with symptoms of fatigue, pallor, and shortness of breath, the priority action for the nurse is to administer iron supplements as prescribed. Iron supplementation is essential to treat iron-deficiency anemia and improve the child's symptoms promptly. Monitoring hemoglobin levels is important but administering iron supplements takes precedence to address the underlying cause. Educating parents about dietary iron sources is valuable for prevention but not the immediate priority. Notifying the healthcare provider may be necessary but should not delay the initiation of treatment with iron supplements.

4. The mother of a 4-month-old asks the nurse for advice in preventing diaper rash. What suggestion should the nurse provide?

Correct answer: C

Rationale: Using a barrier cream like zinc oxide protects the skin and helps prevent diaper rash.

5. When reviewing the dietary guidelines for a child with nephrotic syndrome, which diet should the practical nurse reinforce with the parents?

Correct answer: B

Rationale: The correct diet that the practical nurse should reinforce with the parents of a child with nephrotic syndrome is a low-sodium diet. This diet is crucial for managing fluid retention and reducing the risk of edema, which are common concerns in children with nephrotic syndrome.

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