Pediatrics HESI Guide 2 1. Remember: Remember: If you you know the normal; normal; you are then then able to identify identify what is not normal. Age ewborn
Pulse 100 to 160
Resps. 30 to 60
Blood Pressure Systolic: 65-95 Diastolic: 30-60
Temperature 97.7-99.1 a!illary"
1 to 11 months 1 to ! years "toddler# ! to $ years "pres%hooler#
100 to 150 #0 to 130
25 to 35 20 to 30
#0 to 120
20 to 25
Girls: 91-10$%52-66 &oys: 93-107% 50-65
97.5-9#.6 a!illary"
& to 1' years "s%hool age# 1' to 1& years "adoles%ent#
70 to 110
1# to 22
97.5-9#.6 oral"
60 to 90
16 to 20
Girls: 102-115%60-7$ &oys: 102-115%61-75 Girls: 111-12$%66-#0 &oys: 116-130%65-#0
( )afety basi%s*+arious fa%ts: Airway and breathing are always first,, 'e(e()er t*e +&,s: • +- airay: ate/t airay alays riority 1 o
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97.5-9#.6 oral" Respiratory Distress RR w/ use of axillary muscles to breath Tachycardia Tachycardia
ae reardless o &- )reat*i/ & in child's o ,- circulatio/ breathin$ o D- disa)ilities 4," Restless early asal Flare E- e!osure o eedi/: 10#cal%%day ,*ild alls 8 )u(s *ead: E'4 +SSESS;E< I'S< Tripod Tripod Preerred I; site: =astus ateralis Poiso/ I/estio/: 4 syru o iecac to i/duce = '< re)ou/d corrosio/ o/
t*roat"> tyical treat(e/t: acti?ated c*arcoal (ay /eed astric la?ae -. 'e?ie G8D ;ilesto/es <*eorists"-------c*ater $ P 55 a. $(o $(o old old@ @*at *at is e!ec e!ecte ted d i. Soci Social al s(i s(ile le occu occurs rs at at 2(o 2(o ii. ii. Head Head tur/s tur/s to loca locate te sou/ sou/ds ds at at 3(o 3(o C()LD iii. ;oro 8 ot*er ot*er ri(iti? ri(iti?ee rele!es rele!es aside aside ro( &artal &artalo/i o/i disaear disaear"" *ROOF i?. i?. AASteady AASteady *ead co/trol co/trol *old *ead *ead a/d c*est c*est uri*t uri*t *ile *ile lyi/ lyi/ o/ C()LD sto(ac* duri/ tu((y ti(e"> ic 8 us* it* t*eir eet *ROOF 1. 'oll 'oll ro( ro( &+,B &+,B to SIDE SIDE C()LD *ROOF
Respirator y Failure RR/ Apnea
Bradycard ia LOC !runt "LAT# si$n% Breath
?. Ha/ds or or toet*er toet*er to (o?e (o?e toy%s*ae toy%s*ae rattle@re rattle@readily adily ra)s ra)s o)Cects o)Cects close close )y a/d uts t*e( i/ (out* ). 'olls ro( +&D +&D to &+,B 5(o" +D +D &+,B <4 +&D 6(o" i. Sit u/suor u/suorted ted at #(o> #(o> cral cral at 9%10(o> 9%10(o> al al at 10-12> 10-12> 15-1#(o 15-1#(o ready ready to ru/ c. *e/ *e/ s*ould s*ould a c*ild c*ild sel sel eed eed it* it* a soo/ soo/ a/d cu 2yo d. esell/s theory of de+elopment: )io*ysical de?elo(e/t )ased o/ c*ildFs e/etic )lueri/t a/d i/lue/ced )y e!erie/ces t*ereore u/iue a/d i/di?idualied. !. 0aslow/ 0aslow/ss hierar hierar%hy %hy:: Basi% Basi% needs needs %ome %ome first first.. a. P*ysioloica P*ysioloical: l: ater ater slee slee ood ood )reat*i/ )reat*i/ e!creti e!cretio/ o/ *o(eostasi *o(eostasis s se! ). Saety: security o resources )ody *ealt* *o(e etc. c. o?e o?e%) %)el elo/ o/i i/ / d. Estee( e. Sel-actual Sel-actualiati iatio/: o/: (orality (orality acceta acceta/ce /ce o acts acts etc. etc. . 2elegating: 2elegating: 3nderstand 3nderstand the nursing pro%ess pro%ess.. Assessmen Assessment4 t4 planning planning %are4 %are4 edu%ation must be by the R. 4
ualitati?e a/d ua/titati?e 2. Dia/osis a. +/alyi/ assess(e/t data to deter(i/e a la)el or t*e /ursi/ dia/osis ). Pro?ides ocus or /ursi/ 3. Pla//i/ a. Strateies to use to lead to e!ected e!ec ted outco(es: esta)lis* riorities clie/t oals e!ected outco(es a/d i/ter?e/tio/s t*e/ co((u/icate t*e la/ o /ursi/ care $. I(le(e/tatio/ a. ,arry out t*e la/ to ro(ote *ealt* 8 S+E e/?iro/(e/t ). Start it* i/ter?e/tio/s (ost liely to ac*ie?e oals 8 e!ected outco(es t*at are /eeded to suort or i(ro?e status 5. E?aluatio/ 4G4IG" a. Deter(i/e i co/ditio/s are i(ro?i/ outco(es (et (ae cli/ical decisio/s%redirect care to (eet clie/t /eeds
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': tas deleatio/
Secialty care Se?ere cases o Sterile rocedure o +ssess(e/t o Pla//i/ care i.e care la/s" o o Sta)le clie/ts> routi/e rocedures o $. 5yme 2isease 6red bull/s eye rash w*in !(!'days7 a. 8hen do you %he%k for ti%ks9 i. +ril to 4cto)er is tic seaso/. ii. ,HE,B 'IGH< ++- ater layi/ or )ei/ outside *ead to toe" esecially i your si/ as e!osed. b. onta%t PP if the ti%k is not %ompletely remo+ed. %. 8hat signs and symptoms indi%ate need for medi%al attention9 i. ;edical atte/tio/ is /eeded *e/ t*e irst set o sy(to(s occurJ 1. e?er (alaise ras*%)ullseye lu-lie S8S -. ater o/: E'4 Kcatc* early a/d treat % a/ti)ioticsL ii. <*ere are 3 staes o sy(to(s o y(e disease: 1. Early localied stae: ?aue lulie sy(to(s (alaise e?er *eadac*e c*ills atiue a/d ?aue (uscle ac*es a/d ai/s." a. Do!ycycli/e is i?e/ *e/ t*ese sy(to(s start to aear. <*ou* t*ey (ay /ot *a?e )ee/ dia/osed it* y(e disease t*is a/ti)iotic is c*ea a/d it does /ot *urt to start usi/ it a/yays. -. Early disse(i/ated stae: 1-$ (o/t*s ater )ite. euroloic sy(to(s (ay )e t*e irst to occur. ,S sy(to(s- se?ere *eadac*es it* (yelitis /ausea ?o(iti/ acial /er?e aralysis &ellFs Palsy" oretul/ess decreased co/ce/tratio/ cere)ral ata!ia> ly(*ade/oat*y Coi/t a/d (uscle ai/. !. ate disse(i/ated stae: (o/t*s to years ater )ite. ,*ro/ic art*ritis roou/d atiue a/d c*ro/ic /euroloic (a/iestatio/s. o
&. hild admitted for persistent < 2. 8hat a%id(base imbalan%e is likely9 a. ;eta)olic alalosis '< e!cessi?e loss o *ydroc*loric acid ro( sto(ac*" ).
i. ;easure t*e aical ulse H' i/crease" =. >piglottitis is a respiratory emergen%y: ?now the identifying symptoms and emergen%y a%tion you should anti%ipate. a. Sy(to(s: Sudde/ o/set +nli,e croup which presents i. 'estless/ess with steeple si$n and O fe-er ii. @igh fe+er "1''. 1hr R 1'1.! 1CD BA2# iii. Sore t*roat dys*aia i?. &uli/ ty(a/ic (e()ra/es i/la(ed" ?. Drooli/ ?i. ;uled ?oice ?ii. Nro-lie croai/O ---cya/otic ?iii. I= a/ti)iotic: ceota!i(e> ria(ici/ ro*yla!is to *ouse*old co/tacts E. roup: what ad+i%e %an you offer parents as an inter+ention at home9 Bring them into a really steamy bathroom •
or the %ool night air ;ai/tai/ a sta)le e/?iro/(e/tal te(erature
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a/d *u(idity *u(idiier stea( ro( s*oer." Bee c*ild ell-*ydrated. <*is *els
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decrease t*e se?erity o attacs. +?oid lare rous o eole a/d eror(
•
ood *a/d *yie/e )ecause crou is a ?iral i/ectio/. +ceta(i/o*e/ a/d I)euro*e/ are
•
eecti?e i/ reduci/ e?er a/d ill *el t*e( eel (ore co(orta)le. +?oid cou* syrus a/d cold (edici/es )ecause t*ese ca/ dry a/d t*ice/ secretio/s
a. 0other brings in %hild/s fa+orite toy while they are in a mist tentF%an they ha+e it9 i. ,*ildre/ it*i/ t*e (ist te/t it* *u(idiied o!ye/ to liuey (ucous secretio/s a/d acilitate )reat*i/s---toys that absorb moisture like stuffed toys and coloring books should be avoided (plastic toys OK; must properly clean!). (dampness lowers resistance to infection and toys can harbor pathogens) ii. +)le to see c*ild )ut ca//ot *old t*e( stay close i ossi)le a/d tell t*e( you ill /ot lea?e" iii. I c*ild cries: reac* i/side a/d stroe *ead or )ac i+. ;ac*i/e does (ae loud /oises: assure c*ild it ill /ot *urt t*e( ca/ ut aue o?er ears to re?e/t sou/d" +. ;ist dros i/side ca/ )e ied aay or )etter ?ie +i. ,lot*es a/d )eddi/ (ust )e c*a/ed ote/ to re?e/t *yot*er(ia also assess te(J" ee lastic sides o te/t tuced ti*t u/der (attress to re?e/t suocatio/ G. 2igoCin "5anoCin#: Therapeuti% >ffe%t: will bring @R into normal range for %hild a. 2igoCin : c*ild ill tae t*is tice a day or se?eral (o/t*s to years. i. It *els t*e *eart u( )lood (ore eecti?ely t*ere)y i(ro?i/ t*e circulatio/ o t*e )lood a/d ro(oti/ t*e /or(al eli(i/atio/ o e!cess luid. ii. *at you /eed to /o: 1. Dio!i/ a/o!i/" is alays i?e/ e?ery (or/i/ a/d e?e/i/. ou (ay adCust t*e ti(es to it you a/d your c*ildFs sc*edule. Therapeutic le-els. 012 2. Gi?e Dio!i/ 20-30 (i/utes )eore a eedi/. Gi?e it at t*e sa(e 30n$/mL 4hypo,alemia5 ti(e e?ery day so t*at it )eco(es a art o your routi/e.@4< i/ hypercalcemia5 hypoma$nesia can inc these or(ula or ood le-els6 3. <*e a(ou/t o Dio!i/ you i?e your c*ild (ust )e (easured careully it* a syri/e /ot t*e droer ro?ided it* t*e (ed. Baseline #7!8 Apical pulse for $. Put a e dros o Dio!i/ i/to your c*ildFs (out* a/d let t*e 9 min prior to admin "assess c*ild sallo it )eore i?i/ (ore. for bradycardia% :9bpm 5. I you oret to i?e your c*ild a si/le dose o Dio!i/ i?e t*e ,ids hold5 :;bpm adults hold dose *e/ you re(e()er it> t*e/ resu(e your orii/al sc*edule. a. S*ould /ot si 8 Ndou)le uO <?>. 7. I you (iss o your c*ild ?o(its 2 doses i/ a ro 4' c*ild ?o(its -omitin$222often call t*e cardioloy deart(e/t or *ysicia/". o-erloo,ed as @spit2up #. Bee t*e Dio!i/ i/ a lace *ere c*ildre/ li?i/ or layi/ i/ your *o(e ill /ot )e a)le to reac* it. 2anorexia8 /8 blurry 9. I so(eo/e accide/tally taes t*e Dio!i/ %all poison %ontrol or -ision8 photophobia8 tae t*e erso/ a/d Dio!i/ )ottle to t*e e(ere/cy deart(e/t. diarrhea8 abd pain8 fati$ue5 drowsy5 headache8 muscle
10. 4)tai/ reills at least 1 ee )eore you are out o (edici/e. +s or /e rescritio/s as /eeded. b. 2igibind( the antidote to 2igoCin. i. I you tae Dio!i/ )y (istae you ill /eed to tae Dii)i/d. ii. I you reac* to!ic le?els o Dio!i/ you ill /eed to tae Dii)i/d. 1'. Atopi% dermatitis*e%Hema: what uestions should the nurse ask when obtaining a history9 a. ursing 2C: +ltered co(ort '< ?esicular si/ erutio/s b. Assessment: tyically creases i/ )ody '< itc* cut /ails aly (itte/s%el)o restrai/ts ro?ide soot*i/ )at*es" %. 8hat eCa%erbates it: E?eryday t*i/s i/ your e/?iro/(e/tJ i. old eat*er- ee a (oisturier *a/dy. ii. @eat a/d *u(idity 1. Hot ater- tae s*ort )at*s%s*oers. iii. +llergies es to ood"@4
11. 8ilm/s tumor: D4 4< P+P+
4< P+P+
olds". i(ited a)ductio/ o aected *i. /eual le le/t*s. + spi%a %ast is used to i! t*is: (ai/tai/s *is i/ 90 deree le!io/>
ele?ate )uttocs o )ed> (o/itor circulatio/ to t*e eet 1!. 8hat +ital signs will help the nurse assess an infant for pain9 Heart rate a/d resiratio/s. s i/ & are +
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<*e i/a/t is oi/ to )e cryi/ ro( t*e ai/ *ic* ill cause t*e *eart rate a/d
resiratio/s to i/crease. 1. hild with asthma uses inhaler with a spacer : why are they at risk for oral fungal infe%tions9 8hat ad+i%e %an you offer parents9 <*ey are at ris or u/al i/ectio/s )ecause t*e sacer ros er(s a/d u/us • a/d t*e c*ild ill t*e/ )reat* t*e(. +d?ise ood oral *yie/e- ri/se t*e c*ildFs (out* a/d t*e sacer ater eac* use. • 1$. hild with Kawasaki disease "+as%ular inflammation# is brought to the %lini% and mom reports irritability4 refusing to eat4 skin peeling on hands and feet. 8hat does the %hild need most9 <*ey /eed uiet4 rest a/d low stimulation. • <*ese atie/ts are really sic. • *y is asiri/ art o treat(e/t • +/tilatelet eects o Pri/cial oal o treat(e/t: re?e/t coro/ary artery disease 8 relie?e s%s o ;ai/stay o t!: ull doses o i/tra?e/ous i((u/olo)uli/ I=IG" o 1&. Parents ask when they should introdu%e baby foods: *e/ o +" Stos rooti/ rele! B# pens mouth when food is near ," o lo/er aes reue/tly at /i*t D" Gi?es u )ottle or cu -arou/d $-6(o/t*s o ae -less ti(e se/t /ursi/: i/terest i/ oe/i/ (out* or soo/ -i/a/t ca/ sit reac* or o)Cect a/d (ai/tai/ )ala/ce" Ho • o 'ice cereal 1st solid ood added least allere/ic" 1 at a ti(e at least a e days to a ee aart '< ossi)le alleries o =eies )eore ruits '< seet/ess o ruits" o &reasteedi/ (o( u/a)le to ee u it* t*e eedi/ de(a/ds it* u(i/: • *at do you ad?ise Sule(e/t it* )a)y or(ula> store )reast (il as a)le i/ reeer o 1=. A %hild with a fe+er and rash: our co/cer/ is tra/s(issio/JJ • <*is is (ost liely i/ectious. • Isolate t*e c*ild a/d i(le(e/t recautio/s. • 1E. Assessing tube pla%ement: when and how9 a. 4
). Pressure to /ose or Q10 (i/s i. Stui/ /ose could later lead to dislodi/ clot )loci/ additio/al )leedi/ i/ t*e /ose---/ot reco((e/ded -'. ephroti% )yndrome: why is albumin part of treatment9 a. eads to *yoal)u(i/e(ia as rotei/ leas t*rou* t*e lo(eruli (e()ra/e a/d i/to t*e uri/e ). s%s: i/c seciic ra?ity i/ uri/e '< rotei/> i/c H) R Hct '< *yo?ole(ia c. e/courae acti?e (otio/ i/ )ed daily -1. @emophilia: lifelong4 hereditary bleeding disorder s %ure "@gb unaffe%ted until bleed# a. I/ter?iei/: i. 'ece/t trau(a (em A/ ii. I/itial (easures to sto )leed@*o lo/ ressure alied @classic. factor iii. I/c selli/ ater surace )leed stoed---=E' co((o/ K*e(art*rosis: ))) and ) recurre/t )leedi/ i/to Coi/ts@(ay )e rearded as sorts i/CuryL i?. Selli/%sti/ess it*out aare/t trau(a (em B/ ). &asic I/or(atio/: @Christmas i. M-li/ed autoso(al recessi?e disease. factor 1. e(ale carriers (ales aected ) 2. 1st si/s: rolo/ed )leedi/ at t*e u()ilical cord susect" ost circu(cisio/ ?it B i/Cectio/ site (em C. factor ) ild bleedin$ ii. DD+=P: des(oressi/ i?e/ to sti(ulate actor I= tendencies c. S%s: i. P<< is P'44GED /or(: 60-70 t*eraeutic ra/e1.5-2.5! /or(al or co/trol"> /o latelet s%&,s ii. &ruise easily> *e(aturia> tissue trau(a sites d. ;a/ae(e/t: i. *e/ allT*at to do 'I,E rest ice co(ressio/ ele?atio/" 1. Gi?e (issi/ actor I= 4< I;"@(ay also )e i?e/ ro*ylactically 2. I((o)ilie e!tre(ity ele?ate 3. 4 HE+< cold or ?asoco/strictio/ ii. +?oid asiri/ leads to )leedi/" 8 S+IDS iii. +?oid *i* ris acti?ites /o co/tact sorts> ca/ do: si( ol *ie is*> /o: soccer oot)all" i?. ear (edical alert )racelet ?. &leedi/ recautio/s: 1. Sot toot*)rus* or ater ic" 2. Paddi/%sot edes c*ildroo U2"---alays ear to sc*ool 3. Hel(et> S*a?i/@electric raorJJ ?i. *e/ to call P,P: )lu/t or Coi/t trau(a ?ii. ;ay reer to e/etic cou/seli/ --. 0outh dis%omfort*mu%ositis RT %hemo "inter+entions RT %omfort# a. S (out*as*: clea/s %o ad?erse eects es i salloed"
). ;aic (out*as* (alo!%;yla/ta 8 )e/edrylR lidocai/e": deresses a rele! a/d reduces ai/ -!. hemo and dis%harge tea%hing: what are the %on%erns for this patient9 a. 4ld uide: c*ild it* leue(ia a/d lo &,: disc*are i/structio/s ill i/clude *at >trict i. I>TI TR5 - /o li?e ?acci/es AAAGood *a/d *yie/eAAA isolation is reue/t si/ 8 (ucous (e()ra/e assess(e/ts OT ii. atiue '< a/e(ia" Petec*iae '< lo latelets" i/ectio/s '< dec necessary eecti?e leuocytes" ). ,*e(o ?esica/ts t*at ca/ cause se?ere ?ascular da(ae i i/iltrates Klo?es or/ at all ti(es reard all luids as radiatio/L c. ausea: oer cool clear liuids (ils t*ice/s secretio/s 8 ca/ i/duce => oeri/ a? oods ca/ cause associatio/ % eeli/ ill" d. +!illary te(eratures '< ris o da(ae to (ucous (e()ra/es e. +/a*yla!is i.e tu(or lysis sy/dro(e" is ossi)le i. %=%D a/ore!ia let*ary *e(aturia H s (uscle cr(as teta/y sy/coe---S<4P I= i/use S t*e/ /otiy ;d Key to re?e/tio/: *ydratio/L . +llouri/ol: re/al (ed used to dec ris o )rai/ da(ae '< uric acid )uild u duri/ cell lysis -. In what order do you perform an assessment on a %hild9 a. Inspe%tion "always 1 st regardless of age#; Palatio/> Percussio/> +uscultatio/ 1. +)d e!a(: I/sectio/ +uscultatio/ Percussio/ Palatio/ do/Ft a/t to alter &S )eore deter(i/i/ rese/ce a/d c*aracteristics" ii. &ei/ it* least i/?asi?e rocedures irst iii. ri*te/i/ or ote/tially ai/ul rocedures do/e last e!: (out* 8 ears" Infant-Toddler: chest ? thorax Erst i?. De?elo(e/tal aroac* EM: uiet i/a/t@auscultate *eart lu/s a/d Respirations a)do(e/ )eore disruti/ t*e cal(J ";yo. ?. Do/Ft o ast> i?e c*oices *e/ ossi)le> tal it* /ot at t*e c*ild> ee thoracic5 a security o)Cect /ear)y :;yo. b. After performing a de+elopmental assessment4 what do you do9 diaphra$m% i. 4rder: Apical (R "9 1. ,*ie co(lai/t min% 43yo. 2. History o rese/t ill/ess can use 3. Past (edical *! i/cludi/ i((u/iatio/s" radial6 $. Pre/a/cy 8 )irt* *! Blood 5. De?elo(e/tal *! pressure 6. eedi/ *! Temperature 7. 'e?ie o syste(s Preschool: foot to head seGuence #. a(ily *! "obser-ation of 9. Social li?i/ situatio/ 8 co/ditio/s% daycare> co(ositio/ o beha-iors ? a(ily> occuatio/ o are/ts" inspection Erst% -$. Parent understanding of follow up RT treatment of 3TI : School-age: head i. ,o(lete a/ti)iotic to toe ii. %u ollo-u" seci(e/ /eeded Adolescent : head to toe
iii. ie ro/t to )ac 8 ractice ood *yie/e teac* /ot to *old" i?. i/co/ti/e/ce i/ re?iously otty trai/ed c*ild is )iest si/ ?. *ysical causes are eli(i/ated )eore e(otio/al Kstructural deects e!lored ater little co/trol o?er )e*a? ior a/d /eed li(its 8 ?iila/ce to re?e/t i/Cury %. ill deli)erately test are/ts u/til s*o/ *o ar t*ey ca/ o d. ;S< )e co/siste/t i((ediate realistic ae-aroriate loical to t*e i/cide/t clearly e!lai/ed *y e. ;ust )e i?e/ ti(e to reso/d to i/structio/s f. it*draal o lo?e s*ould E=E' )e u/is*(e/t@co(orti/ ater discili/e ro(otes ositi?e eeli/s g. +ru(e/ts 8 e!te/si?e e!la/atio/s a?oided h. AAAASearate t*e toddler ro( t*e )e*a?ior EM NI lo?e you. Hitti/ your sister *as to stoO or Nt*roi/ toys could *urt so(eo/e. I do/Ft lie to see you doi/ t*atO is )etter t*a/ NyouFre a )ad irl or doi/ t*atO
Strateies: i. tyically do/e )eore e/tra/ce i/to collee 1623yo" i.
-G. Testing for 2u%henne 0us%ular 2ystrophy 6ele%tromyelogram7: what to eCpe%t9 6full report may take -(!days7 a. ner+e %ondu%tion test to see *o ell a/d *o ast /er?es ca/ se/d t*e si/als do/e it* se?eral lat disc electrodes directly o?er /er?e t*at se/d se?eral uic lo-?oltae K/ot *i* e/ou* to cause i/CuryL electrical ulses to /er?e> do/e &E4'E E;G i )ot* are do/e> taes 15(i/s-1*r" i. normal: s*o t*at t*e /er?es se/d electrical i(ulses to t*e (uscles or alo/ t*e se/sory /er?es at /or(al seeds or co/ductio/ ?elocities di /er?e di /or( ?elocity Kdo slo do/ as aeL". Se/ sory /er?es allo t*e )rai/ to eel ai/ touc* te(erature a/d ?i)ratio/. b. Purpose "of ele%tromyelogram#: (easures t*e electrical acti?ity o (uscles at rest a/d duri/ co/tractio/ %. how to prepare: i. )lood t*i//ers disco/ti/ued rior ii. ear loose itti/ clot*i/%o/ so (uscles 8 /er?es iii. electrodes attac*ed to si/---4 srays oils crea(s lotio/s i+. (ay )e ased to si/ co/se/t d. how it is done: i. do/e i/ *osital cli/ic or doctorFs oice )y E;G tec* or ;D ii. lie o/ ta)le%)ed or sit i/ recli/i/ c*air so (uscles are rela!ed iii. si/ o?er areas tested are clea/ed i+. /eedle electrode attac*ed )y ires to recordi/ (ac*i/e is i/serted i/to (uscle (easures t*e (uscles at rest" 1. (ay )e (o?ed a /u()er o ti(es 4' i/ diere/t areas o (uscle -. s*o/ as a?y 8 siy li/es o/ ?ideo (o/itor (ay )e *eard o/ loudseaer as (ac*i/e-u/-lie oi/ sou/ds *e/ you co/tract +. tester ill as you to ti*te/ co/tract" (uscle sloly 8 steadily@records +i. total pro%ess: 30-60(i/utes> o/ce do/e electrodes are re(o?ed 8 si/ is clea/ed +ii. how does it feel: 1. uic s*ar ai/ *e/ /eedle electrode i/serted -. sore%ti/li/ eeli/ or u to 2 days !. ai/ is orse or t*ere is selli/ te/der/ess or us call ;D" . (ay et so(e s(all )ruises or selli/ at t*e i/Cectio/ sites $. /eedles are S
!1. Aorti% stenosis a. If %hild in @ has sudden wt gain4 what is 1st assessment9 i. Lungs sounds @tac*y/ea 8 i/c &P> 1. also (o/itor: uri/e outut ede(a ii. Sudde/ t ai/1. ,all ;D ost lu/ assess" b. 8hat findings do you eCpe%t with @9 i. Bey i/dicator: e!ercise i/tolera/ce c*est ai/ a/d dii/ess *ile sta/di/ or lo/ eriods o ti(e c. 4!ye/ ad(i/istratio/ rescri)ed or stressul eriods cryi/ or duri/ i/?asi?e rocedures" d. Dei/itio/: /arroed e/tra/ce to t*e aorta leadi/ toT)lood *a?i/ diiculty loi/ t*rou* aortic ?al?e causi/ i/creased ressure a/d *yertro*y o t*e ?e/tricle dec ,4 dec )lood suly to coro/ary arteries e. e!ercise restrictio/s> )alloo/ ?al?ulolasty Kdelay surical i/ter?e/tio/L 4' aortic ?al?e relace(e/t i recurre/t !-. A%ute rheumati% fe+er: what might the nurse note when obtaining a history9 a. 'ece/t stre i/ectio/%sore t*roat 4' u/e!lai/ed e?er it*i/ t*e last 2 (o/t*s" ). Dei/itio/: diuse i/la((atory reactio/> (ost liely i((u/e %. %hild de+elops %horea(((what to dis%uss with patient i. e!lai/ it ill disaear o?er ti(e !!. TA "Transposition of the reat Arteries# and prostaglandin administration "P>1# a. Purose: (ai/tai/s cardiac outut )y (ai/tai/i/ ate/c y o t*e ductus arteriosus !. ra+e/s disease "@yperthyroidism# @ypert*yroidis( NGra?eFs DiseaseO <$
!$. Pre%o%ious Puberty early onset of puberty K usually idiopathi% a. Xleads to: re(ature 2/dary c*aracteristics> rot* rate> ad?a/ced )o/e rot* early b. %. d.
e.
usio/" Early o/set or girls before E years o ae Ki/ ++@)eore 6yoL@o)esity et*/icity e/es stress etc> Early o/set or boys before G years o ae---(ore idioat*ic 'adiora*ic i/di/s suort dia/osis )y deter(i/i/ )o/e ae a/d (aturatio/ Dia/osis: G/'H sti(ulatio/ testi/> )lood tests Kele?ated H SH estroe/%testostero/eL i. 4 SH ZH ater u)erty" G/'H )locer Nao/istO (o/t*ly I;": i/*i)it G/'H )i/di/ to ituitary i. at ris or se!ual a)use I/ter?e/tio/s: e!lai/ staes o u)erty 8 )e*a?ioral c*a/es> Ne!erie/ci/ /or(al c*a/es at a)/or(al ti(eO> syc*oloical cou/seli/ deal % se!uality"> (edicatio/ ad(i/
.
.
!&. )i%kle ell risis 6autosomal re%essi+e; PAI35; a%ute4 episodi%7 a. 4ccurs *e/ )lood lo to tissues o)structed )y sicled cells leadi/ to *yo!e(ia a/d isc*e(ia b. Pain management < hydration 6promotes hemodilution < %ir%ulation of RBs; 1(1.$C maintenan%e7 LLin that orderLL )ncreased c. a/ti)iotics> 42 ai/ (eds )lood ii. ;o/itor luids '< ris o ul(o/ary ede(a . Pri(ary ro)le(s: tissue *yo!ia Z95[" 8 ?ascular occlusio/ . ,*ec (ucous (e()ra/es 8 si/ turor *. Ste( cell tra/sla/t: curati?e i. Pai/ reciitated )y: i/ectio/ cold stress acidosis local or e/eralied *yo!ia eat*er li(it su/" trau(a de*ydratio/%e!tre(e *eat> a?oid *i* altitudes% dec 42 C. ;a/iestatio/s (ild-se?ere": Coi/t )o/e or li() ai/ it* selli/%art*ralia e *rs-days"> e?er> %=> te/der/ess> i/c ''> se?ere a)d ai/ > *e(aturia> allor%atiue '< c*ro/ic *e(olytic a/e(ia" . o/Ft re?erse sicli/> dec /eu(o/ia ris
i?. 'est ?. 4 iro/ i?e/: ro)le( /ot '< deicie/cy a/e(ia 1. olic acid: (ay )e i?e/ to i/c '&, sy/t*esis ?i. Hydro!yurea: dec reue/cy 8 se?erity o ai/ul e?e/ts !=. Type 1 20 a. @ypogly%emia s*s i. 4/set: raid ii. +dre/eric s%s: 1. Seati/> Pallor> ,la((y si/> +/!ious iii. +lteratio/s i/ 4,% N/eurolycoe/ic s%s: 1. Perso/ality c*a/e> Irrita)ility -. Dru/e/ )e*a?ior> Slurred seec*%i(aired ?isio/ !. Dec 4,- total loss o co/scious/ess . S acti?ity i+. a) data: lucose Z60(%d b. @ypergly%emia: priority(((hydrate < insulin %. 2e+elopmental approa%h*abilities((( P 723 occur sudde/ly sel-li(iti/ resol?e co(letely d. >tiology < In%iden%e: i. I((u/e r!/ to rou + )eta *e(e stre '< 1. Stre *ary/itis t*roat": 1-2 ees -. Pyoder(a stre si/ i/ectio/": 3-6 ees ii. 'are )eore ae 3 tyically 5-12yo you/ sc*ool-ae" e. 0anifestations: Kla)s /or(al i/ 6-12eesL i. He(aturia: s(oy%tea%cola-colored uri/e ii. Protei/uria 0-3R" iii. Ede(a: orse i/ (or/i/> ri(arily eyelids 8 a/le 1. Dec uri/e outut i+. H<: ca/ )e se?ere +. atiue +i. ;+ &E e)rile +ii. Pul(o/ary ede(a lie-t*reate/i/ co(licatio/ f. 2iagnosti% >+aluation: i. H! rese/ti/ s%s la)s ii. +/tistretolysi/ +S4" titer%Stretoy(e test: i/dicates rese/ce o a/ti)odies> ca/ )e ele+ated 1. Decreased co(le(e/t g. Therapeuti% 0anagement: i. Suorti?e> directed toards s%s 8 uided )y deree o re/al i(air(e/t ii. Possi)le 10 day a/ti)iotic t*eray
iii. +cute ': reuires *ositaliatio/ to sta)ilie 8E as ell as re/al u/ctio/ i+. a/tiH< (edicatio/ li(it a 8 ater ossi)le diuretic +. AAAdiuresis (ore uri/e" si/als )ei//i/ o resolutio/ h. ursing are oals: i. Pre?e/t co/seue/ces o luid e!cess ii. Pro?ide adeuate rest iii. ;ai/tai/ si/ i/terity i+. ;ai/tai/ /utritio/al status +. 'elie?e are/t a/!iety !G. )*P "status post# %ardia% %atheteriHation: nsg %onsiderations a. Dei/itio/: cat*eter tyically t*rou*" e(oral artery or ?ei/ a/d directly i/to *eart> ressure )a/dae co?ers Kre(o?ed olloi/ day )a/daid relacesL b. Pote/tial ,o(licatio/s: i. +rr*yt*(ias *e(ody/a(ic co(ro(ise ii. He(orr*ae iii. =ascular da(ae i+. AA=asosas( o cat*eried ?essel oor erusio/ o aected le
*eripheral perfusion== #xtremity often mottled in appearance ? cooler to touch than other extremities222 distal pulses should still be palpable 5 thou$h may be wea,er "chec, w/ Doppler if not% (eparin drip may be used 8 often dischar$ed same day otify Cardiolo$ist. 2no pulses present
+. <*ro()us%e()olus or(atio/ at cat* site" 1. I(aired erusio/ to li() -. Possi)le tra?el to )rai/%lu/ a. it*i/ syste(ic-ul(o/ary artery s*u/ts i/*i)it ul(o/ary )lood lo" !. =e/ous t*ro()us: selli/ i/la((atio/ o le +';" . +rterial t*ro()us: cool/ess discoloratio/ o e!tre(ity loss o ulses distal to t*ro()us +i. I/ectio/ +ii. 'eactio/ to dye ras* ruritus = '+'E: a/a*yla!is" +iii. ,at*eter eroratio/ cardiac ta(o/ade 8 cardiac arrest %. ursi/ ,o/sideratio/s Kocus: re?e/ti/ i(aired eri*eral erusio/L i. ocate 8 (ar distal ulses P'I4' to rocedure ii. Post: 1. Positio/ed % aected le strai*t $-6*rs a. I/a/ts ca/ )e ro/e o/ are/tFs la b. 4lder c*ildre/: )edrest H4& \20] -. I= luids co/tFd u/til tai/ +D retai/i/ adeuate P4 luids !. =S%assess(e/t: a. ^5-15(i/s or 1st *our it* co/ti/uous i/itial (o/itori/ o H' &P '' 42 a/d te( i. &leedi/ early *ours o ost-o 8 % =S": 1. ,*ec i/sertio/ site dressi/> s*eets> u/der c*ild ooled )lood"> u/der li/e/s> ull )ac diaer eri/eal area )leedi/ u/der si/"
ressure % lo?ed *eel o -. I occurs *a/d Q10-15(i/s 8 assess distal erusio/ to e!tre(ity a. I((ediately /otiy cardioloist b. +ssess )lood loss 8 *e(ody/a(ic status . Disc*are i/structio/s a. I/sect cat*eter site: *eali/ i/ectio/ b. &at*i/: li(ited to s*oer so/e )at* )rie tu) 4 soai/" or irst 1-3 days ost %. +?oid stre/uous e!ercise u to 1 ee ost or 6 ees ater de?ice laced d. )%hool: !rd day post e. otiy cardioloist reaso/s at *o(e": i. e?er Y101> &leedi/ drai/ae us" ii. Pallor cool/ess or /u()/ess o e!tre(ity f. 'esu(e /or(al eedi/s a/d (eds> 'e?ie /eed to co/ti/ue a/ti)iotics or de/tal 8 ot*er rocedures g. ollo-u it* cardioloist at sc*eduled ?isit d. Indi%ations of arterial obstru%tion( eCtremity %ool to tou%h4 appears pale < blan%hed '. titis media: why are younger %hildren at risk9 "T>: not %aused by +iruses# a. Dei/itio/: reers to eusio/ luid" a/d i/ectio/ or )locae o t*e (iddle ear i. ;ost ote/ caused )y uer resiratory i/ectio/s b. 'is actors: i. S*orter 8 strai*ter Eustac*ia/ tu)e 8 i((ature (iddle ear t*a/ adults K+ o)structio/ results i/ i/eecti?e drai/ae a/d /o ?e/tilatio/ to earL 1. &ottle eedi/---relu! i/to t*e ears tu)e ro( /aso*ary/! *ile eedi/ sui/e K(ore uri*t i/a/t is less risL a. ot etti/ (ater/al a/ti)odies ro( (o( (ore i/cide/ce o alleries" ii. ,*ildre/ *a?e (ore diiculty i*ti/ o i/ectio/s i((u/e syste(s i((ature" iii. +lleries i+. +tte/da/ce at daycare acilities es Z1yo" 1. +e: 6-2yo u to 6yo" +. Et*/icity *i*er i/ ati?e +(erica/s +lasa/ I/uit a/d ,a/adia/ I/uit" +i. E!osure to ciarette s(oe +ii. Paciier use 1. @ow do you assess the effe%ti+eness of fluid repla%ement therapy9 a. t I84s" =S 4, urine output4 a/d seciic ra?ity /or(: 1.002-1.030> 1.02 i/dicates start o de*ydratio/" b. ,a reill Z2seco/ds %. Si/ turor elastic it* (oist (ucous (e()ra/es d. or(al &S rese/t -. )eiHure pre%autions and nsg inter+entions "sele%t all uestion#
a. &asic te/a/t o t!: treat t*e *ole c*ild i. ;ai/stay o t!: +/tieiletic (eds to treat seiures ii. eli(i/ate t*e seiure it* (i/i(u( side eects 8 least use o (eds> /or(alie t*e li?es o t*e c*ild 8 a(ily )f the sJ lasts iii. +dCu/cti?e" =aus er?e Sti(ulatio/: e/erator i(la/ted i/to c*est $reater than all it* ire clied to ?aus /er?e to deli?er electrical i(ulses to t*e K min alert )rai/ dec /eed or (eds 8 e(ere/cy care" D i?. +dCu/cti?e" Betoe/ic diet: 4 ,+'&S- (ostly at roduces state o immediately etosis t*ou*t to co/trol seiures and admin ). &eore a seiure emer$ency i. &ed i/ lo ositio/ siderails u added sides suctio/ a/d airay at diaJepam )edside "-alium% or ii. Deter(i/e seiure triers a/d a?oid loraJepam c. Duri/ a seiure "ati-an% i. Do 4< lea?e t*e t> stay o)ser?e a/d docu(e/t 1. Date o/set *ere )ei/s" duratio/> trier> 4,> (o?e(e/ts> Si/ c*a/es etc. ii. E/sure adeuate ?e/tilatio/ 1. oose/ clot*i/%restrai/ts 2. D4 4< orce or i/sert a/yt*i/ i/to t*e (out* Coi/ *aard" 3. Side-lyi/ ositio/ reerred to re?e/t asiratio/ iii. Protect ro( i/Cury *el )rea all clear area o ur/iture" i?. D4 4< restrai/ (o?e(e/t o/Ft sto s ill cause i/Cury" ?. 'e(ai/ it* t*e erso/ 8 i?e ?er)al reassura/ce as ell as as (uc* ri?acy as ossi)le d. Post seiure i. +ssess: a rele!> a/y i/Curies or *eadac*e> residual 4, deicits ii. +llo i/di?idual to slee 8 reorie/t uo/ aae/i/ iii. ,o/duct a ost s assess(e/t e. Ho are seiure (edicatio/s disco/ti/ued i.
). I/direct )ili (ay )e ele?ated ii. ;o?ea)le ala)le oli?e-s*aed (ass i/ '^ 1. &est see/ *e/ sto(ac* e(ty 8 i/a/t cal( 2. 'adiora*y a/d ultrasou/d: /arro ylorus % dilated sto(ac* a/d a)se/ce o as distal to ylorus 3. &ariu( sallo: lo/ /arro ca/al 8 delayed astric e(tyi/ $. )%oliosis )%reening "BoC G(G Pg 1G$; &=EM# a. Girls 10yo t*rou* adolesce/ce (ost at ris i. Scree/i/ ti(es: irls- 10 8 12> )oys- 13 or 1$ ). Si/al deor(ity roressio/ dri?e/ )y rot* re(e/strual still roi/ less liely to de(o/strate ull S8S" c. Procedure: i. /clot*ed or eari/ u/dera/ts%o/ or si(suit so t*at c*est )ac a/d *is clearly see/ ii. E?e/ly distri)ute t o/to eet it* les strai*t a/d ar(s *u/ loosely iii. &e/d at aist a/d o)ser?e or S%S 1. o/-ai/ul lateral cur?e to si/e , cur?e or S cur?e" 2. ateral de?iatio/ a/d rotatio/ o eac* ?erte)rae )etter o)ser?ed )y looi/ at ri)s 4' si/e itsel" 3. /eual: s*oulder le/t*s> S,+P+' ro(i/e/ces a/d *ei*ts> aist a/les> ri) ro(i/e/ces 8 c*est sy((etry $. /eual ri) *ei*ts i/ ada(Fs ositio/ 5. Possi)le asy((etry i/ le le/t*s 6. /euro c*ec: stre/t* 8 rele!es d. u/ctio/al scoliosis: aare/t *e/ sta/di/ disaears it* )e/di/ e. Structural scoliosis: i!ed> cur?e rese/t it* sta/di/ or )e/di/ . ,o/e/ital scoliosis o i/a/t: ?isi)le *e/ lyi/ ro/e *els i suse/ded ro/e . 'eerral to ort*oedic sureo/ a/d are/t /otiicatio/ (ade % scolio(eter readi/ Q7 i/dicates 7 deree a/le o tru/ rotatio/" &. Inflammatory bowel diseaseF..delayed growth RT c*ro/ic (ala)sortio/%(al/utritio/> corticosteroids> c*ro/ic ill/ess recurre/t% c*ro/ic diarr*ea" =. al%ulating N wt loss a. 4rii/al t-curre/t t% orii/al t
1. <*e /urse is (o/itori/ a/ i/a/t it* co/e/ital *eart disease closely or si/s o *eart ailure H". <*e /urse s*ould assess t*e i/a/t or *ic* early si/ o H 1. Pallor 2. ,ou* 3.
$. <*e /urse ro?ides *o(e care i/structio/s to t*e are/ts o a c*ild it* *eart ailure reardi/ t*e rocedure or ad(i/istratio/ o dio!i/ a/o!i/". *ic* state(e/t (ade )y t*e are/t i/dicates t*e need for further instru%tions9 1. `I ill /ot (i! t*e (edicatio/ it* ood.` 2. `I ill tae (y c*ilds ulse )eore ad(i/isteri/ t*e (edicatio/.` 3. `I (ore t*a/ o/e dose is (issed I ill call t*e *ealt* care ro?ider.` $. `I (y c*ild ?o(its ater (edicatio/ ad(i/istratio/ I ill reeat t*e dose.` `I (y c*ild ?o(its ater (edicatio/ ad(i/istratio/ I ill reeat t*e dose.`
5. <*e /urse is closely (o/itori/ t*e i/tae a/d outut o a/ i/a/t it* *eart ailure *o is recei?i/ diuretic t*eray. <*e /urse s*ould use *ic* most appropriate (et*od to assess t*e uri/e outut 1. ei*i/ t*e diaers 2. I/serti/ a oley cat*eter 3. ,o(ari/ i/tae it* outut $. ;easuri/ t*e a(ou/t o ater added to or(ula 1. ei*i/ t*e diaers 6. <*e cli/ic /urse re?ies t*e record o a c*ild Cust see/ )y a *ealt* care ro?ider a/d dia/osed it* susected aortic ste/osis. <*e /urse e!ects to /ote docu(e/tatio/ o *ic* cli/ical (a/iestatio/ seciically ou/d i/ t*is disorder 1. Pallor 2. Hyeracti?ity 3. E!ercise i/tolera/ce $. Gastroi/testi/al distur)a/ces . E!ercise i/tolera/ce 7. <*e /urse *as ro?ided *o(e care i/structio/s to t*e are/ts o a c*ild *o is )ei/ disc*ared ater cardiac surery. *ic* state(e/t (ade )y t*e are/ts i/dicates a need for further instru%tions9 1. `+ )ala/ce o rest a/d e!ercise is i(orta/t.` 2. `I ca/ aly lotio/ or oder to t*e i/cisio/ i it is itc*y.` 3. `+cti?ities i/ *ic* (y c*ild could all /eed to )e a?oided or 2 to $ ees.` $. `are crods o eole /eed to )e a?oided or at least 2 ees ater surery.`
2. `I ca/ aly lotio/ or oder to t*e i/cisio/ i it is itc*y.` #. + c*ild it* r*eu(atic e?er ill )e arri?i/ i/ t*e /ursi/ u/it or ad(issio/. 4/ ad(issio/ assess(e/t t*e /urse s*ould as t*e are/ts *ic* uestio/ to elicit assess(e/t i/or(atio/ seciic to t*e de?elo(e/t o r*eu(atic e?er 1. `Has t*e c*ild co(lai/ed o )ac ai/` 2. `Has t*e c*ild co(lai/ed o *eadac*es` 3. `Has t*e c*ild *ad a/y /ausea or ?o(iti/` $. `Did t*e c*ild *a?e a sore t*roat or e?er it*i/ t*e last 2 (o/t*s` $. `Did t*e c*ild *a?e a sore t*roat or e?er it*i/ t*e last 2 (o/t*s`
9. + *ealt* care ro?ider *as rescri)ed o!ye/ as /eeded or a/ i/a/t it* *eart ailure. I/ *ic* situatio/ s*ould t*e /urse ad(i/ister t*e o!ye/ to t*e i/a/t 1. Duri/ slee 2. *e/ c*a/i/ t*e i/a/ts diaers 3. *e/ t*e (ot*er is *oldi/ t*e i/a/t $. *e/ drai/ )lood or electrolyte le?el testi/ $. *e/ drai/ )lood or electrolyte le?el testi/ 10. +ssess(e/t i/di/s o a/ i/a/t ad(itted to t*e *osital re?eal a (ac*i/ery-lie (ur(ur o/ auscultatio/ o t*e *eart a/d si/s o *eart ailure. <*e /urse re?ies co/e/ital cardiac a/o(alies a/d ide/tiies t*e i/a/ts co/ditio/ as *ic* disorder 1. +ortic ste/osis 2. +trial setal deect 3. Pate/t ductus arteriosus $. =e/tricular setal deect 3. Pate/t ductus arteriosus 11. <*e /urse is cari/ or a/ i/a/t it* a dia/osis o tetraloy o allot. <*e i/a/t sudde/ly )eco(es cya/otic a/d t*e /urse reco/ies t*at t*e i/a/t is e!erie/ci/ a *yercya/otic sell )lue or tet sell". <*e /urse immediately laces t*e i/a/t i/ *at ositio/ 1. Pro/e ositio/ 2. B/ee-c*est ositio/ 3. Hi* olers ositio/ $. 'e?erse
2. B/ee-c*est ositio/ 12. <*e /urse is (o/itori/ a/ i/a/t it* *eart ailure H". *ic* si/ alerts t*e /urse to susect luid accu(ulatio/ a/d t*e /eed to call t*e *ealt* care ro?ider H,P" 1. &rady/ea 2. Dia*oresis 3. Decreased )lood ressure $. + ei*t ai/ o 1 l) i/ 1 day $. + ei*t ai/ o 1 l) i/ 1 day
13. + c*ild it* a dia/osis o tetraloy o allot e!*i)its a/ i/creased det* a/d rate o resiratio/s. 4/ urt*er assess(e/t t*e /urse /otes i/creased *yo!e(ia. <*e /urse i/terrets t*ese i/di/s as i/dicati/ *ic* situatio/ 1. +/!iety 2. + te(er ta/tru( 3. + *yercya/otic eisode $. <*e /eed or i((ediate *ealt* care ro?ider H,P" /otiicatio/ 3. + *yercya/otic eisode 1$. <*e (ot*er o a c*ild )ei/ disc*ared ater *eart surery ass t*e /urse *e/ t*e c*ild ill )e a)le to retur/ to sc*ool. *ic* is t*e most appropriate reso/se to t*e (ot*er 1. `<*e c*ild (ay retur/ to sc*ool i/ 1 ee.` 2. `<*e c*ild ill /ot )e a)le to retur/ to sc*ool duri/ t*is acade(ic year.` 3. `<*e c*ild (ay retur/ to sc*ool i/ 1 ee )ut /eeds to o *al-days or t*e irst 2 ees.` $. `<*e c*ild (ay retur/ to sc*ool i/ 3 ees )ut /eeds to o *al-days or t*e irst e days.` $. `<*e c*ild (ay retur/ to sc*ool i/ 3 ees )ut /eeds to o *al-days or t*e irst e days.` 15. + c*ild *as )ee/ te/tati?ely dia/osed it* r*eu(atic e?er. <*e /urse i/terrets t*at t*is dia/osis is co/siste/t it* *ic* la)oratory result o)tai/ed or t*is c*ild 1. Ele?ated a/tistretolysi/ 4 +S4" titer 2. Decreased eryt*rocyte sedi(e/tatio/ rate ES'" 3. eati?e result o/ a/ti/uclear a/ti)ody ++" assay $. eati?e result o/ ,-reacti?e rotei/ ,'P" deter(i/atio/
1. Ele?ated a/tistretolysi/ 4 +S4" titer 16. + 12-year-old is ad(itted to t*e *osital it* a lo-rade e?er a/d Coi/t ai/. *ic* dia/ostic test i/di/ ill assist to deter(i/e a dia/osis o r*eu(atic e?er 1. Prese/ce o +sc*os )odies 2. +)se/ce o ,-reacti?e rotei/ 3. Prese/ce o 'eed-Ster/)er cells $. Decreased a/tistretolysi/ 4 titer 1. Prese/ce o +sc*os )odies
17. <*e /urse re?ies t*e la)oratory results or a c*ild it* r*eu(atic e?er a/d ould e!ect to /ote *ic* i/di/s )ele%t all that apply. 1. Prese/ce o +sc*os )odies 2. +)se/ce o ,-reacti?e rotei/ 3. Ele?ated a/tistretolysi/ 4 titer $. Prese/ce o 'eed-Ster/)er cell 5. Ele?ated eryt*rocyte sedi(e/tatio/ rate o
1. Prese/ce o +sc*os )odies
o
3. Ele?ated a/tistretolysi/ 4 titer
o
5. Ele?ated eryt*rocyte sedi(e/tatio/ rate
1#. Prostala/di/ E1 is rescri)ed or a c*ild it* tra/sositio/ o t*e reat arteries. <*e (ot*er o t*e c*ild is a reistered /urse a/d ass t*e /urse *y t*e c*ild /eeds t*e (edicatio/. *at is t*e most appropriate reso/se to t*e (ot*er a)out t*e actio/ o t*e (edicatio/ 1. Pre?e/ts )lue tet" sells 2. ;ai/tai/s adeuate cardiac outut 3. ;ai/tai/s a/ adeuate *or(o/al le?el $. ;ai/tai/s t*e ositio/ o t*e reat arteries 2. ;ai/tai/s adeuate cardiac outut 19. <*e /urse is teac*i/ cardioul(o/ary resuscitatio/ ,P'" to a rou o co((u/ity (e()ers. <*e /urse tells t*e rou t*at *e/ c*e st co(ressio/s are eror(ed o/ c*ildre/ a/d i/a/ts t*e ster/u( s*ould )e deressed *o ar 1. 1b to 2 i/c*es
2. 2b to 3 i/c*es 3. Dee e/ou* to (ae a i/er i(ressio/ $. 4/e t*ird to o/e *al t*e det* o t*e c*est $. 4/e t*ird to o/e *al t*e det* o t*e c*est 20. <*e /ursi/ i/structor teac*es a rou o stude/ts a)out cardioul(o/ary resuscitatio/ ,P'". <*e i/structor ass a stude/t to ide/tiy t*e most appropriate locatio/ at *ic* to assess t*e ulse o a/ i/a/t you/er t*a/ 1 year o ae. *ic* reso/se ould i/dicate t*at t*e stude/t u/dersta/ds t*e aroriate assess(e/t rocedure 1. 'adial artery 2. ,arotid artery 3. &rac*ial artery $. Politeal artery &rac*ial artery
21. + 1-year-old i/a/t it* a dia/osis o *eart ailure is rescri)ed dio!i/ a/o!i/". <*e /urse taes t*e aical ulse or 1 (i/ute )eore ad(i/isteri/ t*e (edicatio/ a/d o)tai/s a result o 102 )eats%(i/. *ic* actio/ s*ould t*e / urse tae 1. 'etae t*e aical ulse. 2. it**old t*e (edicatio/. 3. +d(i/ister t*e (edicatio/. $. it**old t*e (edicatio/ a/d /otiy t*e *ealt* care ro?ider. 3. +d(i/ister t*e (edicatio/. 22. <*e /urse is assessi/ a /e)or/ it* *eart ailure )eore ad(i/isteri/ t*e rescri)ed dio!i/ a/o!i/". I/ re?iei/ t*e la)oratory da ta t*e /urse /otes t*at t*e /e)or/ *as a dio!i/ )lood le?el o 2.$ /%( a/d a/ aical *eart rate o 9# )eats%(i/. <*e (ot*er also tells t*e /urse t*at t*e /e)or/ Cust ?o(ited *er or(ula. *ic* i/ter?e/tio/ s*ould t*e /urse tae 1. 'etae t*e aical ulse. 2. +d(i/ister t*e (edicatio/. 3. it**old t*e (edicatio/ or 1 *our. $. it**old t*e (edicatio/ a/d /otiy t*e *ealt* care ro?ider. $. it**old t*e (edicatio/ a/d /otiy t*e *ealt* care ro?ider. 23. <*e /urse is de?eloi/ a la/ o care or a c*ild ad(itted it* a dia/osis o Baasai disease. I/ de?eloi/ t*e i/itial la/ o care t*e /urse s*ould i/clude to (o/itor t*e c*ild or si/s o *ic* co/ditio/ 1. &leedi/
2. ailure to t*ri?e 3. Heart ailure H" $. Decreased tolera/ce to sti(ulatio/ 3. Heart ailure H" 2$. <*e /urse is re?iei/ t*e *ealt* care ro?iders rescritio/s or a c*ild it* r*eu(atic e?er '" *o is susected o *a?i/ a ?iral i/ectio/. <*e /urse /otes t*at acetylsalicylic acid asiri/" is rescri)ed or t*e c*ild. *ic* /ursi/ actio/ is most appropriate9 1. +d(i/ister t*e asiri/ i t*e c*ilds te(erature is ele?ated. 2. +d(i/ister t*e asiri/ i t*e c*ild e!erie/ces a/y Coi/t ai/. 3. ,o/sult it* t*e *ealt* care ro?ider to ?eriy t*e rescritio/. $. +d(i/ister aceta(i/o*e/
25. + /urse is assi/ed to care or a/ i/a/t it* tetraloy o allot. <*e (ot*er o t*e i/a/t calls t*e /urse to t*e roo( )ecause t*e i/a/t sudde/ly see(s to )e *a?i/ diiculty )reat*i/. <*e /urse e/ters t*e roo( a/d /otes t*at t*e i/a/t is e!erie/ci/ a *yercya/otic eisode. *at is t*e initial actio/ )y t*e /urse 1. Place t*e i/a/t i/ a ro/e ositio/. 2. ,all a code a/d /otiy t*e suer?isor. 3. Place t*e i/a/t i/ a /ee-c*est ositio/. $. ,o/tact t*e resiratory t*eray deart(e/t. 3. Place t*e i/a/t i/ a /ee-c*est ositio/. 26. + /urse is cari/ or a/ i/a/t it* co/e/ital *eart disease. *ic* i /oted i/ t*e i/a/t s*ould alert t*e /urse to t*e early de?elo(e/t o *eart ailure H" 1. Pale/ess o t*e si/ 2. Stro/ suci/ rele! 3. Dia*oresis duri/ eedi/ $. Slo a/d s*allo )reat*i/ 3. Dia*oresis duri/ eedi/ 27. <*e /urse is cari/ or a c*ild it* a dia/osis o a ri*t-to-let cardiac s*u/t. 4/ re?ie o t*e c*ilds record t*e /urse s*ould e!ect to /ote docu(e/tatio/ o *ic* most co((o/ assess(e/t i/di/ 1. Se?ere )radycardia 2. +sy(to(atic i/di/s
3. &luis* discoloratio/ o t*e si/ $. Hi*er t*a/ /or(al )ody ei*t 3. &luis* discoloratio/ o t*e si/ 2#. <*e /urse is collecti/ data o/ a c*ild it* a dia/osis o r*eu(atic e?er '". *ic* uestio/ s*ould t*e /urse initially as t*e (ot*er o t*e c*ild 1. `Has t*e c*ild )ee/ ?o(iti/` 2. `Has t*e c*ild *ad a/y diarr*ea` 3. `Does t*e c*ild co(lai/ o c*est ai/ a/d /u()/ess i/ t*e ri*t ar(` $. `Has t*e c*ild co(lai/ed o a sore t*roat it*i/ t*e ast e (o/t*s` $. `Has t*e c*ild co(lai/ed o a sore t*roat it*i/ t*e ast e (o/t*s`
29. + /urse is re?iei/ t*e *ealt* record o a/ i/a/t it* a dia/osis o co/e/ital *eart disease. <*e /urse /otes docu(e/tatio/ i/ t*e record t*at t*e i/a/t *as clu))i/ o t*e i/ers. <*e /urse u/dersta/ds t*at t*is i/di/ is caused )y *ic* ro)le( 1. ,*ro/ic atiue 2. Poor o!ye/atio/ 3. Poor suci/ a)ility $. ,o/siste/t suci/ o/ t*e i/ers 2. Poor o!ye/atio/ 30. + c*ild is )ei/ disc*ared ro( t*e *osital olloi/ *eart surery. Prior to disc*are t*e /urse re?ies t*e disc*are i/structio/s it* t*e (ot*er. *ic* state(e/t )y t*e (ot*er i/dicates a need for further tea%hing9 1. `^uiet acti?ities are alloed.` 2. `<*e c*ild s*ould lay i/side or /o.` 3. `=isitors are /ot alloed or 1 (o/t*.` $. `<*e reular sc*edule or /as is resu(ed.` 3. `=isitors are /ot alloed or 1 (o/t*.`
