Chapter 1, 20, 3, 4, 5, 9, 10, 11, 12, 13, 14, 15, 16

CRIES pain scale

Crying- characteristic of pain Requires O2 for SaO2 ,95% Increased Vital signs Expression Sleepless

Match the following terms related to food sensitivities to the accurate descriptions. a. Food allergy b. Food allergen c. Food intolerance d. Sensitization e. Atopy 1. A food elicits a reproducible adverse reaction but does not have an established immunologic mechanism 2. An adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food 3. Specific components of food or ingredients in food that are recognized by allergen-specific immune cells eliciting an immune reaction 4. Allergy with a hereditary tendency 5. Initial exposure to an allergen resulting in an immune response; subsequent exposure induces a much stronger response

1. ANS: C 2. ANS: A 3. ANS: B 4. ANS: E 5. ANS: D

Match each neurologic reflex that appears in infancy to its description. a.Labyrinth righting b.Body righting c.Otolith righting d.Landau e.Parachute 1. When the body of an erect infant is tilted, the head is returned to an upright, erect position. 2. An infant in the prone or supine position is able to raise his or her head. 3. Turning the hips and shoulders to one side causes all the other body parts to follow. 4. When the infant is suspended in a horizontal prone position and suddenly thrust downward, the hands and fingers extend forward as if to protect against falling. 5. When the infant is suspended in a horizontal prone position, the head is raised and the legs and spine are extended.

1. ANS: C DIF: Cognitive Level: Understanding REF: p. 414 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 2. ANS: A DIF: Cognitive Level: Understanding REF: p. 414 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 3. ANS: B DIF: Cognitive Level: Understanding REF: p. 414 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 4. ANS: E DIF: Cognitive Level: Understanding REF: p. 414 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 5. ANS: D DIF: Cognitive Level: Understanding REF: p. 414 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Children as young as age 3 years can use facial scales for discrimination. What are some suggested anchor words for the preschool age group? A. No hurt. B. Red pain. C. Zero hurt. D. Least pain.

A "No hurt" is a phrase that is simple, concrete, and appropriate to the preoperational stage of the child. Using color is complicated for this age group. The child needs to identify colors and pain levels and then choose an appropriate symbolic color. This is appropriate for an older child. Zero is an abstract construct not appropriate for this age group. "Least pain" is less concrete than "no hurt."

A burn patient is experiencing anxiety over dressing changes. Which prescription should the nurse expect to be ordered to control anxiety? A. Lorazepam (Ativan) B. Oxycodone (OxyContin) C. Fentanyl (Sublimaze) D. Morphine Sulfate (Morphine)

A A benzodiazepine such as lorazepam is prescribed as an antianxiety agent. Oxycodone, fentanyl, and morphine sulfate are opioid analgesics.

Preschoolers' fears can best be dealt with by which intervention? a. Actively involving them in finding practical methods to deal with the frightening experience b. Forcing them to confront the frightening object or experience in the presence of their parents c. Using logical persuasion to explain away their fears and help them recognize how unrealistic the fears are d. Ridiculing their fears so that they understand that there is no need to be afraid

A Actively involving them in finding practical methods to deal with the frightening experience is the best way to deal with fears. Forcing a child to confront fears may make the child more afraid. Preconceptual thought prevents logical understanding. Ridiculing fears does not make them go away. DIF: Cognitive Level: Apply REF: p. 388 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Health Promotion and Maintenance

What describes nonpharmacologic techniques for pain management? A. They may reduce pain perception. B. They usually take too long to implement. C. They make pharmacologic strategies unnecessary. D. They trick children into believing they do not have pain.

A Nonpharmacologic techniques provide coping strategies that may help reduce pain perception, make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics. The nonpharmacologic strategy should be matched with the child's pain severity and be taught to the child before the onset of the painful experience. Tricking children into believing they do not have pain may mitigate the child's experience with mild pain, but the child will still know the discomfort was present.

Which is a complication that can occur after abdominal surgery if pain is not managed? A. Atelectasis B. Hypoglycemia C. Decrease in heart rate D. Increase in cardiac output

A Pain associated with surgery in the abdominal region (e.g., appendectomy, cholecystectomy, splenectomy) may result in pulmonary complications. Pain leads to decreased muscle movement in the thorax and abdominal area and leads to decreased tidal volume, vital capacity, functional residual capacity, and alveolar ventilation. The patient is unable to cough and clear secretions, and the risk for complications such as pneumonia and atelectasis is high. Severe postoperative pain also results in sympathetic overactivity, which leads to increases in heart rate, peripheral resistance, blood pressure, and cardiac output. Hypoglycemia, decreases in heart rate, and increases in cardiac output are not complications of poor pain management.

The nurse is caring for a child receiving a continuous intravenous (IV) low-dose infusion of morphine for severe postoperative pain. The nurse observes a slower respiratory rate, and the child cannot be aroused. The most appropriate management of this child is for the nurse to do which first? A. Administer naloxone (Narcan). B. Discontinue the IV infusion. C. Discontinue morphine until the child is fully awake. D. Stimulate the child by calling his or her name, shaking gently, and asking the child to breathe deeply.

A The management of opioid-induced respiratory depression includes lowering the rate of infusion and stimulating the child. If the respiratory rate is depressed and the child cannot be aroused, then IV naloxone should be administered. The child will be in pain because of the reversal of the morphine. The morphine should be discontinued, but naloxone is indicated if the child is unresponsive.

The practitioner has ordered a liquid oral antibiotic for a toddler with otitis media. The prescription reads 1 1/2 tsp four times per day. What should the nurse consider in teaching the mother how to give the medicine? A measuring spoon should be used, and the medication must be given every 6 hours. The mother is not able to handle this regimen. Long-acting intramuscular antibiotics should be administered. A hollow-handled medication spoon is advisable, and the medication should be equally spaced while the child is awake. A household teaspoon should be used and the medicine given when the child wakes up, around lunch time, at dinner time, and before bed.

A hollow-handled medication spoon is advisable, and the medication should be equally spaced when the child is awake A hollow-handled medication spoon allows the mother to measure the correct amount of medication. The order is written for four times a day; every 6 hours dosing is not necessary. There is no indication that the mother is not able to adhere to the medication regimen. She is asking for clarification so she can properly care for her child. Long-acting intramuscular antibiotics are not indicated. Household teaspoons vary greatly and should not be used.

A parent asks the nurse about the "characteristics of a nightmare." What response should the nurse give to the parent? (Select all that apply.) a.Nightmares are scary dreams. b.The child can describe the nightmare. c.The child is reassured by your presence. d.Nightmares occur usually 1 to 4 hours after falling asleep. e.Nightmares take place during non-rapid eye movement sleep

A, B, C

What are symptoms of abusive head trauma (AHT) in the more severe form that may be present? (Select all that apply.) a.Seizures b.Posturing c.Tachypnea d.Tachycardia e.Altered level of consciousness

A, B, E

The nurse is teaching parents of preschool children consequences of inadequate sleep. What should the nurse include in the teaching session? (Select all that apply.) a.Behavior changes b.Increased appetite c.Difficulty concentrating d.Poor control of emotions e.Impaired learning ability

A, C, D, E

What are classified as corrosive poisons? (Select all that apply.) a.Batteries b.Paint thinner c.Drain cleaners d.Mineral seed oil e.Mildew remover

A, C, E

The nurse is teaching parents of preschool-aged children strategies to prevent sexual abuse. What should the nurse include in the teaching session? (Select all that apply.) a.Back up a child's right to say no. b.Don't take what your child says too seriously. c.Take a second look at signals of potential danger. d.Don't be too detailed about examples of sexual assault. e.Remind children that even "nice" people sometimes do mean things.

A, C, E

A parent asks the nurse about the "characteristics of a sleep terror." What response should the nurse give to the parent? (Select all that apply.) a.The child screams during the sleep terror. b.Return to sleep is delayed because of persistent fear. c.The night terror occurs during the second half of night. d.The child has no memory of the dream with a sleep terror. e.The child is not aware of another's presence during a sleep terror.

A, D, E

Turner syndrome is suspected in an adolescent girl with short stature. What causes this? a. Absence of one of the X chromosomes b. Presence of an incomplete Y chromosome c. Precocious puberty in an otherwise healthy child d. Excess production of both androgens and estrogens

A. Absence of one of the X chromosomes Turner syndrome is caused by an absence of one of the X chromosomes. Most girls who have this disorder have one X chromosome missing from all cells. No Y chromosome is present in individuals with Turner syndrome. These young women have 45 rather than 46 chromosomes.

Parents ask the nurse about the characteristics of autosomal recessive inheritance. Which is characteristic of autosomal recessive inheritance? a. Affected individuals have unaffected parents. b. Affected individuals have one affected parent. c. Affected parents have a 50% chance of having an affected child. d. Affected parents will have unaffected children.

A. Affected individuals have unaffected parents. Parents who are carriers of a recessive gene are asymptomatic. For a child to be affected, both parents must have a copy of the gene, which is passed to the child. Both parents are asymptomatic but can have affected children. In autosomal recessive inheritance, there is a 25% chance that each pregnancy will result in an affected child. In autosomal dominant inheritance, affected parents can have unaffected children.

The inheritance of which is X-linked recessive? a. Hemophilia A b. Marfan syndrome c. Neurofibromatosis d. Fragile X syndrome

A. Hemophilia A Hemophilia A is inherited as an X-linked recessive trait. Marfan syndrome and neurofibromatosis are inherited as autosomal dominant disorders. Fragile X is inherited as an Xlinked trait.

Which is a birth defect or disorder that occurs as a new case in a family and is not inherited? a. Sporadic b. Polygenic c. Monosomy d. Association

A. Sporadic Sporadic describes a birth defect previously unidentified in a family. It is not inherited. Polygenic inheritance involves the inheritance of many genes at separate loci whose combined effects produce a given phenotype. Monosomy is an abnormal number of chromosomes whereby the chromosome is represented by a single copy in a somatic cell. A nonrandom cluster of malformations without a specific cause is an association.

A couple expecting their first child has a positive family history for several congenital defects and disorders. The couple tells the nurse that they are opposed to abortion for religious reasons. Which should the nurse consider when counseling the couple? a. The couple should be encouraged to have recommended diagnostic testing. b. The couple needs counseling regarding advantages and disadvantages of pregnancy termination. c. Diagnostic testing is required by law in this situation. d. Diagnostic testing is of limited value if termination of pregnancy is not an option.

A. The couple should be encouraged to have recommended diagnostic testing. The benefits of prenatal diagnostic testing extend beyond decisions concerning abortion. If the child has congenital disorders, decisions can be made about fetal surgery if indicated. In addition, if the child is expected to require neonatal intensive care at birth, the mother is encouraged to deliver at a level III neonatal center. The couple is counseled about the advantages and disadvantages of prenatal diagnosis, not pregnancy termination, although the family cannot be forced to have prenatal testing. The information gives the parents time to grieve and plan for their child if congenital disorders are present. If the child is free of defects, then the parents are relieved of a major worry.

A couple has given birth to their first child, a boy with a recessive disorder. The genetic counselor tells them that the risk of recurrence is one in four. Which statement is a correct interpretation of this information? a. The risk factor remains the same for each pregnancy. b. The risk factor will change when they have a second child. c. Because the parents have one affected child, the next three children should be unaffected. d. Because the parents have one affected child, the next child is four times more likely to be affected.

A. The risk factor remains the same for each pregnancy. Each pregnancy has the same risks for an affected child. Because an odds ratio reflects the risk, this does not change over time. The statement by the genetic counselor refers to a probability. This does not change over time. The statement Because the parents have one affected child, the next child is four times more likely to be affected does not reflect autosomal recessive inheritance.

The recommendation for calcium for children 1 to 3 years of age is _____ milligrams. (Record your answer in a whole number.)

ANS: 500 While limiting fat consumption, it is important to ensure diets contain adequate nutrients such as calcium. The recommendation for daily calcium intake for children 1 to 3 years of age is 500 mg, and the recommendation for children 4 to 8 years of age is 800 mg. DIF: Cognitive Level: Remember REF: p. 389 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance

3. A health care provider prescribes adrenaline (epinephrine), intramuscularly (IM) 0.15 mg, times one, stat. The medication label states: "Epinephrine 1:1000 1 mg/1 ml." The nurse prepares to administer the stat dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer using two decimal places.

ANS: 0.15 Follow the formula for dosage calculation. Desired ----------- Volume = ml per dose Available 0.15 mg ----------- 1 ml = 0.15 ml 1 mg DIF: Cognitive Level: Applying REF: p. 459 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

2. A health care provider prescribes iron supplements (Fer-In-Sol), 1 mg/kg/day orally (PO). The infant weighs 5 kg. The medication label states: "Fer-In-Sol 25 mg/1 ml." The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer to one decimal place.

ANS: 0.2 Follow the formula for dosage calculation. Multiply 1 mg 5 kg to get the dose = 5 mg Desired ----------- Volume = ml per dose Available 5 mg ----------- 1 ml = 0.2 ml 25 mg DIF: Cognitive Level: Applying REF: p. 454 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

1. A health care provider prescribes vitamin D supplements, 300 IU orally, daily. The medication label states: "Vitamin D 1000 IU/10 ml." The nurse prepares to administer one dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank. Record your answer in a whole number.

ANS: 3 Follow the formula for dosage calculation. Desired ----------- Volume = ml per dose Available 300 IU ----------- 10 ml = 3 ml 1000 IU DIF: Cognitive Level: Applying REF: p. 453 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

A health care provider prescribes haloperidol (Haldol), PO, 0.5 mg, twice a day, for a child with schizophrenia. The medication label states: "Haloperidol (Haldol) oral concentrate, 1 mg/1 ml." The nurse prepares to administer one dose. How many milliliters should the nurse prepare to administer one dose? Fill in the blank. Record your answer to one decimal place. ________________

ANS: 0.5 Follow the formula for dosage calculation. Desired ----------- × Volume = ml per dose Available 0.5 mg ----------- × 1 ml = 0.5 ml 1 mg

A health care provider prescribes paroxetine (Paxil), 20 mg, PO, daily for a child with depression. The medication label states: "Paroxetine (Paxil) 10 mg/1 tablet." The nurse prepares to administer one dose. How many tablet(s) should the nurse prepare to administer one dose? Fill in the blank. Record your answer as a whole number. ________________

ANS: 2 Follow the formula for dosage calculation. Desired ----------- × Quantity = Tablets per dose Available 20 mg ----------- × 1 = 2 tabs 10 mg

A health care provider prescribes methylphenidate hydrochloride (Ritalin), PO, 20 mg, twice a day, for a child with attention deficit hyperactivity disorder. The medication label states: "Methylphenidate hydrochloride (Ritalin), 10 mg/1 tablet." The nurse prepares to administer one dose. How many tab(s) should the nurse prepare to administer one dose? Fill in the blank. Record your answer as a whole number. ________________

ANS: 2 Follow the formula for dosage calculation. Desired ----------- × Quantity = Tablets per dose Available 20 mg ----------- × 1 = 2 tabs 10 mg

A health care provider prescribes risperidone (Risperdal), PO, 2 mg, twice a day, for a child with schizophrenia. The medication label states: "Risperidone (Risperdal) oral concentrate, 1 mg/1 ml." The nurse prepares to administer one dose. How many milliliters should the nurse prepare to administer one dose? Fill in the blank. Record your answer as a whole number. ________________

ANS: 2 Follow the formula for dosage calculation. Desired ----------- × Volume = ml per dose Available 2 mg ----------- × 1 ml = 2 ml 1 mg

A health care provider prescribes sertraline (Zoloft) PO, 50 mg, daily, for a child with depression. The medication label states: "Sertraline (Zoloft) oral concentrate, 20 mg/1 ml." The nurse prepares to administer one dose. How many milliliters should the nurse prepare to administer one dose? Fill in the blank. Record your answer to one decimal place. ________________

ANS: 2.5 Follow the formula for dosage calculation. Desired ----------- × Volume = ml per dose Available 50 mg ----------- × 1 ml = 2.5 ml 20 mg

A health care provider prescribes clonidine hydrochloride (Kapvay), PO, 0.3 mg, daily for a child with attention deficit hyperactivity disorder. The medication label states: "Clonidine hydrochloride (Kapvay), 0.1 mg/1 tablet." The nurse prepares to administer one dose. How many tablet(s) should the nurse prepare to administer one dose? Fill in the blank. Record your answer as a whole number. ________________

ANS: 3 Follow the formula for dosage calculation. Multiply 1 mg × 10 kg to get the dose = 10 mg Desired ----------- × Quantity = Tablets per dose Available 0.3 mg ----------- × 1 tab = 3 tabs 0.1 mg

What information should be given to the parents of a 12-month-old child regarding appropriate play activities for this age? a.Give large push-pull toys for kinetic stimulation. b.Place a cradle gym across the crib to help develop fine motor skills. c.Provide the child with finger paints to enhance fine motor skills. d.Provide a stick horse to develop gross motor coordination.

ANS: A A 12-month-old child is able to pull to a stand and walk holding on or independently. Appropriate toys for this age child include large push-pull toys for kinetic stimulation. A cradle gym should not be placed across the crib. Finger paints are appropriate for older children. A 12-month-old child does not have the stability to use a stick horse.

The school nurse needs to obtain authorization for a child who requires medications while at school. From whom does the nurse obtain the authorization? a. The parents b. The pharmacist c. The school administrator d. The prescribing practitioner

ANS: A A child who requires medication during the school day requires written authorization from the parent or guardian. Most schools also require that the medication be in the original container appropriately labeled by the pharmacist or physician. Some schools allow children to receive over-the-counter medications with parental permission. The pharmacist may be asked to appropriately label the medication for use at the school, but authorization is not required. The school administration should have a policy in place that facilitates the administration of medications for children who need them. The prescribing practitioner is responsible for ensuring that the medication is appropriate for the child. Because the child is a minor, parental consent is required.

Deficiency of which vitamin or mineral results in an inadequate inflammatory response? a. A b. B1 c. C d. Zinc

ANS: A A deficiency of vitamin A results in an inadequate inflammatory response. Deficiencies of vitamins B1 and C result in decreased collagen formation. A deficiency of zinc leads to impaired epithelialization.

The nurse is admitting a child with frostbite. What health care prescription should the nurse question and verify? a. Massage the injured tissue. b. Apply a loose dressing after rewarming. c. Avoid any application of dry heat to the area. d. Administer acetaminophen (Tylenol) for discomfort.

ANS: A A frostbite victim should not have injured tissue rubbed. It is contraindicated because it can cause damage by rupture of crystallized cells. After rewarming, a loose dressing is applied to the affected skin, and analgesia is administered if indicated. Dry heat is not applied.

In teaching parents about appropriate pacifier selection, the nurse should recommend which characteristic? a.Easily grasped handle b.Detachable shield for cleaning c.Soft, pliable material d.Ribbon or string to secure to clothing

ANS: A A good pacifier should be easily grasped by the infant. One-piece construction is necessary to avoid having the nipple and guard separate, posing a risk for aspiration. The material should be sturdy and flexible. If the pacifier is too pliable, it may be aspirated. No ribbon or string should be attached. This poses additional risks.

A 9-year-old child has just been diagnosed with recurrent abdominal pain (RAP). In preparing for discharge, the nurse should include what in the home care instructions to the parents? a. Following a high-fiber diet b. Using stimulant laxatives c. Using ice packs on the abdomen when pain occurs d. Sitting on the toilet for 30 minutes after each meal

ANS: A A high-fiber diet with possible addition of bulk laxatives is beneficial for children with RAP. Bulk-forming laxatives such as psyllium are recommended. Stimulant laxatives may produce painful cramping for the child. Warm packs, such as a heating pad, may help ease the discomfort. Bowel training is recommended to assist the child in establishing regular bowel habits. Thirty minutes is too long for the child to sit on the toilet. The time should be limited to 15 minutes.

The nurse is teaching parents of preschoolers about plants that are poisonous. What plant should the nurse include in the teaching session? a.Azalea b.Begonia c.Boston fern d.Asparagus fern

ANS: A All parts of the azalea are poisonous. Begonias, Boston ferns, and asparagus ferns are nonpoisonous plants.

The nurse is caring for a child with suspected ingestion of some type of poison. What action should the nurse take next after initiating cardiopulmonary resuscitation (CPR)? a.Empty the mouth of pills, plants, or other material. b.Question the victim and witness. c.Place the child in a side-lying position. d.Call poison control.

ANS: A Emptying the mouth of any leftover pills, plants, or other ingested material is the next step after assessment and initiation of CPR if needed. Questioning the victim and witnesses, calling poison control, and placing the child in a side-lying position are follow-up steps.

An infant, age 5 months, is brought to the clinic by his parents for a well-baby checkup. What is the best advice that the nurse should include at this time about injury prevention? a."Keep buttons, beads, and other small objects out of his reach." b."Do not permit him to chew paint from window ledges because he might absorb too much lead." c."When he learns to roll over, you must supervise him whenever he is on a surface from which he might fall." d."Lock the crib sides securely because he may stand and lean against them and fall out of bed."

ANS: A Aspiration of foreign objects is a great risk at this age. Parents are instructed to keep small objects out of the infant's reach. At this age, the child is not mobile enough to reach window sills. If window sills have cracked or chipped paint, it needs to be removed before he is a toddler. This child should already be rolling over. This information is reinforced but should have been taught earlier. Pulling to a stand occurs between 8 and 12 months of age.

What is an appropriate play activity for a 7-month-old infant to encourage visual stimulation? a.Playing peek-a-boo b.Playing pat-a-cake c.Imitating animal sounds d.Showing how to clap hands

ANS: A Because object permanence is a new achievement, peek-a-boo is an excellent activity to practice this new skill for visual stimulation. Playing pat-a-cake and showing how to clap hands help with kinetic stimulation. Imitating animal sounds helps with auditory stimulation.

The management of a child who has just been stung by a bee or wasp should include applying what? a. Cool compresses b. Antibiotic cream c. Warm compresses d. Corticosteroid crea

ANS: A Bee or wasp stings are initially treated by carefully removing the stinger, cleansing with soap and water, applying cool compresses, and using common household agents such as lemon juice or a paste made with aspirin and baking soda. Antibiotic cream is unnecessary unless a secondary infection occurs. Warm compresses are avoided. Corticosteroid cream is not part of the initial therapy. If a severe reaction occurs, systemic corticosteroids may be indicated.

An 8-year-old girl tells the nurse that she has cancer because God is punishing her for being bad. What should the nurse interpret this as? a. A common belief at this age b. Indicative of excessive family pressure c. Faith that forms the basis for most religions d. Suggestive of a failure to develop a conscience

ANS: A Children at this age may view illness or injury as a punishment for a real or imagined misbehavior. School-age children expect to be punished and tend to choose a punishment that they think fits the crime. This is a common belief and not related to excessive family pressure. Many faiths do not include a God that causes cancer in response for bad behavior. This statement reflects the childs belief in what is right and wrong.

The nurse is teaching parents of a preschool child strategies to implement when the child delays going to bed. What strategy should the nurse recommend? a.Use consistent bedtime rituals. b.Give in to attention-seeking behavior. c.Take the child into the parent's bed for an hour. d.Allow the child to stay up past the decided bedtime.

ANS: A For children who delay going to bed, a recommended approach involves a consistent bedtime ritual and emphasizing the normalcy of this type of behavior in young children. Parents should ignore attention-seeking behavior, and the child should not be taken into the parents' bed or allowed to stay up past a reasonable hour.

The mother of a 3-month-old breastfed infant asks about giving her baby water because it is summer and very warm. What should the nurse tell her? a.Fluids in addition to breast milk are not needed. b.Water should be given if the infant seems to nurse longer than usual. c.Clear juices are better than water to promote adequate fluid intake. d.Water once or twice a day will make up for losses resulting from environmental temperature.

ANS: A Infants who are breastfed or bottle fed do not need additional water during the first 4 months of life. Excessive intake of water can create problems such as water intoxication, hyponatremia, or failure to thrive. Juices provide empty calories for infants.

A child is admitted with a suspected diagnosis of Munchausen syndrome by proxy (MSBP). What is an important consideration in the care of this child? a.Monitoring the parents whenever they are with the child b.Reassuring the parents that the cause of the disorder will be found c.Teaching the parents how to obtain necessary specimens d.Supporting the parents as they cope with diagnosis of a chronic illness

ANS: A MSBP refers to an illness that one person fabricates or induces in another. The child must be continuously observed for development of symptoms to determine the cause. MSBP is caused by an individual harming the child for the purpose of gaining attention. Nursing staff should obtain all specimens for analyzing. This minimizes the possibility of the abuser contaminating the sample. The child must be supported through the diagnosis of MSBP. The abuser must be identified and the child protected from that individual.

What is an important consideration in preventing injuries during middle childhood? a. Achieving social acceptance is a primary objective. b. The incidence of injuries in girls is significantly higher than it is in boys. c. Injuries from burns are the highest at this age because of fascination with fire. d. Lack of muscular coordination and control results in an increased incidence of injuries.

ANS: A School-age children often participate in dangerous activities in an attempt to prove themselves worthy of acceptance. The incidence of injury during middle childhood is significantly higher in boys compared with girls. Motor vehicle collisions are the most common cause of severe injuries in children. Children have increasing muscular coordination. Children who are risk takers may have inadequate self-regulatory behavior.

A 9-year-old girl often comes to the school nurse complaining of stomach pains. Her teacher says she is completing her school work satisfactorily but lately has been somewhat aggressive and stubborn in the classroom. The school nurse should recognize this as which? a. Signs of stress b. Developmental delay c. Lack of adjustment to school environment d. Physical problem that needs medical intervention

ANS: A Signs of stress include stomach pains or headache, sleep problems, bedwetting, changes in eating habits, aggressive or stubborn behavior, reluctance to participate, or regression to earlier behaviors. The child is completing school work satisfactorily; any developmental delay would have been diagnosed earlier. The teacher reports that this is a departure from the childs normal behavior. Adjustment issues would most likely be evident soon after a change. Medical intervention is not immediately required. Recognizing that this constellation of symptoms can indicate stress, the nurse should help the child identify sources of stress and how to use stress reduction techniques. The parents are involved in the evaluation process.

A breastfed infant is being seen in the clinic for a 6-month checkup. The mother tells the nurse that the infant recently began to suck her thumb. Which is the best nursing intervention? a.Reassure the mother that this is normal at this age. b.Recommend the mother substitute a pacifier for her thumb. c.Assess the infant for other signs of sensory deprivation. d.Suggest the mother breastfeed the infant more often to satisfy her sucking needs.

ANS: A Sucking is an infant's chief pleasure, and the infant may not be satisfied by bottle-feeding or breastfeeding alone. During infancy and early childhood, there is no need to restrict nonnutritive sucking. The nurse should explore with the mother her feelings about a pacifier versus the thumb. No data support that the child has sensory deprivation.

What statement is correct about young children who report sexual abuse? a.They may exhibit various behavioral manifestations. b.In more than half the cases, the child has fabricated the story. c.Their stories should not be believed unless other evidence is apparent. d.They should be able to retell the story the same way to another person.

ANS: A Victims of sexual abuse have no typical profile. The child may exhibit various behavioral manifestations, none of which is diagnostic for sexual abuse. When children report potentially sexually abusive experiences, their reports need to be taken seriously. Other children in the household also need to be evaluated. In children who are sexually abused, it is often difficult to identify other evidence. In one study, approximately 96% of children who were sexually abused had normal genital and anal findings. The ability to retell the story is partly dependent on the child's cognitive level. Children who repeatedly tell identical stories may have been coached.

The nurse is checking reflexes on a 7-month-old infant. When the infant is suspended in a horizontal prone position, the head is raised and the legs and spine are extended. Which reflex is this? a.Landau b.Parachute c.Body righting d.Labyrinth righting

ANS: A When the infant is suspended in a horizontal prone position, the head is raised and the legs and spine are extended; this describes the Landau reflex. It appears at 6 to 8 months and persists until 12 to 24 months. The parachute reflex occurs when the infant is suspended in a horizontal prone position and suddenly thrust downward; the infant extends the hands and fingers forward as if to protect against falling. This appears at age 7 to 9 months and lasts indefinitely. Body righting occurs when turning the hips and shoulders to one side causes all other body parts to follow. It appears at 6 months of age and persists until 24 to 36 months. The labyrinth-righting reflex appears at 2 months and is strongest at 10 months. This reflex involves holding infants in the prone or supine position. They are able to raise their heads.

Girls experience an increase in weight and fat deposition during puberty. What do nursing considerations related to this include? a. Give reassurance that these changes are normal. b. Suggest dietary measures to control weight gain. c. Encourage a low-fat diet to prevent fat deposition. d. Recommend increased exercise to control weight gain.

ANS: A A certain amount of fat is increased along with lean body mass to fill the characteristic contours of the adolescent's gender. A healthy balance must be achieved between expected healthy weight gain and obesity. Suggesting dietary measures or increased exercise to control weight gain would not be recommended unless weight gain was excessive because eating disorders can develop in this group. Some fat deposition is essential for normal hormonal regulation. Menarche is delayed in girls with body fat contents that are too low.

The clinic nurse is reviewing statistics on infant mortality for the United States versus other countries. Compared with other countries that have a population of at least 25 million, the nurse makes which determination? a. The United States is ranked last among 27 countries. b. The United States is ranked similar to 20 other developed countries. c. The United States is ranked in the middle of 20 other developed countries. d. The United States is ranked highest among 27 other industrialized countries.

ANS: A Although the death rate has decreased, the United States still ranks last in infant mortality among nations with a population of at least 25 million. The United States has the highest infant death rate of developed nations.

28. The nurse is collecting a stool sample from an infant with lactose intolerance. Which fecal pH should the nurse expect as the result? a. 5.5 b. 7.0 c. 7.5 d. 8

ANS: A An acidic pH (5-5.5) indicates malabsorption, which occurs with lactose intolerance. The normal pH of the stool is 7.0 to 7.5. A finding of 8 would be alkaline. DIF: Cognitive Level: Analyzing REF: p. 462 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

Steven, 16 months old, falls down a few stairs. He gets up and "scolds" the stairs as if they caused him to fall. This is an example of which of the following? a. Animism b. Ritualism c. Irreversibility d. Delayed cognitive development

ANS: A Animism is the attribution of lifelike qualities to inanimate objects. By scolding the stairs, the toddler is attributing human characteristics to them. Ritualism is the need to maintain the sameness and reliability. It provides a sense of comfort to the toddler. Irreversibility is the inability to reverse or undo actions initiated physically. Steven is acting in an age-appropriate manner.

7. An infant has been diagnosed with an allergy to milk. In teaching the parent how to meet the infant's nutritional needs, the nurse states that a. Most children will grow out of the allergy. b. All dairy products must be eliminated from the child's diet. c. It is important to have the entire family follow the special diet. d. Antihistamines can be used so the child can have milk products.

ANS: A Approximately 80 percent of children with cow's milk allergy develop tolerance by the fifth birthday. The child can have eggs. Any food that has milk as a component or filler is eliminated. These foods include processed meats, salad dressings, soups, and milk chocolate. Having the entire family follow the special diet would provide support for the child, but the nutritional needs of other family members must be addressed. Antihistamines are not used for food allergies. DIF: Cognitive Level: Applying REF: p. 460 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity

What is most descriptive of the spiritual development of older adolescents? a. Beliefs become more abstract. b. Rituals and practices become increasingly important. c. Strict observance of religious customs is common. d. Emphasis is placed on external manifestations, such as whether a person goes to church.

ANS: A Because of their abstract thinking abilities, adolescents are able to interpret analogies and symbols. Rituals, practices, and strict observance of religious customs become less important as adolescents question values and ideals of families. Adolescents question external manifestations when not supported by adherence to supportive behaviors.

25. The nurse is teaching a parent with a 2-month-old infant who has been diagnosed with colic about ways to relieve colic. Which statement by the parent indicates the need for additional teaching? a. "I should let my infant cry for at least 30 minutes before I respond." b. "I will swaddle my infant tightly with a soft blanket." c. "I should massage my infant's abdomen whenever possible." d. "I will place my infant in an upright seat after feeding."

ANS: A Because the infant has been diagnosed with colic, the parent should respond to the infant immediately or any type of interventions to relieve colic may not be effective. Also, the infant may develop a mistrust of the world if his or her needs are not met. The parent should swaddle the baby tightly with a soft blanket, massage the baby's abdomen, and place the infant in an upright seat after a feeding to help relieve colic. DIF: Cognitive Level: Applying REF: p. 471 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity

By which age should the nurse expect that most children could obey prepositional phrases such as "under," "on top of," "beside," and "behind"? a. 18 months b. 24 months c. 3 years d. 4 years

ANS: D At 4 years, children can understand directional phrases. Children at 18 months, 24 months, and 3 years are too young. DIF: Cognitive Level: Understand REF: p. 385 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance

The nurse is describing clinical reasoning to a group of nursing students. Which is most descriptive of clinical reasoning? a. Purposeful and goal directed b. A simple developmental process c. Based on deliberate and irrational thought d. Assists individuals in guessing what is most appropriate

ANS: A Clinical reasoning is a complex developmental process based on rational and deliberate thought. When thinking is clear, precise, accurate, relevant, consistent, and fair, a logical connection develops between the elements of thought and the problem at hand.

11. The parent of an infant with colic tells the nurse, "All this baby does is scream at me; it is a constant worry." What is the nurse's best action? a. Encourage the parent to verbalize feelings. b. Encourage the parent not to worry so much. c. Assess the parent for other signs of inadequate parenting. d. Reassure the parent that colic rarely lasts past age 9 months.

ANS: A Colic is multifactorial, and no single treatment is effective for all infants. The parent is verbalizing concern and worry. The nurse should allow the parent to put these feelings into words. An empathetic, gentle, and reassuring attitude, in addition to suggestions about remedies, will help alleviate the parent's anxiety. The nurse should reassure the parent that he or she is not doing anything wrong. The infant with colic is experiencing spasmodic pain that is manifested by loud crying, in some cases up to 3 hours each day. Telling the parent that it will eventually go away does not help him or her through the current situation. DIF: Cognitive Level: Applying REF: p. 479 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

Which is the leading cause of death in infants younger than 1 year in the United States? a. Congenital anomalies b. Sudden infant death syndrome c. Disorders related to short gestation and low birth weight d. Maternal complications specific to the perinatal period

ANS: A Congenital anomalies account for 20.1% of deaths in infants younger than 1 year compared with sudden infant death syndrome, which accounts for 8.2%; disorders related to short gestation and unspecified low birth weight, which account for 16.5%; and maternal complications such as infections specific to the perinatal period, which account for 6.1% of deaths in infants younger than 1 year of age.

Which accurately describes the speech of the preschool child? a. Dysfluency in speech patterns is normal. b. Sentence structure and grammatic usage are limited. c. By age 5 years, child can be expected to have a ] vocabulary of about 1000 words. d. Rate of vocabulary acquisition keeps pace with the degree of comprehension of speech.

ANS: A Dysfluency includes stuttering and stammering, a normal characteristic of language development. Children speak in sentences of three or four words at age 3 to 4 years and eight words by age 5 years. At 5 years, children have a vocabulary of 2100 words. Children often gain vocabulary beyond degree of comprehension. DIF: Cognitive Level: Understand REF: p. 389 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance

The most fatal type of burn in the toddler age group is: a. flame burn from playing with matches. b. scald burn from high-temperature tap water. c. hot object burn from cigarettes or irons. d. electric burn from electric outlets.

ANS: A Flame burns from matches and lighters represent one of the most fatal types of burns in the toddler age group. High-temperature tap water, hot objects, and electrical outlets are all significant causes of burn injury. The child should be protected from these causes by reducing the temperature on the hot water in the home, keeping objects such as cigarettes and irons away from children, and placing protective guards over electric outlets when not in use.

Which is the leading cause of death during the toddler period? a. Injuries b. Infectious diseases c. Congenital disorders d. Childhood diseases

ANS: A Injuries are the single most common cause of death in children ages 1 through 4 years. This represents the highest rate of death from injuries of any childhood age group except adolescence. Infectious diseases and childhood diseases are less common causes of deaths in this age group. Congenital disorders are the second leading cause of death in this age group.

2. Which factors will decrease iron absorption and should not be given at the same time as an iron supplement? a. Milk b. Fruit juice c. Multivitamin d. Meat, fish, poultry

ANS: A Many foods interfere with iron absorption and should be avoided when iron is consumed. These foods include phosphates found in milk, phytates found in cereals, and oxalates found in many vegetables. Vitamin C-containing juices enhance the absorption of iron. Multivitamins may contain iron; no contraindication exists to taking the two together. Meat, fish, and poultry do not affect absorption. DIF: Cognitive Level: Understanding REF: p. 454 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

Parents tell the nurse that their toddler daughter eats little at mealtime, only sits at the table with the family briefly, and wants snacks "all the time." Which intervention should the nurse recommend? a. Give her nutritious snacks. b. Offer rewards for eating at mealtimes. c. Avoid snacks so she is hungry at mealtimes. d. Explain to her in a firm manner what is expected of her.

ANS: A Most toddlers exhibit a physiologic anorexia in response to the decreased nutritional requirement associated with the slower growth rate. Parents should help the child develop healthy eating habits. The toddler is often unable to sit through a meal. Frequent nutritious snacks are a good way to ensure proper nutrition. To help with developing healthy eating habits, food should be not be used as positive or negative reinforcement for behavior. The child may develop habits of overeating or eat nonnutritious foods in response.

12. What may a clinical manifestations of failure to thrive (FTT) in a 13-month-old include? a. Irregularity in activities of daily living b. Preferring solid food to milk or formula c. Weight that is at or below the 10th percentile d. Appropriate achievement of developmental landmarks

ANS: A One of the clinical manifestations of children with FTT is irregularity or low rhythmicity in activities of daily living. Children with FTT often refuse to switch from liquids to solid foods. Weight below the fifth percentile is indicative of FTT. Developmental delays, including social, motor, adaptive, and language, exist. DIF: Cognitive Level: Understanding REF: p. 462 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

The nurse is aware that which age group is at risk for childhood injury because of the cognitive characteristic of magical and egocentric thinking? a. Preschool b. Young school age c. Middle school age d. Adolescent

ANS: A Preschool children have the cognitive characteristic of magical and egocentric thinking, meaning they are unable to comprehend danger to self or others. Young and middle school-aged children have transitional cognitive processes, and they may attempt dangerous acts without detailed planning but recognize danger to themselves or others. Adolescents have formal operational cognitive processes and are preoccupied with abstract thinking

6. At a well-child check-up, the nurse notes that an infant with a previous diagnosis of failure to thrive (FTT) is now steadily gaining weight. The nurse should recommend that fruit juice intake be limited to no more than how much? a. 4 oz/day b. 6 oz/day c. 8 oz/day d. 12 oz/day

ANS: A Restrict juice intake in children with FTT until adequate weight gain has been achieved with appropriate milk sources; thereafter, give no more than 4 oz/day of juice. DIF: Cognitive Level: Understanding REF: p. 465 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

20. Parents are concerned that their child is showing aggressive behaviors. Which suggestion should the nurse make to the parents? a. Supervise television viewing. b. Ignore the behavior. c. Punish the child for the behavior. d. Accept the behavior if the child is male.

ANS: A Television is also a significant source for modeling at this impressionable age. Research indicates there is a direct correlation between media exposure, both violent and educational media, and preschoolers exhibiting physical and relational aggression (Ostrov, Gentile, and Crick, 2006). Therefore, parents should be encouraged to supervise television viewing. The behavior should not be ignored because it can escalate to hyperaggression. The child should not be punished because it may reinforce the behavior if the child is seeking attention. For example, children who are ignored by a parent until they hit a sibling or the parent learn that this act garners attention. The behavior should not be accepted from a male child; this is using a "double standard" and aggression should not be equated with masculinity. DIF: Cognitive Level: Apply REF: p. 383 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance

How does the onset of the pubertal growth spurt compare in girls and boys? a. In girls, it occurs about 1 year before it appears in boys. b. In girls, it occurs about 3 years before it appears in boys. c. In boys. it occurs about 1 year before it appears in girls. d. It is about the same in both boys and girls.

ANS: A The average age of onset is 9 1/2 years for girls and 10 1/2 years for boys. Although pubertal growth spurts may occur in girls 3 years before it appears in boys on an individual basis, the average difference is 1 year. Usually girls begin their pubertal growth spurt earlier than boys.

The parents of a 2-year-old tell the nurse that they are concerned because the toddler has started to use "baby talk" since the arrival of their new baby. The nurse should recommend which intervention? a. Ignore the "baby talk." b. Explain to the toddler that "baby talk" is for babies. c. Tell the toddler frequently, "You are a big kid now." d. Encourage the toddler to practice more advanced patterns of speech.

ANS: A The baby talk is a sign of regression in the toddler. It should be ignored, while praising the child for developmentally appropriate behaviors. Regression is children's way of expressing stress. The parents should not introduce new expectations and allow the child to master the developmental tasks without criticism.

Which technique is best for dealing with the negativism of the toddler? a. Offer the child choices. b. Remain serious and intent. c. Provide few or no choices for child. d. Quietly and calmly ask the child to comply.

ANS: A The child should have few opportunities to respond in a negative manner. Questions and requests should provide choices. This allows the child to be in control and reduces opportunities for negativism. The child will continue trying to assert control. The toddler is too young for verbal explanations. The negativism is the child testing limits. These should be clearly defined by structured choices.

The parent of a 16-month-old toddler asks, "What is the best way to keep our son from getting into our medicines at home?" The nurse's best advice is: a. "All medicines should be locked securely away." b. "The medicines should be placed in high cabinets." c. "The child just needs to be taught not to touch medicines." d. "Medicines should not be kept in the homes of small children."

ANS: A The major reason for poisoning in the home is improper storage. Toddlers can climb, unlatch cabinets, and obtain access to high-security places. For medications, only a locked cabinet is safe. Toddlers can climb by using furniture. High places are not a deterrent to an exploring toddler. Toddlers are not able to generalize as dangerous all the different forms of medications that may be available in the home. It is not feasible to not keep medicines in the homes of small children. Many parents require medications for chronic illnesses. Parents must be taught safe storage for their home and when they visit other homes.

The nurse is planning a teaching session to adolescents about deaths by unintentional injuries. Which should the nurse include in the session with regard to deaths caused by injuries? a. More deaths occur in males. b. More deaths occur in females. c. The pattern of deaths does not vary according to age and sex. d. The pattern of deaths does not vary widely among different ethnic groups.

ANS: A The majority of deaths from unintentional injuries occur in males. The pattern of death does vary greatly among different ethnic groups, and the causes of unintentional deaths vary with age and gender.

A nurse places some x-ray contrast the toddler is to drink in a small cup instead of a large cup. Which concept of a toddler's preoperational thinking is the nurse using? a. Inability to conserve b. Magical thinking c. Centration d. Irreversibility

ANS: A The nurse is using the toddler's inability to conserve. This is when the toddler is unable to understand the idea that a mass can be changed in size, shape, volume, or length without losing or adding to the original mass. Instead, toddlers judge what they see by the immediate perceptual clues given to them. A small glass means less amount of contrast. Magical thinking is believing that thoughts are all-powerful and can cause events. Centration is focusing on one aspect rather than considering all possible alternatives. Irreversibility is the inability to undo or reverse the actions initiated, such as being unable to stop doing an action when told.

19. The parents of a 3-month-old infant report that their infant sleeps supine (face up) but is often prone (face down) while awake. The nurse's response should be based on remembering what? a. This is acceptable to encourage head control and turning over. b. This is acceptable to encourage fine motor development. c. This is unacceptable because of the risk of sudden infant death syndrome (SIDS). d. This is unacceptable because it does not encourage achievement of developmental milestones.

ANS: A These parents are implementing the guidelines to reduce the risk of SIDS. Infants should sleep on their backs to reduce the risk of SIDS and then be placed on their abdomens when awake to enhance achievement of milestones such as head control. These position changes encourage gross motor, not fine motor, development. DIF: Cognitive Level: Analyzing REF: p. 473 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity

A parent of an 18-month-old boy tells the nurse that he says "no" to everything and has rapid mood swings. If he is scolded, he shows anger and then immediately wants to be held. The nurse's best interpretation of this behavior is included in which statement? a. This is normal behavior for his age. b. This is unusual behavior for his age. c. He is not effectively coping with stress. d. He is showing he needs more attention.

ANS: A Toddlers use distinct behaviors in the quest for autonomy. They express their will with continued negativity and the use of the word "no." Children at this age also have rapid mood swings. The nurse should reassure the parents that their child is engaged in expected behavior for an 18-month-old. Having a rapid mood swing is an expected behavior for a toddler.

According to Erikson, the psychosocial task of adolescence is developing what? a. Identity b. Intimacy c. Initiative d. Independence

ANS: A Traditional psychosocial theory holds that the developmental crises of adolescence lead to the formation of a sense of identity. Intimacy is the developmental stage for early adulthood. Independence is not one of Erikson's developmental stages.

Which is a useful skill that the nurse should expect a 5-year-old child to be able to master? a. Tie shoelaces b. Use knife to cut meat c. Hammer a nail d. Make change out of a quarter

ANS: A Tying shoelaces is a fine motor task of 5-year-olds. Using a knife to cut meat is a fine motor task of a 7-year-old. Hammering a nail and making change out of a quarter are fine motor and cognitive tasks of an 8- to 9-year-old. DIF: Cognitive Level: Understand REF: p. 386 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance

The nurse is talking to a group of parents of school-age children at an after-school program about childhood health problems. Which statement should the nurse include in the teaching? a. Childhood obesity is the most common nutritional problem among children. b. Immunization rates are the same among children of different races and ethnicity. c. Dental caries is not a problem commonly seen in children since the introduction of fluoridated water. d. Mental health problems are typically not seen in school-age children but may be diagnosed in adolescents.

ANS: A When teaching parents of school-age children about childhood health problems, the nurse should include information about childhood obesity because it is the most common problem among children and is associated with type 2 diabetes. Teaching parents about ways to prevent obesity is important to include. Immunization rates differ depending on the child's race and ethnicity; dental caries continues to be a common chronic disease in childhood; and mental health problems are seen in children as young as school age, not just in adolescents.

8. Lactose intolerance is diagnosed in an 11-month-old infant. Which should the nurse recommend as a milk substitute? a. Yogurt b. Ice cream c. Fortified cereal d. Cow's milk-based formula

ANS: A Yogurt contains the inactive lactase enzyme, which is activated by the temperature and pH of the duodenum. This lactase activity substitutes for the lack of endogenous lactase. Ice cream and cow's milk-based formula contain lactose, which will probably not be tolerated by the child. Fortified cereal does not have the nutritional equivalents of milk. DIF: Cognitive Level: Applying REF: p. 462 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity

What are the goals of organized athletics for preadolescent children? (Select all that apply.) a. Physical fitness b. Basic motor skills c. A positive self-image d. Commitment to winning

ANS: A, B, C The goals of organized athletics for preadolescent children include physical fitness, basic motor skills, and a positive self-image. The commitment is to the values of teamwork, fair play, and sportsmanship, not to winning.

3. The nurse has administered a dose of epinephrine to a 12-month-old infant. For which adverse reactions of epinephrine should the nurse monitor? (Select all that apply.) a. Nausea b. Tremors c. Irritability d. Bradycardia e. Hypotension

ANS: A, B, C Epinephrine increases activation of the sympathetic nervous system. Adverse effects include nausea, tremors, and irritability. Tachycardia would occur, not bradycardia, and hypertension, not hypotension, would occur. DIF: Cognitive Level: Applying REF: p. 459 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

The nurse is conducting a teaching session for parents on nutrition. Which characteristics of families should the nurse consider that can cause families to struggle in providing adequate nutrition? (Select all that apply.) a. Homelessness b. Lower income c. Migrant status d. Working parents e. Single parent status

ANS: A, B, C Families that struggle with lower incomes, homelessness, and migrant status generally lack the resources to provide their children with adequate food intake, nutritious foods such as fresh fruits and vegetables, and appropriate protein intake. Working parents and single parent status do not mean the families will struggle to provide adequate nutrition.

The nurse is planning strategies to assist difficult or easily distracted children when they participate in activities. What strategies should the nurse plan? (Select all that apply.) a. Role-play before the activity. b. Handle behavior with firmness. c. Acquaint them with what to expect. d. Be patient with inappropriate behavior. e. Dont give them much information about the activity.

ANS: A, B, C, D Difficult or easily distracted children may benefit from practice sessions in which they are prepared for a given event by role-playing, visiting the site, reading or listening to stories, or using other methods to acquaint them with what to expect. Nurses need to handle children with difficult temperaments with exceptional patience, firmness, and understanding so they can learn appropriate behavior in their interactions with others.

The school nurse is evaluating the number of school-age children classified as obese. The nurse recognizes that the percentile of body mass index that classifies a child as obese is greater than which? a. 50th percentile b. 75th percentile c. 80th percentile d. 95th percentile

ANS: D Obesity in children and adolescents is defined as a body mass index at or greater than the 95th percentile for youth of the same age and gender.

The nurse is caring for a child with neurofibromatosis. What local manifestations does the nurse expect to assess in this child? (Select all that apply.) a. Pigmented nevi b. Axillary freckling c. Café-au-lait spots d. Slowly growing cutaneous neurofibromas e. Wheals that spread irregularly and fade within a few hours

ANS: A, B, C, D Local manifestations of neurofibromatosis include pigmented nevi, axillary freckling, café-au-lait spots, and slowly growing cutaneous neurofibromas. Wheals that spread irregularly and fade within a few hours are characteristic of urticaria.

The school nurse recognizes that students who are targeted for repeated harassment and bullying may exhibit what? (Select all that apply.) a. Skip school b. Attempt suicide c. Bring weapons to school d. Attend extracurricular activities e. Report symptoms of depression

ANS: A, B, C, E Students targeted for repeated teasing and harassment are more likely to skip school, to report symptoms of depression, and to attempt suicide. Equally troubling, teens who are regularly harassed or bullied are also more likely to bring weapons to school to feel safe. Students who are bullied do not want to attend extracurricular activities.

The nurse is planning play activities for a 2-month-old hospitalized infant to stimulate the auditory sense. Which activities should the nurse implement? (Select all that apply.) a.Talk to the infant. b.Play a music box. c.Place a squeaky doll in the crib. d.Give the infant a small-handled clear rattle.

ANS: A, B, D Auditory stimulation appropriate for a 2-month-old infant includes talking to the infant, playing a music box, and giving the infant a small-handled clear rattle. Placing a squeaky doll in the crib is appropriate for an infant 6 months of age or older.

The nurse is teaching a school-age child about factors that can delay wound healing. What factors should the nurse include in the teaching session? (Select all that apply.) a. Deficient vitamin C b. Deficient vitamin D c. Increased circulation d. Dry wound environment e. Increase in white blood cells

ANS: A, B, D Factors that delay wound healing are a dry wound environment (allows epithelial cells to dry), deficient vitamin C (inhibits formation of collagen fibers), and deficient vitamin D (regulates growth and differentiation of cell types). Decreased, not increased, circulation delays healing. An increase in the white blood cell count may occur but does not delay healing.

The school nurse is assessing a child's severely scraped knee for infection. What are signs of a wound infection? (Select all that apply.) a. Odor b. Edema c. Dry scab d. Purulent exudate e. Decreased temperature

ANS: A, B, D Signs of wound infection are odor, edema, and purulent exudate. Increased, not decreased, temperature indicates infection. A dry scab over the wound is part of the healing process.

Which actions by the nurse demonstrate overinvolvement with patients and their families? (Select all that apply.) a. Buying clothes for the patients b. Showing favoritism toward a patient c. Focusing on technical aspects of care d. Spending off-duty time with patients and families e. Asking questions if families are not participating in care

ANS: A, B, D Actions that show overinvolvement include buying clothes for patients, showing favoritism toward a patient, and spending off-duty time with patients and families. Focusing on technical aspects of care is an action that indicates underinvolvement, and asking questions if families are not participating in care indicates a positive action.

What are characteristics of middle adolescence (15-17 years) with regard to relationships with peers? (Select all that apply.) a. Behavioral standards set by peer group b. Acceptance of peers extremely important c. Seeks peer affiliations to counter instability d. Exploration of ability to attract opposite sex e. Peer group recedes in importance in favor of individual friendship

ANS: A, B, D Characteristics of middle adolescence relationships with peers include behavioral standards set by the peer group, acceptance of peers is extremely important, and exploration of the ability to attract opposite sex. Seeking peer affiliations to counter instability is a characteristic of early adolescence relationships with peers. Peer groups receding in importance in favor of individual friendships is characteristic of late adolescence relationships with peers.

5. The nurse is preparing to feed a 10-month-old child diagnosed with failure to thrive (FTT). Which actions should the nurse plan to implement? (Select all that apply.) a. Be persistent. b. Introduce new foods slowly. c. Provide a stimulating atmosphere. d. Maintain a calm, even temperament. e. Feed the infant only when signs of hunger are exhibited.

ANS: A, B, D Feeding strategies for children with FTT should include persistence; introducing new foods slowly; and maintaining a calm, even temperament. The environment should be unstimulating, and a structured routine should be developed with regard to feeding, not just when the infant shows signs of hunger. DIF: Cognitive Level: Applying REF: p. 463 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

Which should the nurse teach to parents regarding oral health of children? (Select all that apply.) a. Fluoridated water should be used. b. Early childhood caries is a preventable disease. c. Dental caries is a rare chronic disease of childhood. d. Dental hygiene should begin with the first tooth eruption. e. Childhood caries does not happen until after 2 years of age.

ANS: A, B, D Oral health instructions to parents of children should include use of fluoridated water and dental hygiene beginning with the first tooth eruption. In addition, early childhood caries is a preventable disease and should be included in the teaching session. Dental caries is a common, not rare, chronic disease of childhood. Childhood caries may begin before the first birthday.

The nurse is reviewing the Healthy People 2020 leading health indicators for a child health promotion program. Which are included in the leading health indicators? (Select all that apply.) a. Decrease tobacco use. b. Improve immunization rates. c. Reduce incidences of cancer. d. Increase access to health care. e. Decrease the number of eating disorders.

ANS: A, B, D The Healthy People 2020 leading health indicators provide a framework for identifying essential components for child health promotion programs designed to prevent future health problems in our nation's children. Some of the leading health indicators include decreasing tobacco use, improving immunization rates, and increasing access to health care. Reducing the incidence of cancer and decreasing the number of eating disorders are not on the list as leading health indicators.

Which toys should a nurse provide to promote imaginative play for a 3-year- old hospitalized child? (Select all that apply.) a. Plastic telephone b. Hand puppets c. Jigsaw puzzle (100 pieces) d. Farm animals and equipment e. Jump rope

ANS: A, B, D To promote imaginative play for a 3-year-old child, the nurse should provide: dress-up clothes, dolls, housekeeping toys, dollhouses, play-store toys, telephones, farm animals and equipment, village sets, trains, trucks, cars, planes, hand puppets, or medical kits. A 100-piece jigsaw puzzle and a jump rope would be appropriate for a young, school-age child but not a 3-year-old child. DIF: Cognitive Level: Apply REF: p. 383 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance

An adolescent asks the nurse about the "safety of getting a tattoo." The nurse explains to the adolescent that it is important to find a qualified operator using proper sterile technique because an unsterilized needle or contaminated tattoo ink can cause what? (Select all that apply.) a. Hepatitis C virus b. Hepatitis B virus c. Hepatitis E virus d. Human immunodeficiency virus (HIV) e. Mycobacterium chelonae skin infections

ANS: A, B, D, E Using the same unsterilized needle to tattoo body parts of multiple teenagers presents the same risk for human immunodeficiency virus (HIV), hepatitis C virus, and hepatitis B virus transmission as occurs with other needle-sharing activities. Contaminated tattoo ink can cause nontuberculous M. chelonae skin infections. The hepatitis E virus is transmitted via the fecal-oral route, principally via contaminated water, not by contaminated needles.

The nurse is evaluating a 7-month-old infant's cognitive development. Which behaviors should the nurse anticipate evaluating? (Select all that apply.) a.Imitates sounds b.Shows interest in a mirror image c.Comprehends simple commands d.Actively searches for a hidden object e.Attracts attention by methods other than crying

ANS: A, B, E A 7-month-old infant is in the secondary circular reactions (4-8 months) stage of cognitive development. Behaviors in this stage include imitating sounds, showing interest in a mirror image, and attracting attention by methods other than crying. Comprehending simple commands and actively searching for a hidden object are behaviors seen in the coordination of secondary schemas (9-12 months).

The nurse is providing anticipatory guidance to parents of a 4-month-old infant on preventing an aspiration injury. What should the nurse include in the teaching? (Select all that apply.) a.Keep baby powder out of reach. b.Inspect toys for removable parts. c.Allow the infant to take a bottle to bed. d.Teething biscuits can be used for teething discomfort. e.The infant should not be fed hard candy, nuts, or foods with pits.

ANS: A, B, E Anticipatory guidance to prevent aspiration for a 4-month-old infant takes into account that the infant will begin to be more active and place objects in the mouth. Toys should be checked for removable parts; baby powder should be kept out of reach; and hard candy, nuts, and foods with pits should be avoided. The infant should not go to bed with a bottle. Teething biscuits should be used with caution because large chunks may be broken off and aspirated.

What growth and development milestones are expected between the ages of 8 and 9 years? (Select all that apply.) a. Can help with routine household tasks b. Likes the reward system for accomplished tasks c. Uses the telephone for practical purposes d. Chooses friends more selectively e. Goes about home and community freely, alone or with friends

ANS: A, B, E Children between the age of 8 and 9 years accomplish many growth and development milestones, including helping with routine household tasks, liking the reward system when a task is accomplished well, and going out with friends or alone more independently and freely. Using the telephone for practical reasons, choosing friends more selectively, and finding enjoyment in family with new-found respect for parents are tasks accomplished between the ages of 10 and 12 years.

Parents of an adolescent ask the school nurse, "It is OK for our adolescent to get a job?" The nurse should answer telling the parents the effects of adolescents who work more than 20 hours a week are what? (Select all that apply.) a. Can lead to fatigue b. Can lead to poorer grades c. Improves an interest in school d. Enhances development and identity e. Can reduce extracurricular involvement

ANS: A, B, E Detrimental effects are likely for adolescents who work more than 20 hours a week. Greater involvement in work can lead to fatigue, decreased interest in school, reduced extracurricular involvement, and poorer grades. Involvement in work may take time away from other activities that could contribute to identity development. Adolescent work as it exists today may negatively affect development.

What guidelines should the nurse use when interviewing adolescents? (Select all that apply.) a. Ensure privacy. b. Use open-ended questions. c. Share your thoughts and assumptions. d. Explain that all interactions will be confidential. e. Begin with less sensitive issues and proceed to more sensitive ones.

ANS: A, B, E Guidelines for interviewing adolescents include ensuring privacy, using open-ended questions, and beginning with less sensitive issues and proceeding to more sensitive ones. The nurse should not share thoughts but maintain objectivity and should avoid assumptions, judgments, and lectures. It may not be possible for all interactions to be confidential. Limits of confidentiality include a legal duty to report physical or sexual abuse and to get others involved if an adolescent is suicidal.

1. The nurse is planning care for an infant with eczema. Which interventions should the nurse include in the care plan? (Select all that apply.) a. Avoid giving the infant a bubble bath. b. Avoid the use of a humidifier in the infant's room. c. Avoid overdressing the infant. d. Avoid the use of topical steroids on the infant's skin. e. Avoid wet compresses on the infant's most affected areas.

ANS: A, C Guidelines for care of an infant with eczema include avoiding a bubble bath and harsh soaps and avoiding overdressing the infant to prevent perspiration, which can cause a flare-up. The care plan should include using a humidifier in the infant's room, topical steroids, and wet compresses on the most affected areas. DIF: Cognitive Level: Applying REF: p. 469 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

A school-age child has been a victim of bullying. What characteristics does the nurse assess for in this child? (Select all that apply.) a. Anxiety b. Outgoing c. Low self-esteem d. Psychosomatic complaints e. Good academic performance

ANS: A, C, D Victims of bullying are at increased risk for low self-esteem; anxiety; depression; feelings of insecurity and loneliness; poor academic performance; and psychosomatic complaints such as feeling tense, tired, or dizzy.

Which gross motor milestones should the nurse assess in an 18-month-old child? (Select all that apply.) a. Jumps in place with both feet b. Takes a few steps on tiptoe c. Throws ball overhand without falling d. Pulls and pushes toys e. Stands on one foot momentarily

ANS: A, C, D An 18-month-old child can jump in place with both feet, throw a ball overhand without falling, and pull and push toys. Taking a few steps on tiptoe and standing on one foot momentarily is not acquired until 30 months of age.

The nurse is providing anticipatory guidance to parents of an 8-month-old infant on preventing a drowning injury. Which should the nurse include in the teaching? (Select all that apply.) a.Fence swimming pools. b.Keep bathroom doors open. c.Eliminate unnecessary pools of water. d.Keep one hand on the child while in the tub. e.Supervise the child when near any source of water.

ANS: A, C, D, E Anticipatory guidance to prevent drowning for an 8-month-old infant takes into account that the child will begin to crawl, cruise around furniture, walk, and climb. Fences should be placed around swimming pools, unnecessary pools of water should be eliminated, one hand should be kept on the child when bathing, and the child should be supervised when near any source of water. The bathroom doors should be kept closed.

The nurse is preparing to complete documentation on a patient's chart. Which should be included in documentation of nursing care? (Select all that apply.) a. Reassessments b. Incident reports c. Initial assessments d. Nursing care provided e. Patient's response of care provided

ANS: A, C, D, E The patient's medical record should include: initial assessments, reassessments, nursing care provided, and the patient's response of care provided. Incident reports are not documented in the patient's chart.

The nurse is providing anticipatory guidance to the parents of a 1-month-old infant on preventing a suffocation injury. Which should the nurse include in the teaching? (Select all that apply.) a.Do not place pillows in the infant's crib. b.Crib slats should be 4 inches or less apart. c.Keep all plastic bags stored out of the infant's reach. d.Plastic over the mattress is acceptable if it is covered with a sheet. e.A pacifier should not be tied on a string around the infant's neck.

ANS: A, C, E Anticipatory guidance for a 1-month-old infant to prevent a suffocation injury takes into account that the infant will have increased eye-hand coordination and a voluntary grasp reflex as well as a crawling reflex that may propel the infant forward or backward. Pillows should not be placed in the infant's crib, plastic bags should be kept out of reach, and a pacifier should not be tied on a string around the neck. Crib slats should be 2.4 inches apart (4 inches is too wide), and the mattress should not be covered with plastic even if a sheet is used to cover it.

Parents are concerned about their child riding an all-terrain vehicle. What should the nurse tell the parents about safe use of all-terrain vehicles? (Select all that apply.) a. Restrict riding to familiar terrain. b. Limit street use to the neighborhood. c. Nighttime riding should not be allowed. d. Vehicles should not carry more than two persons. e. Vehicles should include seat belts, roll bars, and automatic headlights.

ANS: A, C, E Safe use of all-terrain vehicles includes restricting riding to familiar terrain; not allowing nighttime riding; and assuring the vehicle has seat belts, roll bars, and automatic headlights. Street use should not be allowed, and the vehicle should not carry more than one person.

Which responsibilities are included in the pediatric nurse's promotion of the health and well-being of children? (Select all that apply.) a. Promoting disease prevention b. Providing financial assistance c. Providing support and counseling d. Establishing lifelong friendships e. Establishing a therapeutic relationship f. Participating in ethical decision making

ANS: A, C, E, F The pediatric nurse's role includes promoting disease prevention, providing support and counseling, establishing a therapeutic relationship, and participating in ethical decision making; a pediatric nurse does not need to establish lifelong friendships or provide financial assistance to children and their families. Boundaries should be set and clear.

The nurse is teaching parents of a school-age child how to cleanse small wounds. What should the nurse advise the parents to avoid using to cleanse a wound? (Select all that apply.) a. Alcohol b. Normal saline c. Tepid water d. Povidone-iodine e. Hydrogen peroxide

ANS: A, D, E Caution caregivers to avoid cleansing the wound with povidone-iodine, alcohol, and hydrogen peroxide because these products disrupt wound healing. Normal saline and tepid water are safe to use when cleansing wounds.

The nurse is planning strategies to assist a slow-to-warm child to try new experiences. What strategies should the nurse plan? (Select all that apply.) a. Attend after-school activities with a friend. b. Suggest the child move quickly into a new situation. c. Avoid trying new experiences until the child is ready. d. Allow the child to adapt to the experience at his or her own pace. e. Contract for permission to withdraw after a trial of the experience.

ANS: A, D, E The nurse should encourage slow-to-warm children to try new experiences but allow them to adapt to their surroundings at their own speed. Pressure to move quickly into new situations only strengthens their tendency to withdraw. After-school activities can be a cause for reaction, but attending with a friend or contracting for permission to withdraw after a trial of a specified number of times may provide them with sufficient incentive to try.

6. The nurse is teaching parents about foods that are hyperallergenic. Which foods should the nurse include? (Select all that apply.) a. Peanuts b. Bananas c. Potatoes d. Egg noodles e. Tomato juice

ANS: A, D, E Hyperallergenic foods include peanuts, egg noodles, and tomato juice. Bananas and potatoes are not hyperallergenic. DIF: Cognitive Level: Applying REF: p. 470 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

7. The nurse is teaching parents about potential causes of colic in infancy. Which should the nurse include in the teaching session? (Select all that apply.) a. Overeating b. Understimulation c. Frequent burping d. Parental smoking e. Swallowing excessive air

ANS: A, D, E Potential causes of colic include too rapid feeding, overeating, swallowing excessive air, improper feeding technique (especially in positioning and burping), emotional stress or tension between the parent and child, parental smoking, and overstimulation. DIF: Cognitive Level: Applying REF: p. 470 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

The nurse is explaining the purpose of using a vacuum-assisted closure (VAC) device to assist in the healing of a wound. What should the nurse explain as the purpose of using a VAC device? a. The device will decrease capillary flow. b. The device applies gentle continuous suction. c. The device will allow the wound to remain open. d. The device will prevent the formation of granulation tissue.

ANS: B A VAC device uses a technique that involves placing a foam dressing into the wound, covering it with an occlusive dressing, and applying gentle continuous suction. The negative pressure of the suction is applied from the foam dressing to the wound surfaces. The mechanical force removes excess fluids from the wound, stimulates formation of granulation tissue, restores capillary flow, and fosters closure of the wound.

The parent of an 8.2-kg (18-lb) 9-month-old infant is borrowing a federally approved car seat from the clinic. The nurse should explain that the safest way to put in the car seat is what? a.Front facing in back seat b.Rear facing in back seat c.Front facing in front seat with air bag on passenger side d.Rear facing in front seat if an air bag is on the passenger side

ANS: B A rear-facing car seat provides the best protection for an infant's disproportionately heavy head and weak neck. The middle of the back seat is the safest position for the child. Severe injuries and deaths in children have occurred from air bags deploying on impact in the front passenger seat.

A 6-year-old boy with very fair skin will be joining his family during a beach vacation. What should the nurse recommend? a. Keep him off the beach during the daytime hours. b. Use sunscreen with an SPF of at least 15 and reapply it every 2 to 3 hours. c. Apply a topical sunscreen product with an SPF of 30 in the morning. d. Dress him in long pants and long-sleeved shirt and keep him under a beach umbrella

ANS: B A sunscreen with an SPF (sun protection factor) of at least 15 is recommended. The sunscreen should be reapplied every 2 to 3 hours and after the child is in the water or sweating excessively. During a beach vacation, avoiding the beach during daytime hours is impractical. The highest risk of sun exposure is from 10 AM to 3 PM. Sunlight exposure should be limited during this time. An SPF of 30 is good, but reapplying it is necessary every 2 to 3 hours and when the child gets wet. Long pants and a shirt are impractical. The beach umbrella can be used with the sunscreen to limit exposure to the sun.

An awake, alert 4-year-old child has just arrived at the emergency department after an ingestion of aspirin at home. The practitioner has ordered activated charcoal. The nurse administers charcoal in which manner? a. Giving half of the solution and then repeating the other half in 1 hour b. Mixing with a flavorful beverage in an opaque container with a straw c. Serving it in a clear plastic cup so the child can see how much has been drunk d. Administering it through a nasogastric tube because the child will not drink it because of the taste

ANS: B Although activated charcoal can be mixed with a flavorful sugar-free beverage, it will be black and resemble mud. When it is served in an opaque container, the child will not have any preconceived ideas about its being distasteful. The ability to see the charcoal solution may affect the child's desire to drink the solution. The child should be encouraged to drink the solution all at once. The nasogastric tube would be traumatic. It should be used only in children who cannot be cooperative or those without a gag reflex.

At which age should the nurse expect an infant to begin smiling in response to pleasurable stimuli? a.1 month b.2 months c.3 months d.4 months

ANS: B At age 2 months, the infant has a social, responsive smile. A reflex smile is usually present at age 1 month. A 3-month-old infant can recognize familiar faces. At age 4 months, infants can enjoy social interactions.

A male school-age student asks the school nurse, How much with my height increase in a year? The nurse should give which response? a. Your height will increase on average 1 inch a year. b. Your height will increase on average 2 inches a year. c. Your height will increase on average 3 inches a year. d. Your height will increase on average 4 inches a year.

ANS: B Between the ages of 6 and 12 years, children grow an average of 5 cm (2 inches) per year.

A child is admitted to the hospital with lesions on his abdomen that appear like cigarette burns. What should accurate documentation by the nurse include? a.Two unhealed lesions are on the child's abdomen. b.Two round 4-mm lesions are on the child's lower abdomen. c.Two round symmetrical lesions are on the child's lower abdomen. d.Two round lesions on the child's abdomen that appear to be cigarette burns.

ANS: B Burn documentation should include the location, pattern, demarcation lines, and presence of eschar or blisters. The option that includes the size of the lesions is the most accurate.

The nurse is interviewing the father of a 10-month-old girl. The child is playing on the floor when she notices an electrical outlet and reaches up to touch it. Her father says "no" firmly and moves her away from the outlet. The nurse should use this opportunity to teach the father what? a.That the child should be given a time-out b.That the child is old enough to understand the word "no" c.That the child will learn safety issues better if she is spanked d.That the child should already know that electrical outlets are dangerous

ANS: B By age 10 months, children are able to associate meaning with words. The father is using both verbal and physical cues to alert the child to dangerous situations. A time-out is not appropriate. The child is just learning about the environment. Physical discipline should be avoided. The 10-month-old child is too young to understand the purpose of an electrical outlet.

The school nurse is providing guidance to families of children who are entering elementary school. What is essential information to include? a. Meet with teachers only at scheduled conferences. b. Encourage growth of a sense of responsibility in children. c. Provide tutoring for children to ensure mastery of material. d. Homework should be done as soon as child comes home from school.

ANS: B By being responsible for school work, children learn to keep promises, meet deadlines, and succeed in their jobs as adults. Parents should meet with the teachers at the beginning of the school year, for scheduled conferences, and whenever information about the child or parental concerns needs to be shared. Tutoring should be provided only in special circumstances in elementary school, such as in response to prolonged absence. The parent should not dictate the study time but should establish guidelines to ensure that homework is done.

What is the most common form of child maltreatment? a. Sexual abuse b. Child neglect c. Physical abuse d. Emotional abuse

ANS: B Child neglect, which is characterized by the failure to provide for the child's basic needs, is the most common form of child maltreatment. Sexual abuse, physical abuse, and emotional abuse are individually not as common as neglect.

The parents of a 7-year-old boy tell the nurse that lately he has been cruel to their family pets and actually caused physical harm. The nurse's recommendation should be based on remembering what? a. This is an expected behavior at this age. b. This is a warning sign of a serious problem. c. This is harmless venting of anger and frustration. d. This is common in children who are physically abused.

ANS: B Cruelty to family pets is not an expected behavior. Hurting animals can be one of the earliest symptoms of a conduct disorder. Abusing animals does not dissipate violent emotions; rather, the acts may fuel the abusive behaviors. Referral for evaluation is essential. This behavior may be seen in emotional abuse or neglect, not physical abuse

The clinic nurse is teaching parents about physiologic anemia that occurs in infants. What statement should the nurse include about the cause of physiologic anemia? a.Maternally derived iron stores are depleted in the first 2 months. b.Fetal hemoglobin results in a shortened survival of red blood cells. c.The production of adult hemoglobin decreases in the first year of life. d.Low levels of fetal hemoglobin depress the production of erythropoietin.

ANS: B Fetal hemoglobin results in a shortened survival of red blood cells (RBCs) and thus a decreased number of RBCs. Maternally derived iron stores are present for the first 5 to 6 months results in a shortened survival of RBCs and thus a decreased number of RBCs. High levels of fetal hemoglobin depress the production of erythropoietin, a hormone released by the kidney that stimulates RBC production.

Parents are concerned that their 6-year-old son continues to occasionally wet the bed. What does the nurse explain? a. This is likely because of increased stress at home. b. Enuresis usually ceases between 6 and 8 years of age. c. Drug therapy will be prescribed to treat the enuresis. d. Testing will be necessary to determine what type of kidney problem exists

ANS: B Further data must be gathered before the diagnosis of enuresis is made. Enuresis is the inappropriate voiding of urine at least twice a week. This child does meet the age criterion, but the parents need to be questioned about and keep a diary on the frequency of events. If the bedwetting is infrequent, parents can be encouraged that the child may grow out of this behavior. Drug therapy will not be prescribed until a more complete evaluation is done. Additional assessment information must be gathered, but at this time, there is no indication of renal disease.

What is a clinical manifestation of acetaminophen poisoning? a. Hyperpyrexia b. Hepatic involvement c. Severe burning pain in stomach d. Drooling and inability to clear secretions

ANS: B Hepatic involvement is the third stage of acetaminophen poisoning. Hyperpyrexia is a severe elevation in body temperature and is not related to acetaminophen poisoning. Acetaminophen does not cause burning pain in stomach and does not pose an airway threat.

What is descriptive of the social development of school-age children? a. Identification with peers is minimum. b. Children frequently have best friends. c. Boys and girls play equally with each other. d. Peer approval is not yet an influence for the child to conform.

ANS: B Identification with peers is a strong influence in childrens gaining independence from parents. Interaction among peers leads to the formation of close friendships with same-sex peersbest friends. Daily relationships with age mates in the school setting provide important social interactions for school-age children. During the later school years, groups are composed predominantly of children of the same sex. Conforming to the rules of the peer group provides children with a sense of security and relieves them of the responsibility of making decisions.

Parents phone the nurse and say that their child just knocked out a permanent tooth. What should the nurse's instructions to the parents include? a. Place the tooth in dry container for transport. b. Hold the tooth by the crown and not by the root area. c. Transport the child and tooth to a dentist within 18 hours. d. Take the child to hospital emergency department if his or her mouth is bleeding

ANS: B It is important to avoid touching the root area of the tooth. The tooth should be held by the crown area; rinsed in milk, saline, or running water; and reimplanted as soon as possible. The tooth is kept moist during transport to maintain viability. Cold milk is the most desirable medium for transport. The child needs to be seen by a dentist as soon as possible. Tooth evulsion causes a large amount of bleeding. The child will need to be seen by a dentist because of the loss of a tooth, not the bleeding.

The development of sexual orientation during adolescence is what? a. Inflexible b. A developmental process c. Differs for boys and girls d. Proceeds in a defined sequence

ANS: B The development of sexual orientation as a part of sexual identity includes several developmental milestones during late childhood and throughout adolescence. The sequence and time spent in phases are different for each individual. Boys and girls pass through the same developmental milestones.

The nurse is discussing development and play activities with the parent of a 2-month-old boy. Which statement by the parent would indicate a correct understanding of the teaching? a."I can give my baby a ball of yarn to pull apart or different textured fabrics to feel." b."I can use a music box and soft mobiles as appropriate play activities for my baby." c."I should introduce a cup and spoon or push-pull toys for my baby at this age." d."I do not have to worry about appropriate play activities at this age."

ANS: B Music boxes and soft mobiles are appropriate play activities for a 2-month-old infant. A ball of yarn to pull apart or different textured fabrics are appropriate for an infant at 6 to 9 months. A cup and spoon or push-pull toys are appropriate for an older infant. Infants of all ages should be exposed to appropriate types of stimulation.

A toddler has a deep laceration contaminated with dirt and sand. Before closing the wound, the nurse should irrigate with what solution? a. Alcohol b. Normal saline c. Povidone-iodine d. Hydrogen peroxid

ANS: B Normal saline is the only acceptable fluid for irrigation listed. The nurse should cleanse the wound with a forced stream of normal saline or water. Alcohol is not used for wound irrigation. Povidone-iodine is contraindicated for cleansing fresh, open wounds. Hydrogen peroxide can cause formation of subcutaneous gas when applied under pressure.

The parents of a 2-month-old boy are concerned about spoiling their son by picking him up when he cries. What is the nurse's best response? a."Allow him to cry for no longer than 15 minutes and then pick him up." b."Babies need comforting and cuddling. Meeting these needs will not spoil him." c."Babies this young cry when they are hungry. Try feeding him when he cries." d."If he isn't soiled or wet, leave him, and he'll cry himself to sleep."

ANS: B Parents need to learn that a "spoiled child" is a response to inconsistent discipline and limit setting. It is important to meet the infant's developmental needs, including comforting and cuddling. The data suggest that responding to a child's crying can actually decrease the overall crying time. Allowing him to cry for no longer than 15 minutes and then picking him up will reinforce prolonged crying. Infants at this age have other needs besides feeding. The parents should be taught to identify their infant's cues. Counseling parents on letting the baby cry himself to sleep when not soiled or wet refers to sleep issues, not general infant behavior.

What is the best age to introduce solid food into an infant's diet? a.2 to 3 months b.4 to 6 months c.When birth weight has tripled d.When tooth eruption has started

ANS: B Physiologically and developmentally, 4- to 6-month-old infants are in a transition period. The extrusion reflex has disappeared, and swallowing is a more coordinated process. In addition, the gastrointestinal tract has matured sufficiently to handle more complex nutrients and is less sensitive to potentially allergenic food. Infants of this age will try to help during feeding. Two to 3 months is too young. The extrusion reflex is strong, and the child will push food out with the tongue. No research indicates that the addition of solid food to a bottle has any benefit. Infant birth weight doubles at 1 year. Solid foods can be started earlier. Tooth eruption can facilitate biting and chewing; most infant foods do not require this ability.

What is a significant secondary prevention nursing activity for lead poisoning? a. Chelation therapy b. Screening children for blood lead levels c. Removing lead-based paint from older homes d. Questioning parents about ethnic remedies containing lead

ANS: B Screening children for lead poisoning is an important secondary prevention activity. Screening does not prevent the initial exposure of the child to lead. It can lead to identification and treatment of children who are exposed. Chelation therapy is treatment, not prevention. Removing lead-based paints from older homes before children are affected is primary prevention. Questioning parents about ethnic remedies containing lead is part of the assessment to determine the potential source of lead.

A child has been admitted to the hospital with a blood lead level of 72 mcg/dL. What treatment should the nurse anticipate? a.Referral to social services b.Initiation of chelation therapy c.Follow-up testing within 1 month d.Aggressive environmental intervention

ANS: B Severe lead toxicity (lead level ?5=70 mcg/dL) requires immediate inpatient chelation treatment. Referral to social service and follow-up in 1 month are prescribed for lead levels of 15 to 19 mcg/dL. Aggressive environmental intervention would be initiated after chelation treatments.

A 3-month-old infant dies shortly after arrival to the emergency department. The infant has subdural and retinal hemorrhages but no external signs of trauma. What should the nurse suspect? a. Unintentional injury b. Shaken baby syndrome c. Congenital neurologic problem d.Sudden infant death syndrome (SIDS)

ANS: B Shaken baby syndrome causes internal bleeding but may have no external signs. Unintentional injury would not cause these injuries. With unintentional injuries, external signs are usually present. Congenital neurologic problems would usually have signs of abnormal neurologic anatomy. SIDS does not usually have identifiable injuries.

A school-age child has begun to sleepwalk. What does the nurse advise the parents to perform? a. Wake the child and help determine what is wrong. b. Leave the child alone unless he or she is in danger of harming him- or herself or others. c. Arrange for psychologic evaluation to identify the cause of stress. d. Keep the child awake later in the evening to ensure sufficient tiredness for a full night of sleep.

ANS: B Sleepwalking is usually self-limiting and requires no treatment. The child usually moves about restlessly and then returns to bed. Usually the actions are repetitive and clumsy. The child should not be awakened unless in danger. If there is a need to awaken the child, it should be done by calling the childs name to gradually bring to a state of alertness. Some children, who are usually well behaved and tend to repress feelings, may sleepwalk because of strong emotions. These children usually respond to relaxation techniques before bedtime. If a child is overly fatigued, sleepwalking can increase.

The American Academy of Pediatrics (AAP) recommends that children younger than the age of 16 years be prohibited from participating in what? a. Skateboarding b. Snowmobiling c. Trampoline use d. Horseback riding

ANS: B The AAP views the use of snowmobiles and all-terrain vehicles as major health hazards for children. This group opposes the use of these vehicles by children younger than 16 years of age. The AAP recommends that children younger than the age of 10 years not use skateboards without parental supervision. Protective gear is always suggested. Trampoline use has increased along with injuries. Adults should supervise use. Horseback riding injuries are also a source of concern. Parents should determine the instructors safety record with students.

A child has had contact with some poison ivy. The school nurse understands that the full-blown reaction should be evident after how many days? a. 1 day b. 2 days c. 3 days d. 4 days

ANS: B The full-blown reaction to poison ivy is evident after about 2 days, with linear patches or streaks of erythemic, raised, fluid-filled vesicles; swelling; and persistent itching at the site of contact.

A school-age child has been bitten on the leg by a large snake that may be poisonous. During transport to an emergency facility, what should the care include? a. Apply ice to the snakebite. b. Immobilize the leg with a splint. c. Place a loose tourniquet distal to the bite. d. Apply warm compresses to the snakebite

ANS: B The leg should be immobilized. Ice decreases blood flow to the area, which allows the venom to work more destruction and decreases the effect of antivenin on the natural immune mechanisms. A loose tourniquet is placed proximal, not distal, to the area of the bite to delay the flow of lymph. This can delay movement of the venom into the peripheral circulation. The tourniquet should be applied so that a pulse can be felt distal to the bite. Warmth increases circulation to the area and helps the toxin into the peripheral circulation.

What is an important consideration for the school nurse who is planning a class on bicycle safety? a. Most bicycle injuries involve collision with an automobile. b. Head injuries are the major causes of bicycle-related fatalities. c. Children should wear a bicycle helmet if they ride on paved streets. d. Children should not ride double unless the bicycle has an extra large seat.

ANS: B The most important aspect of bicycle safety is to encourage the rider to use a protective helmet. Head injuries are the major cause of bicycle-related fatalities. Although motor vehicle collisions do cause injuries to bicyclists, most injuries result from falls. The child should always wear a properly fitted helmet approved by the U.S. Consumer Product Safety Commission. Children should not ride double unless it is a tandem bike (built for two).

The mother of a 6-month-old infant has returned to work and is expressing breast milk to be frozen. She asks for directions on how to safely thaw the breast milk in the microwave. What should the nurse recommend? a.Heat only 10 oz or more. b.Do not thaw or heat breast milk in a microwave oven. c.Always leave the bottle top uncovered to allow heat to escape. d.Shake the bottle vigorously for at least 30 seconds after heating.

ANS: B Using a microwave oven to thaw or heat breast milk decreases the anti-infective properties of the breast milk, lowers the vitamin C content, and changes the fat content. Breast milk should be thawed overnight in a refrigerator or in a warm water bath. A microwave should not be used. If steam is created, the milk is too hot. The bottle should be inverted several times after defrosting or warming.

A father calls the clinic because he found his young daughter squirting Visine eyedrops into her mouth. What is the most appropriate nursing action? a. Reassure the father that Visine is harmless. b. Direct him to seek immediate medical treatment. c. Recommend inducing vomiting with ipecac. d. Advise him to dilute Visine by giving his daughter several glasses of water to drink.

ANS: B Visine is a sympathomimetic and if ingested may cause serious consequences. Medical treatment is necessary. Inducing vomiting is no longer recommended for ingestions. Dilution will not decrease risk.

When teaching injury prevention during the school-age years, what should the nurse include? a. Teach children about the need to fear strangers. b. Teach basic rules of water safety. c. Avoid letting children cook in microwave ovens. d. Caution children against engaging in competitive sports.

ANS: B Water safety instruction is an important component of injury prevention at this age. The child should be taught to swim, select safe and supervised places to swim, swim with a companion, check sufficient water depth for diving, and use an approved flotation device. Teach stranger safety, not fear of strangers. This includes telling the child not to go with strangers, not to wear personalized clothing in public places, to tell parents if anyone makes child feel uncomfortable, and to say no in uncomfortable situations. Teach the child safe cooking. Caution against engaging in dangerous sports such as jumping on trampolines.

The nurse is caring for a hospitalized 4-year-old boy. His parents tell the nurse that they will be back to visit at 6 PM. When the child asks the nurse when his parents are coming, the nurse's best response is a. "They will be here soon." b. "They will come after dinner." c. "Let me show you on the clock when 6 PM is." d. "I will tell you every time I see you how much longer it will be."

ANS: B A 4-year-old child understands time in relation to events such as meals. Children perceive "soon" as a very short time. The nurse may lose the child's trust if his parents do not return in the time he perceives as "soon." Children cannot read or use a clock for practical purposes until age 7 years. I will tell you every time I see you how much longer it will be assumes the child understands the concepts of hours and minutes, which are not developed until age 5 or 6 years. DIF: Cognitive Level: Apply REF: p. 385 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Health Promotion and Maintenance

22. What is an important nursing responsibility when dealing with a family experiencing the loss of an infant from sudden infant death syndrome (SIDS)? a. Discourage the parents from making a last visit with the infant. b. Make a follow-up home visit to the parents as soon as possible after the child's death. c. Explain how SIDS could have been predicted and prevented. d. Interview the parents in depth concerning the circumstances surrounding the child's death.

ANS: B A competent, qualified professional should visit the family at home as soon as possible after the death. Printed information about SIDS should be provided to the family. Parents should be allowed and encouraged to make a last visit with their child. SIDS cannot always be prevented or predicted, but parents can take steps to reduce the risk (e.g., supine sleeping, removing blankets and pillows from the crib, and not smoking). Discussions about the cause only increase parental guilt. The parents should be asked only factual questions to determine the cause of death. DIF: Cognitive Level: Analyzing REF: p. 477 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

The parent of a 4-year-old boy tells the nurse that the child believes that monsters and boogeymen are in his bedroom at night. What is the nurse's best suggestion for coping with this problem? a. Let the child sleep with his parents. b. Keep a night-light on in the child's bedroom. c. Help the child understand that these fears are illogical. d. Tell the child frequently that monsters and boogeymen do not exist.

ANS: B A night-light shows a child that imaginary creatures do not lurk in the darkness. Letting the child sleep with parents will not get rid of the fears. A 4-year-old child is in the preconceptual age and cannot understand logical thought. DIF: Cognitive Level: Apply REF: p. 388 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance

What aspects of cognition develop during adolescence? a. Ability to see things from the point of view of another b. Capability of using a future time perspective c. Capability of placing things in a sensible and logical order d. Progress from making judgments based on what they see to making judgments based on what they reason

ANS: B Adolescents are no longer restricted to the real and actual. They also are concerned with the possible; they think beyond the present. During concrete operations (between ages 7 and 11 years), children exhibit thought processes that enable them to see things from the point of view of another, place things in a sensible and logical order, and progress from making judgments based on what they see to making judgments based on what they reason.

Which is descriptive of a toddler's cognitive development at age 20 months? a. Searches for an object only if he or she sees it being hidden b. Realizes that "out of sight" is not out of reach c. Puts objects into a container but cannot take them out d. Understands the passage of time, such as "just a minute" and "in an hour"

ANS: B At this age, the child is in the final sensorimotor stage. Children will now search for an object in several potential places, even though they saw only the original hiding place. Children have a more developed sense of objective permanence. They will search for objects even if they have not seen them hidden. When a child puts objects into a container but cannot take them out, this is indicative of tertiary circular reactions. An embryonic sense of time exists, although the children may behave appropriately to time-oriented phrases; their sense of timing is exaggerated.

An adolescent patient wants to make decisions about treatment options, along with his parents. Which moral value is the nurse displaying when supporting the adolescent to make decisions? a. Justice b. Autonomy c. Beneficence d. Nonmaleficence

ANS: B Autonomy is the patient's right to be self-governing. The adolescent is trying to be autonomous, so the nurse is supporting this value. Justice is the concept of fairness. Beneficence is the obligation to promote the patient's well-being. Nonmaleficence is the obligation to minimize or prevent harm

The school nurse is assessing children for risk factors related to childhood injuries. Which child has the most risk factors related to childhood injury? a. Female, multiple siblings, stable home life b. Male, high activity level, stressful home life c. Male, even tempered, history of previous injuries d. Female, reacts negatively to new situations, no serious previous injuries

ANS: B Boys have a preponderance for injuries over girls because of a difference in behavioral characteristics, a high activity temperament is associated with risk-taking behaviors, and stress predisposes children to increased risk taking and self-destructive behaviors. Therefore, a male child with a high activity level and living in a stressful environment has the highest number of risk factors. A girl with several siblings and a stable home life is low risk. A boy with previous injuries has two risk factors, but an even temper is not a risk factor for injuries. A girl who reacts negatively to new situations but has no previous serious illnesses has only one risk factor.

13. Which one of the following strategies might be recommended for an infant with failure to thrive (FTT) to increase caloric intake? a. Vary the schedule for routine activities on a daily basis. b. Be persistent through 10 to 15 minutes of food refusal. c. Avoid solids until after the bottle is well accepted. d. Use developmental stimulation by a specialist during feedings.

ANS: B Calm perseverance through 10 to 15 minutes of food refusal will eventually diminish negative behavior. Children with FTT need a structured routine to help establish rhythmicity in their activities of daily living. Many children with FTT are fed exclusively from a bottle. Solids should be fed first. Stimulation is reduced during mealtimes to maintain the focus on eating. DIF: Cognitive Level: Understanding REF: p. 465 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

Which situation denotes a nontherapeutic nurse-patient-family relationship? a. The nurse is planning to read a favorite fairy tale to a patient. b. During shift report, the nurse is criticizing parents for not visiting their child. c. The nurse is discussing with a fellow nurse the emotional draw to a certain patient. d. The nurse is working with a family to find ways to decrease the family's dependence on health care providers.

ANS: B Criticizing parents for not visiting in shift report is nontherapeutic and shows an underinvolvement with the parents. Reading a fairy tale is a therapeutic and age appropriate action. Discussing feelings of an emotional draw with a fellow nurse is therapeutic and shows a willingness to understand feelings. Working with parents to decrease dependence on health care providers is therapeutic and helps to empower the family

The nurse is assessing the Tanner stage in an adolescent female. The nurse recognizes that the stages are based on which? a. The stages of vaginal changes b. The progression of menstrual cycles to regularity c. Breast size and the shape and distribution of pubic hair d. The development of fat deposits around the hips and buttocks

ANS: C In females, the Tanner stages describe pubertal development based on breast size and the shape and distribution of pubic hair. The stages of vaginal changes, progression of menstrual cycles to regularity, and the development of fat deposits occur during puberty but are not used for the Tanner stages.

Which should the nurse expect for a toddler's language development at age 18 months? a. Vocabulary of 25 words b. Increasing level of comprehension c. Use of holophrases d. Approximately one third of speech understandable

ANS: B During the second year of life, level of comprehension and understanding of speech increases and is far greater than the child's vocabulary. This is also true for bilingual children, who are able to achieve this linguistic milestone in both languages. The 18-month-old child has a vocabulary of 10 or more words. At this age, the child does not use the one-word sentences that are characteristic of the 1-year-old child. The child has a limited vocabulary of single words that are comprehensible.

Evidence-based practice (EBP), a decision-making model, is best described as which? a. Using information in textbooks to guide care b. Combining knowledge with clinical experience and intuition c. Using a professional code of ethics as a means for decision making d. Gathering all evidence that applies to the child's health and family situation

ANS: B EBP helps focus on measurable outcomes; the use of demonstrated, effective interventions; and questioning what is the best approach. EBP involves decision making based on data, not all evidence on a particular situation, and involves the latest available data. Nurses can use textbooks to determine areas of concern and potential involvement.

A 12-year-old girl asks the nurse about an increase in clear white odorless vaginal discharge. What response should the nurse give? a. "This may mean a yeast infection." b. "This is normal before menstruation starts." c. "This is caused by an increase in progesterone." d. "This is possibly a sign of a sexually transmitted infection."

ANS: B Early in puberty, there is often an increase in normal vaginal discharge (physiologic leukorrhea) associated with uterine development. Girls or their parents may be concerned that this vaginal discharge is a sign of infection. The nurse can reassure them that the discharge is normal and a sign that the uterus is preparing for menstruation. It is caused by an increase in estrogen, not progesterone

27. A bottle-fed infant has been diagnosed with cow's milk allergy. Which formula should the nurse expect to be prescribed for the infant? a. Similac b. Pregestimil c. Enfamil with iron d. Gerber Good Start

ANS: B For infants with cow's milk allergy, the formula will be changed to a casein hydrolysate milk formula (Pregestimil, Nutramigen, or Alimentum) in which the protein has been broken down into its amino acids through enzymatic hydrolysis. Similac, Enfamil with iron, and Gerber Good Start are cow's milk-based formulas. DIF: Cognitive Level: Applying REF: p. 461 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

The most effective way to clean a toddler's teeth is for the: a. child to brush regularly with a toothpaste of his or her choice. b. parent to stabilize the chin with one hand and brush with the other. c. parent to brush the mandibular occlusive surfaces, leaving the rest for the child. d. parent to brush the front labial surfaces, leaving the rest for the child.

ANS: B For young children, the most effective cleaning of teeth is by the parents. Different positions can be used if the child's back is to the adult. The adult should use one hand to stabilize the chin and the other to brush the child's teeth. The child can participate in brushing, but for a thorough cleaning, adult intervention is necessary.

A nurse, instructing parents of a hospitalized preschool child, explains that which is descriptive of the preschooler's understanding of time? a. Has no understanding of time b. Associates time with events c. Can tell time on a clock d. Uses terms like "yesterday" appropriately

ANS: B In a preschooler's understanding, time has a relation with events such as "We'll go outside after lunch." Preschoolers develop an abstract sense of time at age 3 years. Children can tell time on a clock at age 7 years. Children do not fully understand use of time-oriented words until age 6 years. DIF: Cognitive Level: Understand REF: p. 385 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance

Kimberly's parents have been using a rearward-facing, convertible car seat since she was born. Most car seats can be safely switched to the forward-facing position when the child reaches which age? a. 1 b. 2 c. 3 d. 4

ANS: B It is now recommended that all infants and toddlers ride in rear-facing car safety seats until they reach the age of 2 years or height recommended by the car seat manufacturer. Children 2 years old and older who have outgrown the rear-facing height or weight limit for their car safety seat should use a forward-facing car safety seat with a harness up to the maximum height or weight recommended by the manufacturer. One year is too young to switch to a forward-facing position.

What do mortality statistics describe? a. Disease occurring regularly within a geographic location b. The number of individuals who have died over a specific period c. The prevalence of specific illness in the population at a particular time d. Disease occurring in more than the number of expected cases in a community

ANS: B Mortality statistics refer to the number of individuals who have died over a specific period. Morbidity statistics show the prevalence of specific illness in the population at a particular time. Data regarding disease within a geographic region, or in greater than expected numbers in a community, may be extrapolated from analyzing the morbidity statistics

20. After the introduction of the Back to Sleep campaign in 1992, an increased incidence has been noted of which pediatric issues? a. Sudden infant death syndrome (SIDS) b. Plagiocephaly c. Failure to thrive d. Apnea of infancy

ANS: B Plagiocephaly is a misshapen head caused by the prolonged pressure on one side of the skull. If that side becomes misshapen, facial asymmetry may result. SIDS has decreased by more than 40 percent with the introduction of the Back to Sleep campaign. Apnea of infancy and failure to thrive are unrelated to the Back to Sleep campaign. DIF: Cognitive Level: Understanding REF: p. 478 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

Two toddlers are playing in a sandbox when one child suddenly grabs a toy from the other child. Which is the best interpretation of this behavior? a. This is typical behavior because toddlers are aggressive. b. This is typical behavior because toddlers are egocentric. c. Toddlers should know that sharing toys is expected of them. d. Toddlers should have the cognitive ability to know right from wrong.

ANS: B Play develops from the solitary play of infancy to the parallel play of toddlers. The toddler plays alongside other children, not with them. This typical behavior of the toddler is not intentionally aggressive. Shared play is not within their cognitive development. Toddlers do not conceptualize shared play. Because the toddler cannot view the situation from the perspective of the other child, it is okay to take the toy. Therefore, no right or wrong is associated with taking a toy.

Which play item should the nurse bring from the playroom to a hospitalized toddler in isolation? a. Small plastic Lego b. Set of large plastic building blocks c. Brightly colored balloon d. Coloring book and crayons

ANS: B Play objects for toddlers must still be chosen with an awareness of danger from small parts. Large, sturdy toys without sharp edges or removable parts are safest. Large plastic blocks are appropriate for a toddler in isolation. Small plastic toys such as Lego can cause choking or can be aspirated. Balloons can cause significant harm if swallowed or aspirated. Coloring book and crayons would be too advanced for a toddler.

A 4-year-old child is hospitalized with a serious bacterial infection. The child tells the nurse that he is sick because he was "bad." Which is the nurse's best interpretation of this comment? a. Sign of stress b. Common at this age c. Suggestive of maladaptation d. Suggestive of excessive discipline at home

ANS: B Preschoolers cannot understand the cause and effect of illness. Their egocentrism makes them think they are directly responsible for events, making them feel guilty for things outside their control. Children of this age show stress by regressing developmentally or acting out. Maladaptation is unlikely. Telling the nurse that he is sick because he was "bad" does not imply excessive discipline at home. DIF: Cognitive Level: Analyze REF: p. 385 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance

Which is an appropriate recommendation for preventing tooth decay in young children? a. Substitute raisins for candy. b. Substitute sugarless gum for regular gum. c. Use honey or molasses instead of refined sugar. d. When sweets are to be eaten, select a time not during meals.

ANS: B Regular gum has high sugar content. When the child chews gum, the sugar is in prolonged contact with the teeth. Sugarless gum is less cariogenic than regular gum. Raisins, honey, and molasses are highly cariogenic and should be avoided. Sweets should be consumed with meals so that the teeth can be cleaned afterward. This decreases the amount of time that the sugar is in contact with the teeth.

A nurse is teaching parents about language development for preschool children. Which dysfunctional speech pattern is a normal characteristic the parents might expect? a. Lisp b. Stammering c. Echolalia d. Repetition without meaning

ANS: B Stammering and stuttering are normal dysfluency patterns in preschool-age children. Lisps are not a normal characteristic of language development. Echolalia and repetition are traits of toddlers' language. DIF: Cognitive Level: Apply REF: p. 389 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance

In addition to injuries, what are the leading causes of death in adolescents ages 15 to 19 years? a. Suicide and cancer b. Suicide and homicide c. Drowning and cancer d. Homicide and heart disease

ANS: B Suicide and homicide account for 16.7% of deaths in this age group. Suicide and cancer account for 10.9% of deaths, heart disease and cancer account for approximately 5.5%, and homicide and heart disease account for 10.9% of the deaths in this age group.

What is true concerning masturbation during adolescence? a. Homosexuality is encouraged by the practice of masturbation. b. Many girls do not begin masturbation until after they have intercourse. c. Masturbation at an early age leads to sexual intercourse at an earlier age. d. Development of intimate relationships is delayed when masturbation is regularly practiced.

ANS: B The age of first masturbation for girls is variable. Some begin masturbating in early adolescence; many do not begin until after they have had intercourse. Boys typically begin masturbation in early adolescence. Masturbation provides an opportunity for self-exploration. Both heterosexual and homosexual youth use masturbation. It does not affect the development of intimacy.

24. A parent brings a 12-month-old infant into the emergency department and tells the nurse that the infant is allergic to peanuts and was accidentally given a cookie with peanuts in it. The infant is dyspneic, wheezing, and cyanotic. The health care provider has prescribed a dose of epinephrine to be administered. The infant weighs 24 lb. How many milligrams of epinephrine should be administered? a. 0.11 to 0.33 mg b. 0.011 to 0.3 mg c. 1.1 to 3.3 mg d. 11 to 33 mg

ANS: B The correct dose of epinephrine to use in the emergency management of an anaphylactic reaction is 0.001 mg/kg up to a maximum of 0.3 mg, giving a range of 0.011 to 0.3 mg using a weight of 11 kg (24 lb). DIF: Cognitive Level: Applying REF: p. 459 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

18. The nurse is discussing the management of atopic dermatitis (eczema) with a parent. What should be included? a. Dress infant warmly to prevent chilling. b. Keep the infant's fingernails and toenails cut short and clean. c. Give bubble baths instead of washing lesions with soap. d. Launder clothes in mild detergent; use fabric softener in the rinse.

ANS: B The infant's nails should be kept short and clean and have no sharp edges. Gloves or cotton socks can be placed over the child's hands and pinned to the shirt sleeves. Heat and humidity increase perspiration, which can exacerbate the eczema. The child should be dressed properly for the climate. Synthetic material (not wool) should be used for the child's clothing during cold months. Baths are given as prescribed with tepid water, and emollients such as Aquaphor, Cetaphil, and Eucerin are applied within 3 minutes. Soap (except as indicated), bubble bath oils, and powders are avoided. Fabric softener should be avoided because of the irritant effects of some of its components. DIF: Cognitive Level: Applying REF: p. 469 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity

Parents tell the nurse that they found their 3-year-old daughter and a male cousin of the same age inspecting each other closely as they used the bathroom. Which is the most appropriate recommendation the nurse should make? a. Punish children so this behavior stops. b. Neither condone nor condemn the curiosity. c. Allow children unrestricted permission to satisfy this curiosity. d. Get counseling for this unusual and dangerous behavior.

ANS: B Three-year-olds become aware of anatomic differences and are concerned about how the other "works." Such exploration should not be condoned or condemned. Children should not be punished for this normal exploration. Encouraging the children to ask questions of the parents and redirecting their activity are more appropriate than giving permission. Exploration is age- appropriate and not dangerous behavior. DIF: Cognitive Level: Apply REF: p. 387 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance

At which age does an infant start to recognize familiar faces and objects, such as his or her own hand? a.1 month b.2 months c.3 months d.4 months

ANS: C The child can recognize familiar objects at approximately age 3 months. For the first 2 months of life, infants watch and observe their surroundings. The 4-month-old infant is beginning to develop hand-eye coordination.

Which statement is correct about toilet training? a. Bladder training is usually accomplished before bowel training? b. Wanting to please the parent helps motivate the child to use the toilet. c. Watching older siblings use the toilet confuses the child. d. Children must be forced to sit on the toilet when first learning

ANS: B Voluntary control of the anal and urethral sphincters is achieved sometime after the child is walking. The child must be able to recognize the urge to let go and to hold on. The child must want to please parent by holding on rather than pleasing self by letting go. Bowel training precedes bladder training. Watching older siblings provides role modeling and facilitates imitation for the toddler. The child should be introduced to the potty chair or toilet in a nonthreatening manner.

Which are characteristic of physical development of a 30-month-old child? (Select all that apply.) a. Birth weight has doubled. b. Primary dentition is complete. c. Sphincter control is achieved. d. Anterior fontanel is open. e. Length from birth is doubled. f. Left or right handedness is established.

ANS: B, C Usually by age 30 months, the primary dentition of 20 teeth is completed, and the child has sphincter control in preparation for bowel and bladder control. Birth weight doubles at approximately ages 5 to 6 months. The anterior fontanel closes at age 12 to 18 months. Birth length is doubled around age 4. Left or right handedness is not established until about age 5.

The school nurse recognizes that children respond to stress by using which tactics? (Select all that apply.) a. Passivity b. Delinquency c. Daydreaming d. Delaying tactics e. Becoming outgoing

ANS: B, C, D Children respond to stress by using coping mechanisms that include internalizing symptoms such as withdrawal, delaying tactics, and daydreaming, along with externalizing symptoms such as aggression and delinquency.

The nurse is caring for a child with erythema multiforme (Stevens-Johnson syndrome). What local manifestations does the nurse expect to assess in this child? (Select all that apply.) a. Papular urticaria b. Erythematous papular rash c. Lesions absent in the scalp d. Lesions enlarge by peripheral expansion e. Firm papules that may be capped by vesicles

ANS: B, C, D Local manifestations of erythema multiforme include an erythematous popular rash, lesions involving most skin surfaces except the scalp and lesions that enlarge by peripheral expansion. Papular urticaria and firm papules capped by vesicles are characteristics of an insect bite.

The clinic nurse is assessing a 6-month-old infant during a well-child appointment. The nurse should use which approaches to alleviate the infant's stranger anxiety? (Select all that apply.) a.Talk in a loud voice. b.Meet the infant at eye level. c.Avoid sudden intrusive gestures. d.Maintain a safe distance initially. e.Pick up the infant and hold him or her closely.

ANS: B, C, D The best approaches for the nurse to alleviate the infant's stranger anxiety are to talk softly; meet the infant at eye level (to appear smaller); maintain a safe distance from the infant; and avoid sudden, intrusive gestures, such as holding out the arms and smiling broadly. Talking in a loud voice and picking the infant up would increase the infant's anxiety.

9. The nurse is teaching parents strategies to manage their child's refusal to go to sleep. Which should the nurse include in the teaching session? (Select all that apply.) a. Keep bedtime early. b. Enforce consistent limits. c. Use a reward system with the child. d. Have a consistent before bedtime routine.

ANS: B, C, D Strategies to manage a child's refusal to go to sleep include enforcement of consistent limits, using a reward system, and having a consistent before bedtime routine. An evaluation of whether the hour of sleep is too early should be considered because an early bedtime could cause the child to resist sleep if not tired. DIF: Cognitive Level: Applying REF: p. 472 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

The nurse is caring for a child with psoriasis. What local manifestations does the nurse expect to assess in this child? (Select all that apply.) a. Development of wheals b. First lesions appear in the scalp c. Round, thick, dry reddish patches d. Lesions appear in intergluteal folds e. Patches are covered with coarse, silvery scales

ANS: B, C, E Local manifestations of psoriasis include lesions that appear in the scalp initially and round, thick dry patches covered with coarse, silvery scales. Development of wheals is seen in urticaria. Lesions in intergluteal folds are characteristic of intertrigo.

The school nurse is explaining to older school children that obesity increases the risk for which disorders? (Select all that apply.) a. Asthma b. Hypertension c. Dyslipidemia d. Irritable bowel disease e. Altered glucose metabolism

ANS: B, C, E Overweight youth have increased risk for a cluster of cardiovascular factors that include hypertension, altered glucose metabolism, and dyslipidemia. Irritable bowel disease and asthma are not linked to obesity.

4. A 12-month-old infant has been diagnosed with failure to thrive (FTT). Which assessment findings does the nurse expect to be documented with this infant? (Select all that apply.) a. Fear of strangers b. Minimal smiling c. Avoidance of eye contact d. Meeting developmental milestones e. Wide-eyed gaze and continual scan of the environment

ANS: B, C, E Signs and symptoms of FTT include minimal smiling, avoidance of eye contact, and a wide-eyed gaze and continual scan of the environment ("radar gaze"). There is no fear of strangers, and there are developmental delays, including social, motor, adaptive, and language. DIF: Cognitive Level: Analyzing REF: p. 463 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance

Which should the nurse teach to parents of toddlers about accidental poison prevention? (Select all that apply.) a. Keep toxic substances in the garage. b. Discard empty poison containers. c. Know the number of the nearest poison control center. d. Remove colorful labels from containers of toxic substances. e. Caution child against eating nonedible items, such as plants.

ANS: B, C, E To prevent accidental poisoning, parents should be taught to promptly discard empty poison containers, know the number of the nearest poison control center and to caution the child against eating nonedible items, such as plants. Parents should place all potentially toxic agents, including cosmetics, personal care items, cleaning products, pesticides, and medications in a locked cabinet, not in the garage. Parents should be taught to never remove labels from containers of toxic substances.

The nurse is teaching a group of parents at a community education program about introducing solid foods to their infants. Which recommendations should the nurse include? (Select all that apply.) a.Spoon feeding should be introduced after an entire milk feeding. b.It is best to introduce a wide variety of foods during the first year. c.As solid food consumption increases, the quantity of milk should decrease. d.Introduction of low-calorie milk and food should be done by the end of the first year. e.Introduction of citrus fruits, meats, and eggs should be delayed until after 6 months of age. f.Each new food item should be introduced at 5- to 7-day intervals.

ANS: B, C, E, F Teaching related to feeding an infant solid foods should include introducing a wide variety of foods because an infant has not developed a strong food preference as seen with a toddler. As solid food consumption increases, the amount of milk consumed should decrease to less than 1 L/day to prevent overfeeding. Introduction to citrus fruits, meats, and eggs should be delayed until after 6 months of age because of the potential to cause food allergies. New foods should be introduced at 5- to 7-day intervals to evaluate for food allergies. Spoon feedings should be introduced after a small ingestion of milk, not at the end of a milk feeding, to associate the activity with pleasure. In general, low-calorie milk and food should be avoided.

The school nurse is teaching bicycle safety to a group of school-age children. What should the nurse include in the session? (Select all that apply.) a. Ride double file when possible. b. Watch for and yield to pedestrians. c. Only ride double with someone your own size. d. Ride bicycles with traffic away from parked cars. e. Keep both hands on the handlebars except when signaling.

ANS: B, D, E Bicycle safety includes watching for and yielding to pedestrians, riding bicycles with traffic away from parked cars, and keeping both hands on handlebars except when signaling. It is best to ride single file, not double file, and never to ride double on a bicycle.

Characteristics of bullies include what? (Select all that apply.) a. Female b. Depressed c. Good peer relationships d. Poor academic performance e. Exposed to domestic violence

ANS: B, D, E Children who are bullies are likely to be male, depressed, have poor academic performance, be exposed to domestic violence, have poor peer relationships, and have poor communication with their parents.

The emergency department nurse is admitting a child with a temperature of 35° C (95° F). What physical effects of hypothermia should the nurse expect to observe in this child? (Select all that apply.) a. Bradycardia b. Vigorous shivering c. Decreased respiratory rate d. Decreased intestinal motility e. Task performance is impaired

ANS: B, D, E Hypothermia has varying physical effects depending on the child's core temperature. At 35° C (95° F), a child would experience vigorous shivering, decreased intestinal motility, and task performance impairment. Bradycardia and decreased respiratory rate are physical effects observed as the body temperature continues to decrease.

The school nurse teaches adolescents that the detrimental long-term effects of tanning are what? (Select all that apply.) a. Vitamin D deficiency b. Premature aging of the skin c. Exacerbates acne outbreaks d. Increased risk for skin cancer e. Possible phototoxic reactions

ANS: B, D, E Adolescents should be educated regarding the detrimental effects of sunlight on the skin. Long-term effects include premature aging of the skin; increased risk for skin cancer; and, in susceptible individuals, phototoxic reactions. Exposure to levels of sunlight cause an increase in vitamin D production. Tanning can often reduce outbreaks of acne.

What are characteristics of dating relationships in early adolescence? (Select all that apply.) a. One-on-one dating b. Follow ritualized "scripts" c. Are psychosocially intimate d. Involve playing stereotypic roles e. Participating in mixed-gender group activities

ANS: B, D, E Early dating relationships typically follow highly ritualized "scripts" in which adolescents are more likely to play stereotypic roles than to really be themselves. Participating in mixed-gender group activities, such as going to parties or other events, may have a positive impact on young teenagers' well-being. One-on-one dating during early adolescence, however, with a lot of time spent alone, may lead to sexual intimacy before a teen is ready. Although teenagers may begin dating during early adolescence, these early dating relationships are not usually psychosocially intimate.

2. The community health nurse is reviewing risk factors for vitamin D deficiency. Which children are at high risk for vitamin D deficiency? (Select all that apply.) a. Children with fair pigmentation b. Children who are overweight or obese c. Children who are exclusively bottle fed d. Children with diets low in sources of vitamin D e. Children of families who use milk products not supplemented with vitamin D

ANS: B, D, E Populations at risk for vitamin D deficiency include overweight or obese children, children with diets low in sources of vitamin D, and children of families who use milk products not supplemented with vitamin D. Children with dark, not fair, pigmentation and children who are exclusively breast fed, not bottle fed, are also at risk. DIF: Cognitive Level: Analyzing REF: p. 453 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

In terms of language and cognitive development, a 4-year-old child would be expected to have which traits? (Select all that apply.) a. Think in abstract terms. b. Follow directional commands. c. Understand conservation of matter. d. Use sentences of eight words. e. Tell exaggerated stories. f. Comprehend another person's perspective.

ANS: B, E Children ages 3 to 4 years can give and follow simple commands and tell exaggerated stories. Children cannot think abstractly at age 4 years. Conservation of matter is a developmental task of the school-age child. Five-year-old children use sentences with eight words with all parts of speech. A 4-year-old child cannot comprehend another's perspective. DIF: Cognitive Level: Apply REF: p. 383 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance

The nurse is caring for children on an adolescent-only unit. What growth and development milestones should the nurse expect from 11- and 14-year-old adolescents? (Select all that apply.) a. Self-centered with increased narcissism b. No major conflicts with parents c. Established abstract thought process d. Have a rich, idealistic fantasy life e. Highly value conformity to group norms f. Secondary sexual characteristics appear

ANS: B, E, F Growth and development milestones in the 11- to 14-year-old age group include minimal conflicts with parents (compared with the 15- to 17-year-old age group), a high value placed on conformity to the norm, and the appearance of secondary sexual characteristics. Self-centeredness and narcissism are seen in the 15- to 17-year-old age group along with a rich and idealistic fantasy life. Abstract thought processes are not well established until the 18- to 20-year-old age group.

The nurse is performing an assessment on a 12-month-old infant. Which fine or gross motor developmental skill demonstrates the proximodistal acquisition of skills? a.Standing b.Sitting without assistance c.Fully developed pincer grasp d.Taking a few steps holding onto something

ANS: C Acquisition of fine and gross motor skills occurs in an orderly center-to-periphery (proximodistal) or head-to-toe (cephalocaudal) sequence. A fully developed pincer grasp is an example of the proximodistal development because infants use a palmar grasp before developing the finer pincer grasp. Standing, sitting without assistance, and taking a few steps are examples of a cephalocaudal development sequence.

During the 2-month well-child checkup, the nurse expects the infant to respond to sound in which manner? a.Respond to name. b.React to loud noise with Moro reflex. c.Turn his or her head to side when sound is at ear level. d.Locate sound by turning his or her head in a curving arc.

ANS: C At 2 months of age, an infant should turn his or her head to the side when a noise is made at ear level. At birth, infants respond to sound with a startle or Moro reflex. An infant responds to his or her name and locates sounds by turning his or her head in a curving arc at age 6 to 9 months.

The nurse is performing an assessment on a 10-week-old infant. The nurse understands that the developmental characteristic of hearing at this age is which? a.The infant responds to his own name. b.The infant localizes sounds by turning his head directly to the sound. c.The infant turns his head to the side when sound is made at the level of the ear. d.The infant locates sound by turning his head to the side and then looking up or down.

ANS: C At 8 to 12 weeks of age, the infant turns the head to the side when sound is made at the level of the ear. At 16 to 24 weeks, the infant locates sound by turning the head to the side and then looking up or down. At 24 to 32 weeks, infants respond to their own name. At 32 to 40 weeks, the infant localizes sounds by turning the head directly toward the sound.

At which age should the nurse expect most infants to begin to say "mama" and "dada" with meaning? a.4 months b.6 months c.10 months d.14 months

ANS: C Beginning at about age 10 months, an infant is able to ascribe meaning to the words "mama" and "dada." Four to 6 months is too young for this behavior to develop. At 14 months, the child should be able to attach meaning to these words. By age 1 year, the child can say three to five words with meaning and understand as many as 100 words.

At which age do most infants begin to fear strangers? a.2 months b.4 months c.6 months d.12 months

ANS: C Between ages 6 and 8 months, fear of strangers and stranger anxiety become prominent and are related to infants' ability to discriminate between familiar and unfamiliar people. At 2 months, infants are just beginning to respond differentially to their mothers. The infant at age 4 months is beginning the process of separation-individuation, which involves recognizing the self and mother as separate beings. Twelve months is too late; the infant requires referral for evaluation if he or she does not fear strangers by this age.

A female school-age child asks the school nurse, How many pounds should I expect to gain in a year? The nurse should give which response? a. You will gain about 2.4 to 4.6 lb per year b. You will gain about 3.4 to 5.6 lb per year. c. You will gain about 4.4 to 6.6 lb per year. d. You will gain about 5.5 to 7.6 lb per year.

ANS: C Between the ages of 6 and 12 years, children will almost double in weight, increasing 2 to 3 kg (4.4 to 6.6 lb) per year.

What statement accurately describes physical development during the school-age years? a. The childs weight almost triples. b. Muscles become functionally mature. c. Boys and girls double strength and physical capabilities. d. Fat gradually increases, which contributes to childrens heavier appearance.

ANS: C Boys and girls double both strength and physical capabilities. Their consistent refinement in coordination increases their poise and skill. In middle childhood, growth in height and weight occurs at a slower pace. Between the ages of 6 and 12 years, children grow 5 cm/yr and gain 3 kg/yr. Their weight will almost double. Although the strength increases, muscles are still functionally immature when compared with those of adolescents. This age group is more easily injured by overuse. Children take on a slimmer look with longer legs in middle childhood.

The parents of 9-year-old twin children tell the nurse, They have filled up their bedroom with collections of rocks, shells, stamps, and bird nests. The nurse should recognize that this is which? a. Indicative of giftedness b. Indicative of typical twin behavior c. Characteristic of cognitive development at this age d. Characteristic of psychosocial development at this age

ANS: C Classification skills involve the ability to group objects according to the attributes they have in common. School-age children can place things in a sensible and logical order, group and sort, and hold a concept in their mind while they make decisions based on that concept. Individuals who are not twins engage in classification at this age. Psychosocial behavior at this age is described according to Eriksons stage of industry versus inferiority.

The nurse understands that medications delivered by which route are more likely to cause a drug reaction? a. Oral b. Topical c. Intravenous d. Intramuscular

ANS: C Drugs administered by the intravenous route are more likely to cause a reaction than the oral, topical, or intramuscular route.

What statement best describes fear in school-age children? a. Increasing concerns about bodily safety overwhelm them. b. They should be encouraged to hide their fears to prevent ridicule by peers. c. Most of the new fears that trouble them are related to school and family. d. Children with numerous fears need continuous protective behavior by parents to eliminate these fears.

ANS: C During the school-age years, children experience a wide variety of fears, but new fears related predominantly to school and family bother children during this time. Parents and other persons involved with children should discuss childrens fear with them individually or as a group activity. Sometimes school-age children hide their fears to avoid being teased. Hiding the fears does not end them and may lead to phobias.

The parent of 2-week-old infant asks the nurse if fluoride supplements are necessary because the infant is exclusively breastfed. What is the nurse's best response? a."The infant needs to begin taking them now." b."Supplements are not needed if you drink fluoridated water." c."The infant may need to begin taking them at age 6 months." d."The infant can have infant cereal mixed with fluoridated water instead of supplements."

ANS: C Fluoride supplementation is recommended by the American Academy of Pediatrics beginning at age 6 months if the child is not drinking adequate amounts of fluoridated water. Supplementation is not recommended before age 6 months regardless of whether the mother drinks fluoridated water. Infant cereal is not recommended at 2 weeks of age.

At a well-child visit, parents ask the nurse how to know if a daycare facility is a good choice for their infant. Which observation should the nurse stress as especially important to consider when making the selection? a.Developmentally appropriate toys b.Nutritious snacks served to the children c.Handwashing by providers after diaper changes d.Certified caregivers for each of the age groups at the facility

ANS: C Health practices should be most important. With the need for diaper changes and assistance with feeding, young children are at increased risk when handwashing and other hygienic measures are not consistently used. Developmentally appropriate toys are important, but hygiene and the prevention of disease transmission take precedence. An infant should not have snacks. This is a concern for an older child. Certified caregivers for each age group may be an indicator of a high-quality facility, but parental observation of good hygiene is a better predictor of care.

The parents of a 4-month-old infant tell the nurse that they are getting a microwave oven and will be able to heat the baby's formula faster. What should the nurse recommend? a.Heat only 8 oz or more. b.Do not heat a plastic bottle in a microwave oven. c.Leave the bottle top uncovered to allow heat to escape. d.Shake the bottle vigorously for at least 30 seconds after heating.

ANS: C If a microwave is being used, the bottle should be left uncovered. This will allow heat to escape. No more than 4 oz should be heated at any one time. Bottles can be heated safely in microwave ovens if safety guidelines are followed. The bottle should be inverted 10 times; vigorous shaking is not necessary.

According to Piaget, a 6-month-old infant should be in which developmental stage? a.Use of reflexes b.Primary circular reactions c.Secondary circular reactions d.Coordination of secondary schemata

ANS: C Infants are usually in the secondary circular reaction stage from ages 4 to 8 months. This stage is characterized by a continuation of the primary circular reaction for the response that results. Shaking is performed to hear the noise of the rattle, not just for shaking. The use of reflexes stage is primarily during the first month of life. The primary circular reaction stage marks the replacement of reflexes with voluntary acts. The infant is in this stage from ages 1 to 4 months. The fourth sensorimotor stage is coordination of secondary schemata, which occurs at ages 9 to 12 months. This is a transitional stage in which increasing motor skills enable greater exploration of the environment.

An infant weighed 8 lb at birth and was 18 inches in length. What weight and length should the infant be at 5 months of age? a.12 lb, 20 inches b.14 lb, 21.5 inches c.16 lb, 23 inches d.18 lb, 24.5 inches

ANS: C Infants gain 680 g (1.5 lb) per month until age 5 months, when the birth weight has at least doubled. Height increases by 2.5 cm (1 inch) per month during the first 6 months. Therefore, at 5 months the infant should weigh 16 lb and be 23 inches in length.

The nurse should know what about Lyme disease? a. Very difficult to prevent b. Easily treated with oral antibiotics in stages 1, 2, and 3 c. Caused by a spirochete that enters the skin through a tick bite d. Common in geographic areas where the soil contains the mycotic spores that cause the diseas

ANS: C Lyme disease is caused by Borrelia burgdorferi, a spirochete spread by ticks. The early characteristic rash is erythema migrans. Tick bites should be avoided by entering tick-infested areas with caution. Light-colored clothing should be worn to identify ticks easily. Long-sleeve shirts and long pants tucked into socks should be worn. Early treatment of the erythema migrans (stage 1) can prevent the development of Lyme disease. Lyme disease is caused by a spirochete, not mycotic spores.

By which age should the nurse expect that an infant will be able to pull to a standing position? a.5 to 6 months b.7 to 8 months c.11 to 12 months d.14 to 15 months

ANS: C Most infants can pull themselves to a standing position at age 9 months. Infants who are not able to pull themselves to standing by age 11 to 12 months should be further evaluated for developmental dysplasia of the hip. At 6 months, infants have just obtained coordination of arms and legs. By age 8 months, infants can bear full weight on their legs.

An occlusive dressing is applied to a large abrasion. This is advantageous because the dressing will accomplish what? a. Deliver vitamin C to the wound. b. Provide an antiseptic for the wound. c. Maintain a moist environment for healing. d. Promote mechanical friction for healing

ANS: C Occlusive dressings, such as Acuderm, are not adherent to the wound site. They provide a moist wound surface and insulate the wound. The dressing does not have vitamin C or antiseptic capabilities. Acuderm protects against friction.

What is characteristic of dishonest behavior in children ages 8 to 10 years? a. Cheating during games is now more common. b. Stealing can occur because their sense of property rights is limited. c. Lying is used to meet expectations set by others that they have been unable to attain. d. Dishonesty results from the inability to distinguish between fact and fantasy.

ANS: C Older school-age children may lie to meet expectations set by others to which they have been unable to measure up. Cheating usually becomes less frequent as the child matures. Young children may lack a sense of property rights; older children may steal to supplement an inadequate allowance, or it may be an indication of serious problems. In this age group, children are able to distinguish between fact and fantasy.

A parent asks about whether a 7-year-old child is able to care for a dog. Based on the childs age, what does the nurse suggest? a. Caring for an animal requires more maturity than the average 7-year-old possesses. b. This will help the parent identify the childs weaknesses. c. A dog can help the child develop confidence and emotional health. d. Cats are better pets for school-age children.

ANS: C Pets have been observed to influence a childs self-esteem. They can have a positive effect on physical and emotional health and can teach children the importance of nurturing and nonverbal communication. Most 7-year-old children are capable of caring for a pet with supervision. Caring for a pet should be a positive experience. It should not be used to identify weaknesses. The pet chosen does not matter as much as the childs being responsible for a pet.

What is a characteristic of children with depression? a. Increased range of affective response b. Tendency to prefer play instead of schoolwork c. Change in appetite resulting in weight loss or gain d. Preoccupation with need to perform well in school

ANS: C Physiologic characteristics of children with depression include changes in appetite resulting in weight loss or gain, nonspecific complaints of not feeling well, alterations in sleeping patterns, insomnia or hypersomnia, and constipation. Children who are depressed have sad facial expressions with absent or diminished range of affective response. These children withdraw from previously enjoyed activities and engage in solitary play or work with a lack of interest in play. They are uninterested in doing homework or achieving in school, resulting in lower grades.

What is descriptive of the play of school-age children? a. They like to invent games, making up the rules as they go. b. Individuality in play is better tolerated than at earlier ages. c. Knowing the rules of a game gives an important sense of belonging. d. Team play helps children learn the universal importance of competition and winning.

ANS: C Play involves increased physical skill, intellectual ability, and fantasy. Children form groups and cliques and develop a sense of belonging to a team or club. At this age, children begin to see the need for rules. Conformity and ritual permeate their play. Their games have fixed and unvarying rules, which may be bizarre and extraordinarily rigid. With team play, children learn about competition and the importance of winning, an attribute highly valued in the United States but not in all cultures.

In terms of gross motor development, what should the nurse expect an infant age 5 months to do? a.Sit erect without support. b.Roll from the back to the abdomen. c.Turn from the abdomen to the back. d.Move from a prone to a sitting position.

ANS: C Rolling from the abdomen to the back is developmentally appropriate for a 5-month-old infant. The ability to roll from the back to the abdomen is developmentally appropriate for an infant at age 6 months. Sitting erect without support is a developmental milestone usually achieved by 8 months. A 10-month-old infant can usually move from a prone to a sitting position.

What does the nurse understand about caloric needs for school-age children? a. The caloric needs for the school-age children are the same as for other age groups. b. The caloric needs for school-age children are more than they were in the preschool years. c. The caloric needs for school-age children are lower than they were in the preschool years. d. The caloric needs for school-age children are greater than they will be in the adolescent years.

ANS: C School-age children do not need to be fed as carefully, as promptly, or as frequently as before. Caloric needs are lower than they were in the preschool years and lower than they will be during the coming adolescent growth spurt.

What statement best describes the relationship school-age children have with their families? a. Ready to reject parental controls b. Desire to spend equal time with family and peers c. Need and want restrictions placed on their behavior by the family d. Peer group replaces the family as the primary influence in setting standards of behavior and rules

ANS: C School-age children need and want restrictions placed on their behavior, and they are not prepared to cope with all the problems of their expanding environment. Although increased independence is the goal of middle childhood, they feel more secure knowing that an authority figure can implement controls and restriction. In the middle school years, children prefer peer group activities to family activities and want to spend more time in the company of peers. Family values usually take precedence over peer value systems.

The school nurse is seeing a child who collected some poison ivy leaves during recess. He says only his hands touched it. What is the most appropriate nursing action? a. Soak his hands in warm water. b. Apply Burow's solution compresses. c. Rinse his hands in cold running water. d. Scrub his hands thoroughly with antibacterial soap

ANS: C The first recommended action is to rinse his hands in cold running water within 15 minutes of exposure. This will neutralize the urushiol not yet bonded to the skin. Soaking his hands in warm water is effective for soothing the skin lesions after the dermatitis has begun. Antibacterial soap removes protective skin oils and dilutes the urushiol, allowing it to spread.

The nurse is teaching a class on nutrition to a group of parents of 10- and 11-year-old children. What statement by one of the parents indicates a correct understanding of the teaching? a. My child does not need to eat a variety of foods, just his favorite food groups. b. My child can add salt and sugar to foods to make them taste better. c. I will serve foods that are low in saturated fat and cholesterol. d. I will continue to serve red meat three times per week for extra iron.

ANS: C School-age children should be eating foods that are low in saturated fat and cholesterol to prevent long-term consequences. The childs diet should include a variety of foods, include moderate amounts of extra salt and sugar, emphasize consumption of lean protein (chicken and pork), and limit red meat.

A child with corrosive poisoning is being admitted to the emergency department. What clinical manifestation does the nurse expect to assess on this child? a.Nausea and vomiting b.Alterations in sensorium, such as lethargy c.Severe burning pain in the mouth, throat, and stomach d.Respiratory symptoms of acute pulmonary involvement

ANS: C Severe burning pain in the mouth, throat, and stomach is a clinical manifestation of corrosive poisoning. Nausea and vomiting; alterations in sANS: C Severe burning pain in the mouth, throat, and stomach is a clinical manifestation of corrosive poisoning. Nausea and vomiting; alterations in sensorium, such as lethargy; and respiratory symptoms of acute pulmonary involvement are clinical manifestations of hydrocarbon poisoning.

At which age can most infants sit steadily unsupported? a.4 months b.6 months c.8 months d.12 months

ANS: C Sitting erect without support is a developmental milestone usually achieved by 8 months. At age 4 months, an infant can sit with support. At age 6 months, the infant will maintain a sitting position if propped. By 10 months, the infant can maneuver from a prone to a sitting position.

Which intervention is the most appropriate recommendation for relief of teething pain? a.Rub gums with aspirin to relieve inflammation. b.Apply hydrogen peroxide to gums to relieve irritation. c.Give the infant a frozen teething ring to relieve inflammation. d.Have the infant chew on a warm teething ring to encourage tooth eruption.

ANS: C Teething pain is a result of inflammation, and cold is soothing. A frozen teething ring or ice cube wrapped in a washcloth helps relieve the inflammation. Aspirin is contraindicated secondary to the risks of aspiration. Hydrogen peroxide does not have an anti-inflammatory effect. Warmth increases inflammation.

At what age is it safe to give infants whole milk instead of commercial infant formula? a.6 months b.9 months c.12 months d.18 months

ANS: C The American Academy of Pediatrics does not recommend the use of cow's milk for children younger than 12 months. At 6 and 9 months, the infant should be receiving breast milk or iron-fortified commercial infant formula. At age 18 months, milk and formula are supplemented with solid foods, water, and some fruit juices.

A child with diazepam (Valium) poisoning has been admitted to the emergency department. What antidote does the nurse anticipate being prescribed? a.Succimer (Chemet) b.EDTA (Versenate) c.Flumazenil (Romazicon) d.Octreotide acetate (Sandostatin)

ANS: C The antidote for diazepam (Valium) poisoning is flumazenil (Romazicon). Succimer (Chemet) and EDTA (Versenate) are antidotes for heavy metal poisoning. Octreotide acetate (Sandostatin) is an antidote for sulfonylurea poisoning.

The school nurse is teaching female school-age children about the average age of puberty. What is the average age of puberty for girls? a. 10 years b. 11 years c. 12 years d. 13 years

ANS: C The average age of puberty is 12 years in girls.

The school nurse is teaching male school-age children about the average age of puberty. What is the average age of puberty for boys? a. 12 years b. 13 years c. 14 years d. 15 years

ANS: C The average age of puberty is 14 years in boys. Boys experience little sexual maturation during preadolescence.

What is an important nursing consideration when a child is hospitalized for chelation therapy to treat lead poisoning? a. Maintain bed rest. b. Maintain isolation precautions. c.Keep an accurate record of intake and output. d.Institute measures to prevent skeletal fracture.

ANS: C The iron chelates are excreted though the kidneys. Adequate hydration is essential. Periodic measurement of renal function is done. Bed rest is not necessary. Often the chelation therapy is done on an outpatient basis. Chelation therapy is not infectious or dangerous. Isolation is not indicated. Skeletal weakness does not result from high levels of lead.

A parent calls the clinic nurse because his 7-year-old child was bitten by a black widow spider. What action should the nurse advise the parent to take? a. Apply warm compresses. b. Carefully scrape off the stinger. c. Take the child to the emergency department. d. Apply a thin layer of corticosteroid cream

ANS: C The venom of the black widow spider has a neurotoxic effect. The parent should take the child to the emergency department for treatment with antivenin and muscle relaxants as needed. Warm compresses increase the circulation to the area and facilitate the spread of the venom. The black widow spider does not have a stinger. Corticosteroid cream has no effect on the venom.

The nurse is explaining about the developmental sequence in childrens capacity to conserve matter to a group of parents. What type of matter is last in the sequence for a child to develop? a. Mass b. Length c. Volume d. Numbers

ANS: C There is a developmental sequence in childrens capacity to conserve matter. Children usually grasp conservation of numbers (ages 5 to 6 years) before conservation of substance. Conservation of liquids, mass, and length usually is accomplished at about ages 6 to 7 years, conservation of weight sometime later (ages 9 to 10 years), and conservation of volume or displacement last (ages 9 to 12 years).

The nurse is facilitating a conference between the teachers and parents of a 7-year-old child newly diagnosed with attention deficit hyperactivity disorder (ADHD). What does the nurse stress? a. Academic subjects should be taught in the afternoon. b. Low-interest activities in the classroom should be minimized. c. Visual references should accompany verbal instruction. d. The child's environment should be visually stimulating

ANS: C Verbal instructions should always be accompanied by visual or written instructions. This provides the child with reinforcement and a reference to expectations. Academic subjects should be taught in the morning when the child is experiencing the effects of the morning dose of medication. Low-interest activities should be mixed with high-interest activities to maintain the child's attention. Environmental stimulation should be minimized to help eliminate distractions that can overexcite the child.

The school nurse is presenting sexual information to a group of school-age girls. What approach should the nurse take when presenting the information? a. Put off answering questions. b. Give technical terms when giving the presentation. c. Treat sex as a normal part of growth and development. d. Plan to give the presentation with boys and girls together.

ANS: C When nurses present sexual information to children, they should treat sex as a normal part of growth and development. Nurses should answer questions honestly, matter-of-factly, and at the childrens level of understanding. School-age children may be more comfortable when boys and girls are segregated for discussions.

The school nurse has been asked to begin teaching sex education in the fifth grade. What should the nurse recognize? a. Questions need to be discouraged in this setting. b. Most children in the fifth grade are too young for sex education. c. Sexuality is presented as a normal part of growth and development. d. Correct terminology should be reserved for children who are older.

ANS: C When sexual information is presented to school-age children, sex should be treated as a normal part of growth and development. They should be encouraged to ask questions. At 10 to 11 years old, fifth graders are not too young to speak about physiologic changes in their bodies. Preadolescents need precise and concrete information.

16. What is most descriptive of atopic dermatitis (AD) (eczema) in an infant? a. Easily cured b. Worse in humid climates c. Associated with hereditary allergies d. Related to upper respiratory tract infections

ANS: C AD is a type of pruritic eczema that usually begins during infancy and is associated with allergy with a hereditary tendency. Approximately 50 percent of children with AD develop asthma. AD can be controlled but not cured. Manifestations of the disease are worse when environmental humidity is lower. AD is not associated with respiratory tract infections. DIF: Cognitive Level: Understanding REF: p. 468 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

Which play is most typical of the preschool period? a. Solitary b. Parallel c. Associative d. Team

ANS: C Associative play is group play in similar or identical activities but without rigid organization or rules. Solitary play is that of infants. Parallel play is that of toddlers. School-age children play in teams. DIF: Cognitive Level: Understand REF: p. 383 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance

The child of 15 to 30 months is likely to be struggling with which developmental task? a. Trust b. Initiative c. Autonomy d. Intimacy

ANS: C Autonomy vs shame and doubt is the developmental task of toddlers. Trust vs mistrust is the developmental stage of infancy. Initiative vs guilt is the developmental stage of early childhood. Intimacy and solidarity vs isolation is the developmental stage of early adulthood.

A nurse is assessing a preschool-age child and notes the child exhibits magical thinking. According to Piaget, which describes magical thinking? a. Events have cause and effect. b. God is like an imaginary friend. c. Thoughts are all-powerful. d. If the skin is broken, the child's insides will come out.

ANS: C Because of their egocentrism and transductive reasoning, preschoolers believe that thoughts are all-powerful. Cause-and-effect implies logical thought, not magical thinking. Thinking God is like an imaginary friend is an example of concrete thinking in a preschooler's spiritual development. Thinking that if the skin is broken, the child's insides will come out is an example of concrete thinking in development of body image. DIF: Cognitive Level: Apply REF: p. 381 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance

In the clinic waiting room, a nurse observes a parent showing an 18-month-old child how to make a tower out of blocks. The nurse should recognize in this situation that: a. blocks at this age are used primarily for throwing. b. toddlers are too young to imitate the behavior of others. c. toddlers are capable of building a tower of blocks. d. toddlers are too young to build a tower of blocks.

ANS: C Building with blocks is a good parent-child interaction. The 18-month-old child is capable of building a tower of three or four blocks. The ability to build towers of blocks usually begins at age 15 months. With ongoing development, the child is able to build taller towers. The 18-month-old child imitates others around him or her.

Developmentally, most children at age 12 months: a. use a spoon adeptly. b. relinquish the bottle voluntarily. c. eat the same food as the rest of the family. d. reject all solid food in preference to the bottle.

ANS: C By age 12 months, most children are eating the same food that is prepared for the rest of the family. Using a spoon usually is not mastered until age 18 months. The parents should be engaged in weaning a child from a bottle if that is the source of liquid. Toddlers should be encouraged to drink from a cup at the first birthday and be weaned from the bottle totally by 14 months. The child should be weaned from a milk- or formula-based diet to a balanced diet that includes iron-rich sources of food.

14. The nurse is examining an infant, age 10 months, who was brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with satellite lesions. What is the most likely cause? a. Impetigo b. Urine and feces c. Candida albicans infection d. Infrequent diapering

ANS: C C. albicans infection produces perianal inflammation and a maculopapular rash with satellite lesions that may cross the inguinal folds. Impetigo is a bacterial infection that spreads peripherally in sharply marginated, irregular outlines. Eruptions involving the skin in contact with the diaper but sparing the folds are likely to be caused by chemical irritation, especially urine and feces, and may be related to infrequent diapering. DIF: Cognitive Level: Understanding REF: p. 466 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

15. A new parent asks the nurse, "How can diaper rash be prevented?" What should the nurse recommend? a. Wash the infant with soap before applying a thin layer of oil. b. Clean the infant with soap and water every time diaper is changed. c. Wipe stool from the skin using water and a mild cleanser. d. When changing the diaper, wipe the buttocks with oil and powder the creases.

ANS: C Change the diaper as soon as it becomes soiled. Gently wipe stool from the skin with water and mild soap. The skin should be thoroughly dried after washing. Applying oil does not create an effective barrier. Over washing the skin should be avoided, especially with perfumed soaps or commercial wipes, which may be irritating. Baby powder should not be used because of the danger of aspiration. DIF: Cognitive Level: Applying REF: p. 467 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity

The school nurse recognizes that pubertal delay in boys is considered if no enlargement of the testes or scrotal changes have occurred by what age? a. 11 1/2 to 12 years b. 12 1/2 to 13 years c. 13 1/2 to 14 years d. 14 1/2 to 15 years

ANS: C Concerns about pubertal delay should be considered for boys who exhibit no enlargement of the testes or scrotal changes by ages 13 1/2 to 14 years or if genital growth is not complete 4 years after the testicles begin to enlarge.

Although a 14-month-old girl received a shock from an electric outlet recently, her parent finds her about to place a paper clip in another outlet. Which is the best interpretation of this behavior? a. Her cognitive development is delayed. b. This is typical behavior because toddlers are not very developed. c. This is typical behavior because of the inability to transfer knowledge to new situations. d. This is not typical behavior because toddlers should know better than to repeat an act that caused pain.

ANS: C During the tertiary circular reactions stage, children have only a rudimentary sense of the classification of objects. The appearance of an object denotes its function for these children. The slot of an outlet is for putting things into. Her cognitive development is appropriate for her age. Trying to put things into an outlet is typical behavior for a toddler. Only some awareness exists of a causal relation between events.

19. What should injury prevention efforts emphasize during the preschool period? a. Constant vigilance and protection b. Punishment for unsafe behaviors c. Education for safety and potential hazards d. Limitation of physical activities

ANS: C Education for safety and potential hazards is appropriate for preschoolers because they can begin to understand dangers. Constant vigilance and protection is not practical at this age because preschoolers are becoming more independent. Punishment may make children scared of trying new things. Limitation of physical activities is not appropriate. DIF: Cognitive Level: Understand REF: p. 390 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Safe and Effective Care Environment

26. A new parent relates to the nurse that the family has many known food allergies. Which is considered a primary strategy for feeding the infant with many family food allergies? a. Using soy formula for feeding b. Maternal avoidance of cow's milk protein c. Exclusive breastfeeding for 4 to 6 months d. Delaying the introduction of highly allergenic foods past 6 months

ANS: C Exclusive breastfeeding for 4 to 6 months is now considered a primary strategy for avoiding atopy in families with known food allergies; however, there is no evidence that maternal avoidance (during pregnancy or lactation) of cow's milk protein or other dietary products known to cause food allergy will prevent food allergy in children. Researchers indicate that delaying the introduction of highly allergenic foods past 4 to 6 months of age may not be as protective for food allergy as previously believed. Likewise, studies have shown that soy formula does not prevent allergic disease in infants. DIF: Cognitive Level: Analyzing REF: p. 460 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment

30. An infant has been diagnosed with failure to thrive (FTT) classified according to the pathophysiology of defective utilization. The nurse understands that the reason for the FTT is most likely related to what? a. Cystic fibrosis b. Hyperthyroidism c. Congenital infection d. Breastfeeding problems

ANS: C FTT classified according to the pathophysiology of defective utilization is related to a genetic anomaly, congenital infection of metabolic storage disease. Cystic fibrosis would be related to the pathophysiology of inadequate absorption, hyperthyroidism would be related to the pathophysiology of increased metabolism, and breastfeeding problems are related to inadequate caloric intake. DIF: Cognitive Level: Analyzing REF: p. 463 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

23. What is an appropriate action when an infant becomes apneic? a. Shake vigorously. b. Roll the infant's head to the side. c. Gently stimulate the trunk by patting or rubbing. d. Hold the infant by the feet upside down with the head supported.

ANS: C If an infant is apneic, the infant's trunk should be gently stimulated by patting or rubbing. If the infant is prone, turn onto the back. Vigorous shaking, rolling of the head, and hanging the child upside down can cause injury and should not be done. DIF: Cognitive Level: Understanding REF: p. 481 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

In girls, what is the initial indication of puberty? a. Menarche b. Growth spurt c. Breast development d. Growth of pubic hair

ANS: C In most girls, the initial indication of puberty is the appearance of breast buds, an event known as thelarche. The usual sequence of secondary sexual characteristic development in girls is breast changes, a rapid increase in height and weight, growth of pubic hair, appearance of axillary hair, menstruation (menarche), and abrupt deceleration of linear growth.

The school nurse is teaching an adolescent about social networking and texting on phones. What statement by the adolescent indicates a need for further teaching? a. "Social networking can help me develop interpersonal skills." b. "I will have an opportunity to interact with people like myself." c. "My text messaging during class time in school will not cause any disruption." d. "I should be cautious, as the online environment can create opportunities for cyberbullying."

ANS: C Internet chatrooms and social networking sites have created a more public arena for trying out identities and developing interpersonal skills with a wider network of people, occasionally with anonymity. This can create opportunities for young people who have a limited access to friends (because of rural location, shyness, or rare chronic conditions) to interact with people like themselves. Both the online and text environment can create opportunities for cyberbullying, in which teens engage in insults, harassment, and publicly humiliating statements online or on cell phones. Text messaging and instant messaging via cell phones has become a common activity and can sometimes be disruptive during school. If the adolescent indicates it will not be disruptive, further teaching is needed.

31. The nurse is teaching parents guidelines for feeding their 8-month-old infant with failure to thrive (FTT). Which statement by the parents indicates a need for further teaching? a. "We will continue to use the 24-kcal/oz formula." b. "We will be sure to follow the formula preparation instructions." c. "We will be sure to give our infant at least 8 oz of juice every day." d. "We will be sure to feed our infant according to the written schedule."

ANS: C Juice intake in infants with FTT should be withheld until adequate weight gain has been achieved with appropriate milk sources; thereafter, no more than 4/oz day of juice should be given. Further teaching is needed if the parents indicate 8 oz of juice is allowed. For infants with FTT, 24-kcal/oz formulas may be provided to increase caloric intake. Because maladaptive feeding practices often contribute to growth failure, parents should follow specific step-by-step directions for formula preparation, as well as a written schedule of feeding times. Statements by the parents indicating they will use a 24-kcal/oz formula, follow directions for formula preparation, and feed their infant on schedule are accurate statements. DIF: Cognitive Level: Applying REF: p. 463 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

5. What is marasmus? a. Deficiency of protein with an adequate supply of calories b. Syndrome that results solely from vitamin deficiencies c. Not confined to geographic areas where food supplies are inadequate d. Characterized by thin, wasted extremities and a prominent abdomen resulting from edema (ascites)

ANS: C Marasmus is a syndrome of emotional and physical deprivation. It is not confined to geographic areas were food supplies are inadequate. Marasmus is characterized by gradual wasting and atrophy of body tissues, especially of subcutaneous fat. The child appears old, with flabby and wrinkled skin. Marasmus is a deficiency of both protein and calories. DIF: Cognitive Level: Understanding REF: p. 456 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

21. Which snack should the nurse recommend parents offer to their slightly overweight preschool child? a. Carbonated beverage b. 10% fruit juice c. Low fat chocolate milk d. Whole milk

ANS: C Milk and dairy products are excellent sources of calcium and vitamin D (fortified). Low-fat milk may be substituted, so the quantity of milk may remain the same while limiting fat intake overall. Parents should be educated regarding non-nutritious fruit drinks, which usually contain less than 10% fruit juice yet are often advertised as healthy and nutritious; sugar content is dramatically increased and often precludes an adequate intake of milk by the child. In young children, intake of carbonated beverages that are acidic or that contain high amounts of sugar is also known to contribute to dental caries. Low fat milk should be substituted for whole milk if the child is slightly overweight. DIF: Cognitive Level: Apply REF: p. 389 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance

What are characteristics of early adolescence (11-14 years) with regard to identity? (Select all that apply.) a. Mature sexual identity b. Increase in self-esteem c. Trying out of various roles d. Conformity to group norms e. Preoccupied with rapid body changes

ANS: C, D, E Characteristics of early adolescence identity include trying out of various roles, conformity to group norms, and preoccupation with rapid body changes. Mature sexual identity and increase in self-esteem are characteristics of late adolescent identity.

Why are imaginary playmates beneficial to the preschool child? a. Take the place of social interactions b. Take the place of pets and other toys c. Become friends in times of loneliness d. Accomplish what the child has already successfully accomplished

ANS: C One purpose of an imaginary friend is to be a friend in time of loneliness. Imaginary friends do not take the place of social interaction, but may encourage conversation. Imaginary friends do not take the place of pets or toys. Imaginary friends accomplish what the child is still attempting. DIF: Cognitive Level: Understand REF: p. 384 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance

Parents need further teaching about the use of car safety seats if they make which statement? a. "Even if our toddler helps buckle the straps, we will double-check the fastenings." b. "We won't start the car until everyone is properly restrained." c. "We won't need to use the car seat on short trips to the store." d. "We will anchor the car seat to the car's anchoring system."

ANS: C Parents need to be taught to always use the restraint even for short trips. Further teaching is needed if they make this statement. Parents have understood the teaching if they encourage the child to help attach buckles, straps, and shields but always double-check fastenings; do not start the car until everyone is properly restrained; and anchor the car safety seat securely to the car's anchoring system and apply the harness snugly to the child.

A 4-year-old child tells the nurse that she does not want another blood sample drawn because "I need all my insides, and I don't want anyone taking them out." Which is the nurse's best interpretation of this? a. Child is being overly dramatic. b. Child has a disturbed body image. c. Preschoolers have poorly defined body boundaries. d. Preschoolers normally have a good understanding of their bodies.

ANS: C Preschoolers have little understanding of body boundaries, which leads to fears of mutilation. The child is not capable of being dramatic at 4 years of age. She truly has fear. Body image is just developing in the school-age child. Preschoolers do not have good understanding of their bodies. DIF: Cognitive Level: Apply REF: p. 388 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance

4. A 1-year-old child is on a pure vegetarian (vegan) diet. This diet requires supplementation with what? a. Niacin b. Folic acid c. Vitamins D and B12 d. Vitamins C and E

ANS: C Pure vegetarian (vegan) diets eliminate any food of animal origin, including milk and eggs. These diets require supplementation with many vitamins, especially vitamin B6, vitamin B12, riboflavin, vitamin D, iron, and zinc. Niacin, folic acid, and vitamins C and E are readily obtainable from foods of vegetable origin. DIF: Cognitive Level: Applying REF: p. 453 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

In boys, what is the initial indication of puberty? a. Voice changes b. Growth of pubic hair c. Testicular enlargement d. Increased size of penis

ANS: C Testicular enlargement is the first change that signals puberty in boys; it usually occurs between the ages of 9 1/2 and 14 years during Tanner stage 2. Voice change occurs between Tanner stages 3 and 4. Fine pubic hair may occur at the base of the penis; darker hair occurs during Tanner stage 3. The penis enlarges during Tanner stage 3.

According to Piaget, adolescents tend to be in what stage of cognitive development? a. Concrete operations b. Conventional thought c. Postconventional thought d. Formal operational thought

ANS: D Cognitive thinking culminates in the capacity for abstract thinking. This stage, the period of formal operations, is Piaget's fourth and last stage. Concrete operations usually occur between ages 7 and 11 years. Conventional and postconventional thought refers to Kohlberg's stages of moral development.

The nurse is planning care for a hospitalized preschool-aged child. Which should the nurse plan to ensure atraumatic care? a. Limit explanation of procedures because the child is preschool aged. b. Ask that all family members leave the room when performing procedures. c. Allow the child to choose the type of juice to drink with the administration of oral medications. d. Explain that EMLA cream cannot be used for the morning lab draw because there is not time for it to be effective.

ANS: C The overriding goal in providing atraumatic care is first, do no harm. Allowing the child a choice of juice to drink when taking oral medications provides the child with a sense of control. The preschool child should be prepared before procedures, so limiting explanations of procedures would increase anxiety. The family should be allowed to stay with the child during procedures, minimizing stress. Lidocaine/prilocaine (EMLA) cream is a topical local anesthetic. The nurse should plan to use the prescribed cream in time for morning laboratory draws to minimize pain.

A toddler's parent asks the nurse for suggestions on dealing with temper tantrums. Which is the most appropriate recommendation? a. Punish the child. b. Leave the child alone until the tantrum is over. c. Remain close by the child but without eye contact. d. Explain to child that this is wrong.

ANS: C The parent should be told that the best way to deal with temper tantrums is to ignore the behaviors, provided that the actions are not dangerous to the child. Tantrums are common in toddlers as the child becomes more independent and overwhelmed by increasingly complex tasks. The parents and caregivers need to have consistent and developmentally appropriate expectations. Punishment and explanations will not be beneficial. The parent's presence is necessary both for safety and to provide a feeling of control and security to the child when the tantrum is over.

What is an important consideration for the school nurse planning a class on injury prevention for adolescents? a. Adolescents generally are not risk takers. b. Adolescents can anticipate the long-term consequences of serious injuries. c. Adolescents need to discharge energy, often at the expense of logical thinking. d. During adolescence, participation in sports should be limited to prevent permanent injuries.

ANS: C The physical, sensory, and psychomotor development of adolescents provides a sense of strength and confidence. There is also an increase in energy coupled with risk taking that puts them at risk. Adolescents are risk takers because their feelings of indestructibility interfere with understanding of consequences. Sports can be a useful way for adolescents to discharge energy. Care must be taken to avoid overuse injuries.

The nurse is teaching parents about the types of behaviors children exhibit when living with chronic violence. Which statement made by the parents indicates further teaching is needed? a. "We should watch for aggressive play." b. "Our child may show lasting symptoms of stress." c. "We know that our child will show caring behaviors." d. "Our child may have difficulty concentrating in school."

ANS: C The statement that the child will show caring behaviors needs further teaching. Children living with chronic violence may exhibit behaviors such as difficulty concentrating in school, memory impairment, aggressive play, uncaring behaviors, and lasting symptoms of stress

Parents of a hospitalized toddler ask the nurse, "What is meant by family-centered care?" The nurse should respond with which statement? a. Family-centered care reduces the effect of cultural diversity on the family. b. Family-centered care encourages family dependence on the health care system. c. Family-centered care recognizes that the family is the constant in a child's life. d. Family-centered care avoids expecting families to be part of the decision-making process.

ANS: C The three key components of family-centered care are respect, collaboration, and support. Family-centered care recognizes the family as the constant in the child's life. The family should be enabled and empowered to work with the health care system and is expected to be part of the decision-making process. The nurse should also support the family's cultural diversity, not reduce its effect.

What is the major cause of death for children older than 1 year in the United States? a. Heart disease b. Childhood cancer c. Unintentional injuries d. Congenital anomalies

ANS: C Unintentional injuries (accidents) are the leading cause of death after age 1 year through adolescence. The leading cause of death for those younger than 1 year is congenital anomalies, and childhood cancers and heart disease cause a significantly lower percentage of deaths in children older than 1 year of age.

The nurse is explaining to an adolescent the rationale for administering a Tdap (tetanus, diphtheria, acellular pertussis) vaccine 3 years after the last Td (tetanus) booster. What should the nurse tell the adolescent? a. "It is time for a booster vaccine." b. "It is past the time for a booster vaccine." c. "This vaccine will provide pertussis immunity." d. "This vaccine will be the last booster you will need."

ANS: C When the Tdap is used as a booster dose, it may be administered earlier than the previous 5-year interval to provide adequate pertussis immunity (regardless of interval from the last Td dose). It is not time or past time for a booster because they are required every 5 years. Another booster will be needed in 5 years, so it is not the last dose.

The nurse is providing anticipatory guidance to parents of a 6-month-old on preventing an accidental poisoning injury. Which should the nurse include in the teaching? (Select all that apply.) a.Place plants on the floor. b.Place medications in a cupboard. c.Discard used containers of poisonous substances. d.Keep cosmetic and personal products out of the child's reach. e.Make sure that paint for furniture or toys does not contain lead.

ANS: C, D, E Anticipatory guidance for a 7-month-old infant to prevent a suffocation injury takes into account that the infant will become more active and eventually crawl, cruise, and walk. Used containers of poisonous substances should be discarded, cosmetic and personal products should be kept out of the child's reach, and paint for furniture or toys should be lead free. Plants should be hung out of reach or placed on a high shelf. Medications should be locked, not just placed in a cupboard.

The nurse is caring for a child who has a temperature of 30° C (86° F). What physical effects of hypothermia should the nurse expect to observe in this child? (Select all that apply.) a. Reduced urinary output b. Injury to peripheral tissue c. Increased blood pressure d. Tachycardia e. Irritability with loss of consciousness f. Rigid extremities

ANS: C, D, E Hypothermia has varying physical effects depending on the child's core temperature. At 30° C (86° F), a child would experience an increase in blood pressure, tachycardia, and irritability followed by a loss of consciousness. Reduced urinary output from a decrease of blood flow to the kidneys, injury to peripheral tissue, and rigid extremities are physical effects observed as the body temperature continues to decrease.

What are characteristics of late adolescence (18-20 years) with regard to sexuality? (Select all that apply.) a. Exploration of "self-appeal" b. Limited dating, usually group c. Intimacy involves commitment d. Growing capacity for mutuality and reciprocity e. May publicly identify as gay, lesbian, or bisexual

ANS: C, D, E Characteristics of late adolescence sexuality include intimacy involving commitment; growing capacity for mutuality and reciprocity; and publicly identifying as gay, lesbian, or bisexual. Exploration of "self-appeal" is a characteristic of middle adolescence sexuality. Limited dating, usually group, is a characteristic of early adolescence sexuality.

8. What are risk factors for sudden infant death syndrome? (Select all that apply.) a. Postterm b. Female gender c. Low Apgar scores d. Recent viral illness e. Native American infants

ANS: C, D, E Infant risk factors for sudden infant death syndrome include those with low Apgar scores and recent viral illness and Native American infants. Preterm, not postterm, birth and male, not female, gender are other risk factors. DIF: Cognitive Level: Understanding REF: p. 475 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

The nurse is teaching parents about safety for their latchkey children. What should the nurse include in the teaching session? (Select all that apply.) a. Teach the child first-aid procedures. b. Keep the key in an easy place to find. c. Teach the child weather-related safety. d. Teach the child to open the door for delivery people. e. Emphasize fire safety rules and conduct practice fire drills.

ANS: C, E Safety for latchkey children includes teaching the child first-aid procedures, teaching the child weather-related safety, and emphasizing fire safety rules and conducting practice fire drills. Teach the child not to display keys and to always lock doors. The child should be taught to not open the door to anyone, even delivery people.

The nurse is developing a teaching pamphlet for parents of school-age children. What anticipatory guidelines should the nurse include in the pamphlet? a. At age 6 years, parents should be certain that the child is reading independently with books provided by school. b. At age 8 years, parents should expect a decrease in involvement with peers and outside activities. c. At age 10 years, parents should expect a decrease in admiration of the parents with little interest in parentchild activities. d. At age 12 years, parents should be certain that the childs sex education is adequate with accurate information.

ANS: D A 12-year-old child should have been introduced to sex education, and parents should be certain that the information is adequate and accurate and that the child is not embarrassed to talk about sexual feelings or other aspects of sex education. At age 6 years, a child does not need to be reading independently and usually still needs help with reading and enjoys being read to. At 8 years of age, parents should expect their child to show increased involvement with peers and outside activities and should encourage this behavior. A 10-year-old child exhibits increased feelings of admiration of parents, especially fathers, and parentchild activities should be encouraged.

Which characteristic best describes the fine motor skills of an infant at age 5 months? a.Neat pincer grasp b.Strong grasp reflex c.Builds a tower of two cubes d.Able to grasp object voluntarily

ANS: D At age 5 months, the infant should be able to voluntarily grasp an object. The grasp reflex is present in the first 2 to 3 months of life. Gradually, the reflex becomes voluntary. The neat pincer grasp is not achieved until age 11 months. At age 12 months, an infant will attempt to build a tower of two cubes but will most likely be unsuccessful.

The nurse is teaching parents about expected language development for their 6-month-old infant. The nurse recognizes the parents understand the teaching if they make which statement? a."Our baby should comprehend the word 'no.'" b."Our baby knows the meaning of saying 'mama.'" c."Our baby should be able to say three to five words." d."Our baby should begin to combine syllables, such as 'dada.'"

ANS: D By 6 months, infants imitate sounds; add the consonants t, d, and w; and combine syllables (e.g., "dada"), but they do not ascribe meaning to the word until 10 to 11 months of age. By 9 to 10 months, they comprehend the meaning of the word "no" and obey simple commands accompanied by gestures. By age 1 year, they can say three to five words with meaning and may understand as many as 100 words.

The nurse is assisting the family of a child with a history of encopresis. What should be included in the nurse's discussion with the family? a. Instruct the parents to sit the child on the toilet at twice-daily routine intervals. b. Instruct the parents that the child will probably need to have daily enemas. c. Suggest the use of stimulant cathartics weekly. d. Reassure the family that most problems are resolved successfully, with some relapses during periods of stress

ANS: D Children may be unaware of a prior sensation and be unable to control the urge after it begins. They may be so accustomed to bowel accidents that they may be unable to smell or feel them. Family counseling is directed toward reassurance that most problems resolve successfully, although relapses during periods of stress are possible. Sitting the child on the toilet is not recommended because it may intensify the parent-child conflict. Enemas may be needed for impactions, but long-term use prevents the child from assuming responsibility for defecation. Stimulant cathartics may cause cramping that can frighten children.

What is probably the most important criterion on which to base the decision to report suspected child abuse? a.Inappropriate response of child b.Inappropriate parental concern for the degree of injury c.Absence of parents for questioning about child's injuries d.Incompatibility between the history and injury observed

ANS: D Conflicting stories about the "accident" are the most indicative red flags of abuse. The child or caregiver may have an inappropriate response, but this is subjective. Parents should be questioned at some point during the investigation.

The nurse suspects that a child has ingested some type of poison. What clinical manifestation would be most suggestive that the poison was a corrosive product? a. Tinnitus b. Disorientation c. Stupor, lethargy, and coma d. Edema of the lips, tongue, and pharynx

ANS: D Edema of the lips, tongue, and pharynx indicates a corrosive ingestion. Tinnitus is indicative of aspirin ingestion. Corrosives do not act on the central nervous system.

What do inflicted immersion burns often appear as? a.Partial-thickness, asymmetrical burns b.Splash pattern burns on hands or feet c.Any splash burn with dry linear marks d.Sharply demarcated, symmetrical burn

ANS: D Immersion burns are sharply demarcated symmetrical burns. Asymmetrical burns and splash burns are often accidental.

At an 8-month-old well-baby visit, the parent tells the nurse that her infant falls asleep at night during the last bottle feeding but wakes up when moved to the infant's crib. What is the most appropriate response for the nurse to make? a."You should put your baby to sleep 1 hour earlier without the nighttime feeding but with a pacifier for soothing." b."You could place rice cereal in the last bottle feeding of the day to ensure a longer sleep pattern." c."You should have your partner give the last bottle of the day and observe whether your infant stays awake for your partner." d."You could increase daytime feeding intervals to every 4 hours and put your baby in the crib while the baby is still awake."

ANS: D Increasing the daytime intervals to 4 hours and placing the baby in the crib while still awake are interventions for nighttime sleeping problems. Putting the baby to bed 1 hour earlier with a pacifier will not stop the need for the bedtime bottle; there is no research that rice cereal in the bottle helps to satisfy the baby longer at night, and switching partners does not guarantee that the baby will go to sleep better.

A young boy is found squirting lighter fluid into his mouth. His father calls the emergency department. The nurse taking the call should know that the primary danger is what? a. Hepatic dysfunction b. Dehydration secondary to vomiting c. Esophageal stricture and shock d. Bronchitis and chemical pneumonia

ANS: D Lighter fluid is a hydrocarbon. The immediate danger is aspiration. Acetaminophen overdose, not hydrocarbons, causes hepatic dysfunction. Dehydration is not the primary danger. Esophageal stricture is a late or chronic consequence of hydrocarbon ingestion.

What statement characterizes moral development in the older school-age child? a. Rule violations are viewed in an isolated context. b. Judgments and rules become more absolute and authoritarian. c. The child remembers the rules but cannot understand the reasons behind them. d. The child is able to judge an act by the intentions that prompted it rather than just by the consequences.

ANS: D Older school-age children are able to judge an act by the intentions that prompted the behavior rather than just by the consequences. Rule violation is likely to be viewed in relation to the total context in which it appears. Rules and judgments become less absolute and authoritarian. The situation and the morality of the rule itself influence reactions.

What is the role of the peer group in the life of school-age children? a. Decreases their need to learn appropriate sex roles b. Gives them an opportunity to learn dominance and hostility c. Allows them to remain dependent on their parents for a longer time d. Provides them with security as they gain independence from their parents

ANS: D Peer group identification is an important factor in gaining independence from parents. Through peer relationships, children learn ways to deal with dominance and hostility. They also learn how to relate to people in positions of leadership and authority and how to explore ideas and the physical environment. A childs concept of appropriate sex roles is influenced by relationships with peers.

An infant, age 6 months, has six teeth. The nurse should recognize that this is what? a.Normal tooth eruption b.Delayed tooth eruption c.Unusual and dangerous d.Earlier than expected tooth eruption

ANS: D Six months is earlier than expected to have six teeth. At age 6 months, most infants have two teeth. Although unusual, having six teeth at 6 months is not dangerous.

The parents of a 5-year-old child ask the nurse, How many hours of sleep a night does our child need? The nurse should give which response? a. A 5-year-old child requires 8 hours of sleep. b. A 5-year-old child requires 9.5 hours of sleep. c. A 5-year-old child requires 10 hours of sleep. d. A 5-year-old child requires 11.5 hours of sleep.

ANS: D Sleep requirements decrease during school-age years; 5-year-old children generally require 11.5 hours of sleep.

A child with acetaminophen (Tylenol) poisoning has been admitted to the emergency department. What antidote does the nurse anticipate being prescribed? a.Carnitine (Carnitor) b.Fomepizole (Antizol) c.Deferoxamine (Desferal) d.N-acetylcysteine (Mucomyst)

ANS: D The antidote for acetaminophen (Tylenol) poisoning is N-acetylcysteine (Mucomyst). Carnitine (Carnitor) is an antidote for valproic acid (Depakote), fomepizole (Antizol) is the antidote for methanol poisoning, and deferoxamine (Desferal) is the antidote for iron poisoning.

When only one child is abused in a family, the abuse is usually a result of what? a. The child is the firstborn. b. The child is the same gender as the abusing parent. c. The parent abuses the child to avoid showing favoritism. d. The parent is unable to deal with the child's behavioral style.

ANS: D The child unintentionally contributes to the abuse. The "fit" or compatibility between the child's temperament and the parent's ability to deal with that behavior style is an important predictor. Birth order and gender can contribute to abuse, but there is not a specific birth order or gender relationship that is indicative of abuse. Being the firstborn or the same gender as the abuser is not linked to child abuse. Avoidance of favoritism is not usually a cause of abuse.

An older school-age child asks the nurse, "What is the reason for this topical corticosteroid cream?" What rationale should the nurse give? a. The cream is used for an antifungal effect. b. The cream is used for an analgesic effect. c. The cream is used for an antibacterial effect. d. The cream is used for an anti-inflammatory effect.

ANS: D The glucocorticoids are the therapeutic agents used most widely for skin disorders. Their local anti-inflammatory effects are merely palliative, so the medication must be applied until the disease state undergoes a remission or the causative agent is eliminated. It does not have an antifungal, analgesic, or antibacterial effect.

The school nurse is reviewing the process of wound healing. What is the initial response at the site of injury? a. Contraction b. Maturation c. Fibroplasia d. Inflammation

ANS: D The initial response at the site of injury is inflammation, a vascular and cellular response that prepares the tissues for the subsequent repair process. Fibroplasia (granulation or proliferation), the second phase of healing, lasts from 5 days to 4 weeks. During contraction and maturation, the third and fourth phases of wound healing, collagen continues to be deposited and organized into layers, compressing the new blood vessels and gradually stopping blood flow across the wound.

What do nursing interventions to promote health during middle childhood include? a. Stress the need for increased calorie intake to meet increased demands. b. Instruct parents to defer questions about sex until the child reaches adolescence. c. Advise parents that the child will need increasing amounts of rest toward the end of this period. d. Educate parents about the need for good dental hygiene because these are the years in which permanent teeth erupt.

ANS: D The permanent teeth erupt during the school-age years. Good dental hygiene and regular attention to dental caries are vital parts of health supervision during this period. Caloric needs are decreased in relation to body size for this age group. Balanced nutrition is essential to promote growth. Questions about sex should be addressed honestly as the child asks questions. The child usually no longer needs a nap, but most require approximately 11 hours of sleep each night at age 5 years and 9 hours at age 12 years.

What is characteristic of children with posttraumatic stress disorder (PTSD)? a. Denial as a defense mechanism is unusual. b. Traumatic effects cannot remain indefinitely. c. Previous coping strategies and defense mechanisms are not useful. d. Children often play out the situation over and over again

ANS: D The third phase of adjustment to PTSD involves the children playing out the situation over and over to come to terms with their fears. Denial is frequently used as a defense mechanism during the second phase. For some children, traumatic effects can remain indefinitely. Coping is a learned response. During the third stage, the children can be helped to use their coping strategies to deal with their fears.

The parents of a 12-month-old child ask the nurse if the child can eat hot dogs as do their other children. The nurse's reply should be based on what? a.The child is too young to digest hot dogs. b.The child is too young to eat hot dogs safely. c.Hot dogs must be sliced into sections to prevent aspiration. d.Hot dogs must be cut into small, irregular pieces to prevent aspiration.

ANS: D To eat a hot dog safely, the child should be sitting down, and the hot dog should be cut into small, irregular pieces rather than served whole or in slices. The child's digestive system is mature enough to digest hot dogs. Hot dogs are of a consistency, diameter, and shape that may cause complete obstruction of the child's airway if not cut into irregular, small pieces.

The school nurse is discussing after-school sports participation with parents of children age 10 years. The nurses presentation includes which important consideration? a. Teams should be gender specific. b. Organized sports are not appropriate at this age. c. Competition is detrimental to the establishment of a positive self-image. d. Sports participation is encouraged if the type of sport is appropriate to the childs abilities.

ANS: D Virtually every child is suited for some type of sport. The child should be matched to the type of sport appropriate to his or her abilities and physical and emotional makeup. At this age, girls and boys have the same basic structure and similar responses to exercise and training. After puberty, teams should be gender specific because of the increased muscle mass in boys. Organized sports help children learn teamwork and skill acquisition. The emphasis should be on playing and learning. Children do enjoy appropriate levels of competition.

32. The nurse is teaching parents about caring for their infant with seborrheic dermatitis (cradle cap). Which statement by the parents indicates understanding of the teaching? a. "We will rinse off the shampoo quickly and dry the scalp thoroughly." b. "We will shampoo the hair every other day with antiseborrheic shampoo." c. "We will be sure to shampoo the hair without removing any of the crusts." d. "We will use a fine-tooth comb to help remove the loosened crusts from the strands of hair."

ANS: D A fine-tooth comb or a soft facial brush helps remove the loosened crusts from the strands of hair after shampooing. This is an accurate statement. Shampoo should applied to the scalp and allowed to remain on the scalp until the crusts soften. Shampoo should not be rinsed off quickly. The crusts should be removed, and shampooing with antiseborrheic shampoo should be done daily, not every other day. DIF: Cognitive Level: Applying REF: p. 467 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

The nurse is guiding parents in selecting a daycare facility for their child. Which is especially important to consider when making the selection? a. Structured learning environment b. Socioeconomic status of children c. Cultural similarities of children d. Teachers knowledgeable about development

ANS: D A teacher knowledgeable about development will structure activities for learning. A structured learning environment is not necessary at this age. Socioeconomic status is not the most important factor in selecting a preschool. Preschool is about expanding experiences with others, so cultural similarities are not necessary. DIF: Cognitive Level: Apply REF: p. 384 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance

The school nurse recognizes that adolescents should get how many hours of sleep each night? a. 6 hours b. 7 hours c. 8 hours d. 9 hours

ANS: D Adolescents should generally get around 9 hours of sleep each night.

The nurse is preparing a pamphlet for parents of adolescents about guidance during the adolescent years. What suggestion should the nurse include in the pamphlet? a. Provide criticism when mistakes are made or when views are different. b. Use comparisons with older siblings or extended family to promote good outcomes. c. Begin to disengage from school functions to allow the adolescent to gain independence. d. Provide clear, reasonable limits and define consequences when rules are broken.

ANS: D An anticipatory guideline to include when teaching parents of adolescents is to provide clear, reasonable limits and have clear consequences when rules are broken. Parents should avoid criticism when mistakes are made and should allow opportunities for the teen to voice different views and opinions. Parents should try to avoid comparing the teen with a sibling or extended family member. Parents should try to be more engaged in the teen's school functions to show support and unconditional love.

At what age should the nurse expect a child to give both first and last names when asked? a. 15 months b. 18 months c. 24 months d. 30 months

ANS: D At 30 months, the child is able to give both first and last names and refer to self with an appropriate pronoun. At 15 and 18 months, the child is too young to give his or her own name. At 24 months, the child is able to give first name and refer to self by that name.

Which characteristic best describes the language of a 3-year-old child? a. Asks meanings of words b. Follows directional commands c. Describes an object according to its composition d. Talks incessantly regardless of whether anyone is listening

ANS: D Because of the dramatic vocabulary increase at this age, 3-year-olds are known to talk incessantly regardless of whether anyone is listening. A 4- to 5-year-old asks lots of questions and can follow simple directional commands. A 6-year-old can describe an object according to its composition. DIF: Cognitive Level: Understand REF: p. 385 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance

10. Which statement best describes colic? a. Periods of abdominal pain resulting in weight loss b. Usually the result of poor or inadequate mothering c. Periods of abdominal pain and crying occurring in infants older than age 6 months d. A paroxysmal abdominal pain or cramping manifested by episodes of loud crying

ANS: D Colic is described as paroxysmal abdominal pain or cramping that is manifested by loud crying and drawing up the legs to the abdomen. Weight loss is not part of the clinical picture. There are many theories about the cause of colic. Emotional stress or tension between the parent and child is one component. This is not consistent throughout all cases. Colic is most common in infants younger than 3 months of age. DIF: Cognitive Level: Understanding REF: p. 470 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

3. The nurse is helping parents achieve a more nutritionally adequate vegetarian diet for their children. Which is most likely lacking in their particular diet? a. Fat b. Protein c. Vitamins C and A d. Iron and calcium

ANS: D Deficiencies can occur when various substances in the diet interact with minerals. For example, iron, zinc, and calcium can form insoluble complexes with phytates or oxalates (substances found in plant proteins), which impair the bioavailability of the mineral. This type of interaction is important in vegetarian diets because plant foods such as soy are high in phytates. Fat and vitamins C and A are readily available from vegetable sources. Plant proteins are available. DIF: Cognitive Level: Applying REF: p. 454 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity

9. Which term refers to the relative lactase deficiency observed in preterm infants of less than 34 weeks of gestation? a. Congenital lactase deficiency b. Primary lactase deficiency c. Secondary lactase deficiency d. Developmental lactase deficiency

ANS: D Developmental lactase deficiency refers to the relative lactase deficiency observed in preterm infants of less than 34 weeks of gestation. Congenital lactase deficiency occurs soon after birth after the newborn has consumed lactose-containing milk. Primary lactase deficiency, sometimes referred to as late-onset lactase deficiency, is the most common type of lactose intolerance and is manifested usually after 4 or 5 years of age. Secondary lactase deficiency may occur secondary to damage of the intestinal lumen, which decreases or destroys the enzyme lactase. DIF: Cognitive Level: Understanding REF: p. 462 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

What is true concerning the development of autonomy during adolescence? a. Development of autonomy typically involves rebellion. b. Development of autonomy typically involves parent-child conflicts. c. Parent and peer influences are opposing forces in the development of autonomy. d. Conformity to both parents and peers gradually declines toward the end of adolescence.

ANS: D During middle and late adolescence, the conformity to parents and peers declines. Subjective feelings of self-reliance increase steadily over the adolescent years. Adolescents have genuine behavioral autonomy. Rebellion is not typically part of adolescence. It can occur in response to excessively controlling circumstances or to growing up in the absence of clear standards. Parent and peer relationships can play complementary roles in the development of a healthy degree of individual independence

29. An infant has been diagnosed with failure to thrive (FTT) classified according to the pathophysiology of inadequate caloric intake. The nurse understands that the reason for the FTT is most likely related to what? a. Cow's milk allergy b. Congenital heart disease c. Metabolic storage disease d. Incorrect formula preparation

ANS: D FTT classified according to the pathophysiology of inadequate caloric intake is related to incorrect formula preparation, neglect, food fads, excessive juice poverty, breastfeeding problems, behavioral problems affecting eating, parental restriction of caloric intake, or central nervous system problems affecting intake consumption. Cow's milk allergy would be related to the pathophysiology of inadequate absorption, congenital heart disease would be related to the pathophysiology of increased metabolism, and metabolic storage disease is related to defective utilization. DIF: Cognitive Level: Analyzing REF: p. 463 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

1. Rickets is caused by a deficiency in what? a. Vitamin A b. Vitamin C c. Folic acid and iron d. Vitamin D and calcium

ANS: D Fat-soluble vitamin D and calcium are necessary in adequate amounts to prevent rickets. No correlation exists between rickets and folic acid, iron, or vitamins A and C. DIF: Cognitive Level: Remembering REF: p. 452 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

The nurse recommends to parents that peanuts are not a good snack food for toddlers. The nurse's rationale for this action is that they: a. are low in nutritive value. b. are high in sodium. c. cannot be entirely digested. d. can be easily aspirated.

ANS: D Foreign-body aspiration is common during the second year of life. Although they chew well, this age child may have difficulty with large pieces of food, such as meat and whole hot dogs, and with hard foods, such as nuts or dried beans. Peanuts have many beneficial nutrients, but should be avoided because of the risk of aspiration in this age group. The sodium level may be a concern, but the risk of aspiration is more important. Many foods pass through the gastrointestinal tract incompletely undigested. This is not necessarily detrimental to the child.

The school nurse recognizes that pubertal delay in girls is considered if breast development has not occurred by which age? a. 10 years b. 11 years c. 12 years d. 13 years

ANS: D Girls may be considered to have pubertal delay if breast development has not occurred by age 13 years or if menarche has not occurred within 2 to 2 1/2 years of the onset of breast development.

Adolescents often do not use reasoned decision making when issues such as substance abuse and sexual behavior are involved. What is this because of? a. They tend to be immature. b. They do not need to use reasoned decision making. c. They lack cognitive skills to use reasoned decision making. d. They are dealing with issues that are stressful and emotionally laden.

ANS: D In the face of time pressures, personal stress, or overwhelming peer pressure, young people are more likely to abandon rational thought processes. Many of the health-related decisions adolescents confront are emotionally laden or new. Under such conditions, many people do not use their capacity for formal decision making. The majority of adolescents have cognitive skills and are capable of reasoned decision making. Stress affects their ability to process information. Reasoned decision making should be used in issues that are crucial such as substance abuse and sexual behavior.

The psychosocial developmental tasks of toddlerhood include which characteristic? a. Development of a conscience b. Recognition of sex differences c. Ability to get along with age-mates d. Ability to delay gratification

ANS: D If the need for basic trust has been satisfied, then toddlers can give up dependence for control, independence, and autonomy. One of the tasks that the toddler is concerned with is the ability to delay gratification. Development of a conscience occurs during the preschool years. The recognition of sex differences occurs during the preschool years. The ability to get along with age-mates develops during the preschool and school-age years.

The nurse is assessing the Tanner stage in an adolescent male. The nurse recognizes that the stages are based on what? a. Hair growth on the face and chest b. Changes in the voice to a deeper timbre c. Muscle growth in the arms, legs, and shoulders d. Size and shape of the penis and scrotum and distribution of pubic hair

ANS: D In males, the Tanner stages describe pubertal development based on the size and shape of the penis and scrotum and the shape and distribution of pubic hair. During puberty, hair begins to grow on the face and chest; the voice becomes deeper; and muscles grow in the arms, legs, and shoulders, but these are not used for the Tanner stages

33. The nurse is administering an oral antihistamine at bedtime to a child with atopic dermatitis (eczema). Which antihistamine should the nurse expect to be prescribed at bedtime? a. Cetirizine (Zyrtec) b. Loratadine (Claritin) c. Fexofenadine (Allegra) d. Diphenhydramine (Benadryl)

ANS: D Oral antihistamine drugs such as hydroxyzine or diphenhydramine usually relieve moderate or severe pruritus. Nonsedating antihistamines such as cetirizine (Zyrtec), loratadine (Claritin), or fexofenadine (Allegra) may be preferred for daytime pruritus relief. Because pruritus increases at night, a mildly sedating antihistamine such as Benadryl is prescribed. DIF: Cognitive Level: Applying REF: p. 469 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

Which best describes signs and symptoms as part of a nursing diagnosis? a. Description of potential risk factors b. Identification of actual health problems c. Human response to state of illness or health d. Cues and clusters derived from patient assessment

ANS: D Signs and symptoms are the cues and clusters of defining characteristics that are derived from a patient assessment and indicate actual health problems. The first part of the nursing diagnosis is the problem statement, also known as the human response to the state of illness or health. The identification of actual health problems may be part of the medical diagnosis. The nursing diagnosis is based on the human response to these problems. The human response is therefore a component of the nursing diagnostic statement. Potential risk factors are used to identify nursing care needs to avoid the development of an actual health problem when a potential one exists.

The nurse should assess which age group for suicide ideation since suicide in which age group is the third leading cause of death? a. Preschoolers b. Young school age c. Middle school age d. Late school age and adolescents

ANS: D Suicide is the third leading cause of death in children ages 10 to 19 years; therefore, the age group should be late school age and adolescents. Suicide is not one of the leading causes of death for preschool and young or middle school-aged children.

A nurse is planning care for a 17-month-old child. According to Piaget, which stage should the nurse expect the child to be in cognitively? a. Trust b. Preoperational c. Secondary circular reaction d. Tertiary circular reaction

ANS: D The 17-month-old child is in the fifth stage of the sensorimotor phase, tertiary circular reactions. The child uses active experimentation to achieve previously unattainable goals. Trust is Erikson's first stage. Preoperational is the stage of cognitive development usually present in older toddlers and preschoolers. Secondary circular reactions last from about ages 4 to 8 months.

Which characteristic best describes the gross motor skills of a 24-month-old child? a. Skips and can hop in place on one foot b. Rides tricycle and broad jumps c. Jumps with both feet and stands on one foot momentarily d. Walks up and down stairs and runs with a wide stance

ANS: D The 24-month-old child can go up and down stairs alone with two feet on each step and runs with a wide stance. Skipping and hopping on one foot are achieved by 4-year-old children. Jumping with both feet and standing on one foot momentarily are achieved by 30-month-old children. Tricycle riding and broad jumping are achieved at age 3.

The parents of a newborn say that their toddler "hates the baby; he suggested that we put him in the trash can so the trash truck could take him away." Which is the nurse's best reply? a. "Let's see if we can figure out why he hates the new baby." b. "That's a strong statement to come from such a small boy." c. "Let's refer him to counseling to work this hatred out. It's not a normal response." d. "That is a normal response to the birth of a sibling. Let's look at ways to deal with this."

ANS: D The arrival of a new infant represents a crisis for even the best-prepared toddler. Toddlers have their entire schedule and routines disrupted because of the new family member. The nurse should work with parents on ways to involve the toddler in the newborn's care and to help focus attention on the toddler. The toddler does not hate the infant. This is an expected response to the changes in routines and attention that affect the toddler. The toddler can be provided with a doll to tend to the doll's needs at the same time the parent is performing similar care for the newborn.

A father tells the nurse that his daughter wants the same plate and cup used at every meal, even if they go to a restaurant. The nurse should explain that this is: a. a sign the child is spoiled. b. a way to exert unhealthy control. c. regression, common at this age. d. ritualism, common at this age.

ANS: D The child is exhibiting the ritualism that is characteristic at this age. Ritualism is the need to maintain sameness and reliability. It provides a sense of comfort to the toddler. It will dictate certain principles in feeding practices, including rejecting a favorite food because it is served in a different container. Ritualism is not indicative of a child who has unreasonable expectations, but rather normal development. Toddlers use ritualistic behaviors to maintain necessary structure in their lives. This is not regression, which is a retreat from a present pattern of functioning.

21. The nurse is interviewing the parents of a 4-month-old boy brought to the hospital emergency department. The infant is dead, and no attempt at resuscitation is made. The parents state that the baby was found in his crib with a blanket over his head, lying face down in bloody fluid from his nose and mouth. The nurse might initially suspect his death was caused by what? a. Suffocation b. Child abuse c. Infantile apnea d. Sudden infant death syndrome (SIDS)

ANS: D The description of how the child was found in the crib is suggestive of SIDS. The nurse is careful to tell the parents that a diagnosis cannot be confirmed until an autopsy is performed. DIF: Cognitive Level: Applying REF: p. 473 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

The school nurse is teaching a class on injury prevention. What should be included when discussing firearms? a. Adolescents are too young to use guns properly for hunting. b. Gun carrying among adolescents is on the rise, primarily among inner-city youth. c. Nonpowder guns (air rifles, BB guns) are a relatively safe alternative to powder guns. d. Adolescence is the peak age for being a victim or offender in the case of injury involving a firearm.

ANS: D The increase in gun availability in the general population is linked to increased gun deaths among children, especially adolescents. Gun carrying among adolescents is on the rise and not limited to the stereotypic inner-city youth. Adolescents can be taught to safely use guns for hunting, but they must be stored properly and used only with supervision. Nonpowder guns (air rifles, BB guns) cause almost as many injuries as powder guns.

17. Where do eczematous lesions most commonly occur in an infant? a. Abdomen, cheeks, and scalp b. Buttocks, abdomen, and scalp c. Back and flexor surfaces of the arms and legs d. Cheeks and extensor surfaces of the arms and legs

ANS: D The lesions of atopic dermatitis are generalized in infants. They are most common on the cheeks, scalp, trunk, and extensor surfaces of the extremities. The abdomen and buttocks are not common sites of lesions. The back and flexor surfaces are not usually involved. DIF: Cognitive Level: Understanding REF: p. 468 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

A 16-year-old adolescent boy tells the school nurse that he is gay. The nurse's response should be based on what? a. He is too young to have had enough sexual activity to determine this. b. The nurse should feel open to discussing his or her own beliefs about homosexuality. c. Homosexual adolescents do not have concerns that differ from those of heterosexual adolescents. d. It is important to provide a nonthreatening environment in which he can discuss this.

ANS: D The nurse needs to be open and nonjudgmental in interactions with adolescents. This will provide a safe environment in which to provide appropriate health care. Adolescence is when sexual identity develops. The nurse's own beliefs should not bias the interaction with this student. Homosexual adolescents face very different challenges as they grow up because of society's response to homosexuality.

A parent asks the nurse about negativism in toddlers. Which is the most appropriate recommendation? a. Punish the child. b. Provide more attention. c. Ask child not always to say "no." d. Reduce the opportunities for a "no" answer.

ANS: D The nurse should suggest to the parent that questions be phrased with realistic choices rather than yes or no answers. This provides the toddler with a sense of control and reduces the opportunity for negativism. Negativism is not an indication of stubbornness or insolence and should not be punished. The negativism is not a function of attention; the child is testing limits to gain an understanding of the world. The toddler is too young to be asked to not always say "no."

In terms of fine motor development, which should the 3-year-old child be expected to do? a. Lace shoes and tie shoelaces with a bow. b. Use scissors to cut pictures, and print a few numbers. c. Draw a person with seven parts and correctly identify the parts. d. Draw a circle and name what has been drawn.

ANS: D Three-year-olds are able to accomplish this fine motor skill. Being able to lace shoes and tie shoelaces with a bow, use scissors to cut pictures, and print a few numbers, or draw a person with seven parts and correctly identify the parts are fine motor skills of 4- or 5-year-olds. DIF: Cognitive Level: Understand REF: p. 380 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance

Which should the nurse expect of a healthy 3-year-old child? a. Jump rope b. Ride a two-wheel bicycle c. Skip on alternate feet d. Balance on one foot for a few seconds

ANS: D Three-year-olds are able to accomplish this gross motor skill. Jumping rope, riding a two-wheel bicycle, and skipping on alternate feet are gross motor skills of 5-year-olds. DIF: Cognitive Level: Understand REF: p. 391 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance

Which factor is most important in predisposing toddlers to frequent infections? a. Respirations are abdominal. b. Pulse and respiratory rates are slower than those in infancy. c. Defense mechanisms are less efficient than those during infancy. d. Toddlers have a short, straight internal ear canal and large lymph tissue.

ANS: D Toddlers continue to have the short, straight internal ear canal of infants. The lymphoid tissue of the tonsils and adenoids continues to be relatively large. These two anatomic conditions combine to predispose the toddler to frequent infections. The abdominal respirations and lowered pulse and respiratory rate of toddlers do not affect their susceptibility to infection. The defense mechanisms are more efficient compared with those of infancy

The nurse is caring for a child with a decubiti on the buttocks. The nurse notes that the dressing covering the decubiti is loose. What action should the nurse implement? a. Retape the dressing. b. Remove the dressing. c. Change the dressing. d. Reinforce the dressing.

ANS:C Dressings should always be changed when they are loose or soiled. They should be changed more frequently in areas where contamination is likely (e.g., sacral area, buttocks, tracheal area). The dressing should not be retaped, removed, or reinforced.

What is an important consideration in the diagnosis of attention deficit hyperactivity disorder (ADHD)? a. Learning disabilities are apparent at an early age. b. The child will always be distracted by external stimuli. c. Parental observations of the child's behavior are most relevant. d. It must be determined whether the child's behavior is age appropriate or problematic

ANS:D The diagnosis of ADHD is complex. A multidisciplinary evaluation should be done to determine whether the child's behavior is appropriate for the developmental age or whether it is problematic. Learning disabilities are usually not evident until the child enters school. Each child with ADHD responds differently to stimuli. Some children are distracted by internal stimuli and others by external stimuli. Parents can only provide one viewpoint of the child's behavior. Many observers should be asked to provide input with structured tools to facilitate the diagnosis.

Removal of the superficial layers of skin by rubbing or scraping

Abrasion

When the nurse interviews an adolescent, which is especially important? Focus the discussion on the peer group. Allow an opportunity to express feelings. Use the same type of language as the adolescent. Emphasize that confidentiality will always be maintained.

Allow an opportunity to express feelings. Adolescents, like all children, need opportunities to express their feelings. Often they interject feelings into their words. The nurse must be alert to the words and feelings expressed. The nurse should maintain a professional relationship with adolescents. To avoid misunderstanding or misinterpretation of words and phrases used, the nurse should clarify the terms used, what information will be shared with other members of the health care team, and any limits to confidentiality. Although the peer group is important to this age group, the interview should focus on the adolescent.

A 4-year-old girl is admitted to outpatient surgery for removal of a cyst on her back. Her mother puts the hospital gown on her, but the child is crying because she wants to leave on her underpants. What is the most appropriate nursing action at this time? Allow her to wear her underpants. Discuss with her mother why this is important to the child. Ask her mother to explain to her why she cannot wear them. Explain in a kind, matter-of-fact manner that this is hospital policy.

Allow her to wear her underpants It is appropriate for the child to leave her underpants on. If necessary, the underpants can be removed after she has received the initial medications for anesthesia. This allows her some measure of control in this procedure. The mother should not be required to make the child more upset. The child is too young to understand what hospital policy means.

Absence of sensation

Anesthesia

A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as acetaminophen. How should the nurse respond to the parents? Febrile seizures can result. Antipyretics may cause malignant hyperthermia. Correct Antipyretics are of no value in treating hyperthermia. Liver damage may occur in critically ill children.

Antipyretics are of no value in treating hyperthermia Unlike with fever, antipyretics are of no value in hyperthermia because the set point is already normal. Cooling measures are used instead. Antipyretics do not cause seizures. Malignant hyperthermia is a genetic myopathy that is triggered by anesthetic agents. Antipyretic agents do not have this effect. Acetaminophen can result in liver damage if too much is given or if the liver is already compromised. Other antipyretics are available, but they are of no value in hyperthermia.

The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother staying in the room or leaving. This action should be considered which? a. Appropriate because of childs age b. Appropriate, but the mother may be uncomfortable c. Inappropriate because of childs age d. Inappropriate because child is same sex as mother

Appropriate because of childs age It is appropriate to give older school-age children the option of having the parent present or not. During the examination, the nurse should respect the childs need for privacy. Children who are 10 years old are minors, and parents are responsible for health care decisions. The mother of a 10-year-old child would not be uncomfortable. The child should help determine who is present during the examination.

The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active? a. Ask her, Are you sexually active? b. Ask her, Are you having sex with anyone? c. Ask her, Are you having sex with a boyfriend? d. Ask both the girl and her parent if she is sexually active.

Ask her, Are you having sex with anyone? Asking the adolescent girl if she is having sex with anyone is a direct question that is well understood. The phrase sexually active is broadly defined and may not provide specific information for the nurse to provide necessary care. The word anyone is preferred to using gender-specific terms such as boyfriend or girlfriend. Using gender-neutral terms is inclusive and conveys acceptance to the adolescent. Questioning about sexual activity should occur when the adolescent is alone.

The nurse is taking a health history of an adolescent. Which best describes how the chief complaint should be determined? a. Request a detailed listing of symptoms. b. Ask the adolescent, Why did you come here today? c. Interview the parent away from the adolescent to determine the chief complaint. d. Use what the adolescent says to determine, in correct medical terminology, what the problem is.

Ask the adolescent, Why did you come here today? The chief complaint is the specific reason for the childs visit to the clinic, office, or hospital. Because the adolescent is the focus of the history, this is an appropriate way to determine the chief complaint. Requesting a detailed list of symptoms makes it difficult to determine the chief complaint. The parent and adolescent may be interviewed separately, but the nurse should determine the reason the adolescent is seeking attention at this time. The chief complaint is usually written in the words that the parent or adolescent uses to describe the reason for seeking help.

Frequent urine tests for specific gravity are required on a 6-month-old infant. What method is the most appropriate way to collect small amounts of urine for these tests? Apply a urine collection bag to the perineal area. Tape a small medicine cup inside of the diaper. Aspirate urine from cotton balls inside the diaper with a syringe without a needle. Use a syringe without a needle to aspirate urine from a superabsorbent disposable diaper.

Aspirate urine from cotton balls inside the diaper with a syringe without a needle To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly from the diaper. Diapers with superabsorbent gels absorb the urine; if these are used, place a small gauze dressing or cotton balls inside the diaper to collect the urine and aspirate the urine with a syringe. For frequent urine sampling, the collection bag would be too irritating to the child s skin. It is not feasible to tape a small medicine cup to the inside of the diaper; the urine will spill from the cup.

What is the best method to verify the placement of a nasogastric tube before each use? Radiologic confirmation Auscultation of injected air Aspiration of stomach contents Verification of tape placement on tube

Aspiration of stomach contents Visual inspection and pH check of stomach contents is a reliable method of determining placement before each use. Radiologic examination should be obtained after initial placement but would be too cumbersome to do before each use. Auscultation is an unreliable method to confirm tube placement because of the similarity of sounds produced by air in the bronchus, esophagus, or pleural space. Verification of tape placement on the tube can be inaccurate if the tube has moved within the tape or become dislodged from the stomach.

Forcible pulling out or extraction of tissue

Avulsion

A bone marrow aspiration and biopsy are needed on a school-age child. The most appropriate action to provide analgesia during the procedure is which? A. Administer TAC (tetracaine, adrenalin, and cocaine) 15 minutes before the procedure. B. Use a combination of fentanyl and midazolam for conscious sedation. C. Apply EMLA (eutectic mixture of local anesthetics) 1 hour before the procedure. D. Apply a transdermal fentanyl (Duragesic) patch immediately before the procedure.

B A bone marrow biopsy is a painful procedure. The combination of fentanyl and midazolam should be used to provide conscious sedation. TAC provides skin anesthesia about 15 minutes after it is applied to nonintact skin. The gel can be placed on a wound for suturing. It is not sufficient for a bone marrow biopsy. EMLA is an effective topical analgesic agent when applied to the skin 60 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. For this procedure, systemic analgesia is required. Transdermal fentanyl patches are useful for continuous pain control, not rapid pain control.

A cancer patient is experiencing neuropathic cancer pain. Which prescription should the nurse expect to be ordered to control anxiety? A. Lorazepam (Ativan) B. Gabapentin (Neurontin) C. Hydromorphone (Dilaudid) D. Morphine sulfate (MS Contin)

B Anticonvulsants (gabapentin, carbamazepine) have demonstrated effectiveness in neuropathic cancer pain. Ativan is an antianxiety agent, and Dilaudid and MS Contin are opioid analgesics.

Which is the most consistent and commonly used data for assessment of pain in infants? A. Self-report B. Behavioral C. Physiologic D. Parental report

B Behavioral assessment is useful for measuring pain in young children and preverbal children who do not have the language skills to communicate that they are in pain. Infants are not able to self-report. Physiologic measures are not able to distinguish between physical responses to pain and other forms of stress. Parental report without a structured tool may not accurately reflect the degree of discomfort.

The parents of a preterm infant in a neonatal intensive care unit are concerned about their infant experiencing pain from so many procedures. The nurse s response should be based on which characteristic about preterm infants pain? A. They may react to painful stimuli but are unable to remember the pain experience. B. They perceive and react to pain in much the same manner as children and adults. C. They do not have the cortical and subcortical centers that are needed for pain perception. D. They lack neurochemical systems associated with pain transmission and modulation.

B Numerous research studies have indicated that preterm and newborn infants perceive and react to pain in the same manner as children and adults. Preterm infants can have significant reactions to painful stimuli. Pain can cause oxygen desaturation and global stress response. These physiologic effects must be avoided by use of appropriate analgesia. Painful stimuli cause a global stress response, including cardiorespiratory changes, palmar sweating, increased intracranial pressure, and hormonal and metabolic changes. Adequate analgesia and anesthesia are necessary to decrease the stress response.

What is an important consideration when using the FACES pain rating scale with children? A. Children color the face with the color they choose to best describe their pain. B. The scale can be used with most children as young as 3 years. C. The scale is not appropriate for use with adolescents. D. The FACES scale is useful in pain assessment but is not as accurate as physiologic responses.

B The FACES scale is validated for use with children ages 3 years and older. Children point to the face that best describes their level of pain. The scale can be used through adulthood. The child's estimate of the pain should be used. The physiologic measures may not reflect more long-term pain.

Which drug is usually the best choice for patient-controlled analgesia (PCA) for a child in the immediate postoperative period? A. Codeine sulfate (Codeine) B. Morphine (Roxanol) C. Methadone (Dolophine) D. Meperidine (Demerol)

B The most commonly prescribed medications for PCA are morphine, hydromorphone, and fentanyl. Parenteral use of codeine is not recommended. Methadone in parenteral form is not used in a PCA but is given orally or intravenously for pain in the infant. Meperidine is not used for continuous and extended pain relief.

The nurse is teaching the parents of a child with recurrent headaches methods to modify behavior patterns that increase the risk of headache. Which statement by the parents indicates understanding the teaching? A. We will allow the child to miss school if a headache occurs. B. We will respond matter-of-factly to requests for special attention. C. We will be sure to give much attention to our child when a headache occurs. D. We will be sure our child doesn t have to perform at a band concert if a headache occurs.

B To modify behavior patterns that increase the risk of headache or reinforce headache activity, the nurse instructs the parents to avoid giving excessive attention to their child's headache and to respond matter-of-factly to pain behavior and requests for special attention. Parents learn to assess whether the child is avoiding school or social performance demands because of headache.

What are classified as hydrocarbon poisons? (Select all that apply.) a.Bleach b.Gasoline c.Turpentine d.Lighter fluid e.Oven cleaners

B, C , D

The nurse is administering activated charcoal to a preschool child with acetaminophen (Tylenol) poisoning. What potential complications from the use of activated charcoal should the nurse plan to assess for? (Select all that apply.) a.Diarrhea b.Vomiting c.Fluid retention d.Intestinal obstruction

B, D

What identified characteristics occur more frequently in parents who abuse their children? (Select all that apply.) a.Older parents b.Socially isolated c.Middle class parents d.Single-parent families e.Few supportive relationships

B,D, E

Which is characteristic of X-linked recessive inheritance? a. There are no carriers. b. Affected individuals are principally males. c. Affected individuals are principally females. d. Affected individuals will always have affected parents.

B. Affected individuals are principally females. In X-linked recessive disorders, the affected individuals are usually male. With recessive traits, usually two copies of the gene are needed to produce the effect. Because the male only has one X chromosome, the effect is visible with only one copy of the gene. Females are usually only carriers of X-linked recessive disorders. The X chromosome that does not have the recessive gene will produce the normal protein, so the woman will not show evidence of the disorder. The transmission is from mother to son. Usually the mother and father are unaffected.

Which genetic term refers to a person who possesses one copy of an affected gene and one copy of an unaffected gene and is clinically unaffected? a. Allele b. Carrier c. Pedigree d. Multifactorial

B. Carrier An individual who is a carrier is asymptomatic but possesses a genetic alteration, either in the form of a gene or chromosome change. Alleles are alternative expressions of genes at a different locus. A pedigree is a diagram that describes family relationships, gender, disease, status, or other relevant information about a family. Multifactorial describes a complex interaction of both genetic and environmental factors that produce an effect on the individual.

A woman, age 43 years, is 6 weeks pregnant. It is important that she be informed of which? a. The need for a therapeutic abortion b. Increased risk for Down syndrome c. Increased risk for Turner syndrome d. The need for an immediate amniocentesis

B. Increased risk for Down syndrome. Women who are older than age 35 years at the birth of a single child or 31 years at the birth of twins are advised to have prenatal diagnosis. The risk of having a child with Down syndrome increases with maternal age. There is no indication of a need for a therapeutic abortion at this stage. Turner syndrome is not associated with advanced maternal age. Amniocentesis cannot be done at a gestational age of 6 weeks.

The nurse is assessing a neonate who was born 1 hour ago to healthy white parents in their early forties. Which finding should be most suggestive of Down syndrome? a. Hypertonia b. Low-set ears c. Micrognathia d. Long, thin fingers and toes

B. Low set ears Children with Down syndrome have low-set ears. Infants with Down syndrome have hypotonia, not hypertonia. Micrognathia is common in trisomy 16, not Down syndrome. Children with Down syndrome have short hands with broad fingers.

Which abnormality is a common sex chromosome defect? a. Down syndrome b. Turner syndrome c. Marfan syndrome d. Hemophilia

B. Turner syndrome Turner syndrome is caused by an absence of one of the X chromosomes. Down syndrome is caused by trisomy 21 (three copies rather than two copies of chromosome 21). Marfan syndrome is a connective tissue disorder inherited in an autosomal dominant pattern. Hemophilia is a disorder of blood coagulation inherited in an X-linked recessive pattern.

Which are components of the FLACC scale? (Select all that apply.) A. Capillary refill time B. Correct Leg position C. Correct Facial expression D. Correct Activity

B; C; D Facial expression, consolability, cry, activity, and leg position are components of the FLACC scale. Color is a component of the Apgar scoring system. Capillary refill time is a physiologic measure that is not a component of the FLACC scale.

What is a significant common side effect that occurs with opioid administration? A. Euphoria B. Diuresis C. Constipation D. Allergic reactions

C Constipation is one of the most common side effects of opioid administration. Preventive strategies should be implemented to minimize this problem. Sedation is a more common result than euphoria. Urinary retention, not diuresis, may occur with opiates. Rarely, some individuals may have pruritus.

A child is in the intensive care unit after a motor vehicle collision. The child has numerous fractures and is in pain that is rated 9 or 10 on a 10-point scale. In planning care, the nurse recognizes that the indicated action is which? A. Give only an opioid analgesic at this time. B. Increase dosage of analgesic until the child is adequately sedated. C. Plan a preventive schedule of pain medication around the clock. D. Give the child a clock and explain when she or he can have pain medications.

C For severe postoperative pain, a preventive around the clock (ATC) schedule is necessary to prevent decreased plasma levels of medications. The opioid analgesic will help for the present, but it is not an effective strategy. Increasing the dosage requires an order. The nurse should give the drug on a regular schedule and evaluate the effectiveness. Using a clock is counterproductive because it focuses the child's attention on how long he or she will need to wait for pain relief.

The nurse is planning to administer a nonopioid for pain relief to a child. Which timing should the nurse plan so the nonopioid takes effect? A. 15 minutes until maximum effect B. 30 minutes until maximum effect C. 1 hour until maximum effect D. 1½ hours until maximum effect

C Nonsteroidal antiinflammatory drugs (NSAIDs) can provide safe and effective pain relief when dosed at appropriate levels with adequate frequency. Most NSAIDs take about 1 hour for effect, so timing is crucial.

A 6-year-old child has patient-controlled analgesia (PCA) for pain management after orthopedic surgery. The parents are worried that their child will be in pain. What should your explanation to the parents include? A. The child will continue to sleep and be pain free. B. Parents cannot administer additional medication with the button. C. The pump can deliver baseline and bolus dosages. D. There is a high risk of overdose, so monitoring is done every 15 minutes.

C The PCA prescription can be set for a basal rate for a continuous infusion of pain medication. Additional doses can be administered by the patient, parent, or nurse as necessary. Although the goal of PCA is to have effective pain relief, a pain-free state may not be possible. With a 6-year-old child, the parents and nurse must assess the child to ensure that adequate medication is being given because the child may not understand the concept of pushing a button. Evidence-based practice suggests that effective analgesia can be obtained with the parents and nurse giving boluses as necessary. The prescription for the PCA includes how much medication can be given in a defined period. Monitoring every 1 to 2 hours for patient response is sufficient.

A father with an X-linked recessive disorder asks the nurse what the probability is that his sons will have the disorder. Which response should the nurse make? a. "Male children will be carriers." b. "All male children will be affected." c. "None of the sons will have the disorder." d. "It cannot be determined without more data."

C. "none of the sons will have the disorder." When a male has an X-linked recessive disorder, he has one copy of the allele on his X chromosome. The father passes only his Y chromosome (not the X chromosome) to his sons. Therefore, none of his sons will have the X-linked recessive gene. They will not be carriers or be affected by the disorder. No additional data are needed to answer this question.

Chromosome analysis of the fetus is usually accomplished through the testing of which? a. Fetal serum b. Maternal urine c. Amniotic fluid d. Maternal serum

C. Amniotic fluid Amniocentesis is the most common method to retrieve fetal cells for chromosome analysis. Viable fetal cells are sloughed off into the amniotic fluid, and when a sample is taken, they can be cultured and analyzed. It is difficult to obtain a sample of the fetal blood. It is a high-risk situation for the fetus. Fetal cells are not present in the maternal urine or blood.

Parents ask the nurse about the characteristics of autosomal dominant inheritance. Which statement is characteristic of autosomal dominant inheritance? a. Females are affected with greater frequency than males. b. Unaffected children of affected individuals will have affected children. c. Each child of a heterozygous affected parent has a 50% chance of being affected. d. Any child of two unaffected heterozygous parents has a 25% chance of being affected.

C. Each child of a heterozygous affected parent has a 50% chance of being affected. In autosomal dominant inheritance, only one copy of the mutant gene is necessary to cause the disorder. When a parent is affected, there is a 50% chance that the chromosome with the gene for the disorder will be contributed to each pregnancy. Males and females are equally affected. The disorder does not skip a generation. If the child is not affected, then most likely he or she is not a carrier of the gene for the disorder. In autosomal recessive inheritance, any child of two unaffected heterozygous parents has a 25% chance of being affected.

Which is a sex chromosome abnormality that is caused by the presence of one or more additional X chromosomes in a male? a. Turner b. Triple X c. Klinefelter d. Trisomy 13

C. Klinefelter Klinefelter syndrome is characterized by one or more additional X chromosomes. These individuals are tall with male secondary sexual characteristics that may be deficient, and they may be learning disabled. An absence of an X chromosome results in Turner syndrome. Triple X and trisomy 13 are not abnormalities that involve one or more additional X chromosomes in a male (Klinefelter syndrome).

The nurse is teaching parents of a child with cri du chat syndrome about this disorder. The nurse understands parents understand the teaching if they make which statement? a. "This disorder is very common." b. "This is an autosomal recessive disorder." c. "The crying pattern is abnormal and catlike." d. "The child will always have a moon-shaped face."

C. The crying pattern is abnormal and catlike." Typical of this disease is a crying pattern that is abnormal and catlike. Cri du chat, or cats cry, syndrome is a rare (one in 50,000 live births) chromosome deletion syndrome, not autosomal recessive, resulting from loss of the small arm of chromosome 5. In early infancy this syndrome manifests with a typical but nondistinctive facial appearance, often a moon-shaped face with wide-spaced eyes (hypertelorism). As the child grows, this feature is progressively diluted, and by age 2 years, the child is indistinguishable from age-matched control participants.

Which genetic term refers to the transfer of all or part of a chromosome to a different chromosome after chromosome breakage? a. Trisomy b. Monosomy c. Translocation d. Nondisjunction

C. Translocation Translocation is the transfer of all or part of a chromosome to a different chromosome after chromosome breakage. It can be balanced, producing no phenotypic effects, or unbalanced, producing severe or lethal effects. Trisomy is an abnormal number of chromosomes caused by the presence of an extra chromosome, which is added to a given chromosome pair and results in a total of 47 chromosomes per cell. Monosomy is an abnormal number of chromosomes whereby the chromosome is represented by a single copy in a somatic cell. Nondisjunction is the failure of homologous chromosomes or chromatids to separate during mitosis or meiosis.

The nurse is using the CRIES pain assessment tool on a preterm infant in the neonatal intensive care unit. Which are the components of this tool? (Select all that apply.) A. Color B. Moro reflex C. Oxygen saturation D. Posture of arms and legs E. Sleeplessness F. Facial expression

C; E; F Need for increased oxygen, crying, increased vital signs, expression, and sleeplessness are components of the CRIES pain assessment tool used with neonates. Color, Moro reflex, and posture of arms and legs are not components of the CRIES scale.

Which is the single most important factor to consider when communicating with children? Presence of the childs parent Childs physical condition Childs developmental level Childs nonverbal behaviors

Childs developmental level The nurse must be aware of the childs developmental stage to engage in effective communication. The use of both verbal and nonverbal communication should be appropriate to the developmental level. Nonverbal behaviors vary in importance based on the childs developmental level and physical condition. Although the childs physical condition is a consideration, developmental level is much more important. The presence of parents is important when communicating with young children but may be detrimental when speaking with adolescents.

A child who has cystic fibrosis is admitted to the pediatric unit with methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse recognizes that in addition to a private room, the child is placed on what precautions? Droplet Contact Airborne Standard

Contact MRSA is an increasingly significant source of hospital-acquired infections. This organism meets the criteria of being epidemiologically important and can be transmitted by direct contact. Gowns and gloves should be worn when exposed to potentially contagious materials, and meticulous hand washing is required. S. aureus is not an organism that is spread through airborne or droplet mechanisms. Additional precautions, beyond Standard Precautions, are needed to prevent spread of this organism.

A child with acetylsalicylic acid (aspirin) poisoning is being admitted to the emergency department. What early clinical manifestation does the nurse expect to assess on this child? a.Hematemesis b.Hematochezia c.Hyperglycemia d.Hyperventilation

D

Which nonpharmacologic intervention appears to be effective in decreasing neonatal procedural pain? A. Tactile stimulation B. Commercial warm packs C. Doing procedure during infant sleep D. Oral sucrose and nonnutritive sucking

D Nonnutritive sucking attenuates behavioral, physiologic, and hormonal responses to pain. The addition of sucrose has been demonstrated to have calming and pain-relieving effects for neonates. Tactile stimulation has a variable effect on response to procedural pain. No evidence supports commercial warm packs as a pain control measure. With resulting increased blood flow to the area, pain may be greater. The infant should not be disturbed during the sleep cycle. It makes it more difficult for the infant to begin organization of sleep and awake cycles.

A preterm infant has just been admitted to the neonatal intensive care unit. The infant s parents ask the nurse about anesthesia and analgesia when painful procedures are necessary. What should the nurse's explanation be? A. Nerve pathways of neonates are not sufficiently myelinated to transmit painful stimuli. B. The risks accompanying anesthesia and analgesia are too great to justify any possible benefit of pain relief. C. Neonates do not possess sufficiently integrated cortical function to interpret or recall pain experiences. D. Pain pathways and neurochemical systems associated with pain transmission are intact and functional in neonates.

D Pain pathways and neurochemical systems associated with pain transmission are intact and functional in neonates. Painful stimuli cause a global stress response, including cardiorespiratory changes, palmar sweating, increased intracranial pressure, and hormonal and metabolic changes. Adequate analgesia and anesthesia are necessary to decrease the stress response. The pathways are sufficiently myelinated to transmit the painful stimuli and produce the pain response. Local and systemic pharmacologic agents are available to permit anesthesia and analgesia for neonates.

The nurse is planning pain control for a child. Which is the advantage of administering pain medication by the intravenous (IV) bolus route? A. Less expensive than oral medications B. Produces a first-pass effect through the liver C. Does not need to be administered frequently D. Provides most rapid onset of effect, usually in about 5 minutes

D The advantage of pain medication by the IV bolus route is that it provides the most rapid onset of effect, usually in about 5 minutes. IV medications are more expensive than oral medications, and the IV route bypasses the first-pass effect through the liver. Pain control with IV bolus medication needs to be repeated hourly for continuous pain control.

The nurse is teaching a staff development program about levels of sedation in the pediatric population. Which statement by one of the participants should indicate a correct understanding of the teaching? A. With minimal sedation, the patient s respiratory efforts are affected, and cognitive function is not impaired. B. With general anesthesia, the patient s airway cannot be maintained, but cardiovascular function is maintained. C. During deep sedation, the patient can be easily aroused by loud verbal commands and tactile stimulation. D. During moderate sedation, the patient responds to verbal commands but may not respond to light tactile stimulation.

D When discussing levels of sedation, the participants should understand that during moderate sedation, the patient responds to verbal commands but may not respond to light tactile stimulation, cognitive function is impaired, and respiratory function is adequate. In minimal sedation, the patient responds to verbal commands and may have impaired cognitive function; the respiratory and cardiovascular systems are unaffected. In deep sedation, the patient cannot be easily aroused except by painful stimuli; the airway and spontaneous ventilation may be impaired, but cardiovascular function is maintained. With general anesthesia, the patient loses consciousness and cannot be aroused with painful stimuli, the airway cannot be maintained, and ventilation is impaired; cardiovascular function may or may not be impaired.

The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is which? a. Use the small cuff. b. Use the large cuff. c. Use either cuff using the palpation method. d. Wait to take the blood pressure until a proper cuff can be located.

D) locate the proper size cuff before taking the blood pressure. Rationale: To obtain an accurate blood pressure reading, it is preferable to use the proper-size cuff. Thus locating one before taking the blood pressure is the best nursing action. The smaller cuff gives a falsely increased blood pressure and is not the method of choice. The larger cuff, which may give a falsely lowered blood pressure, is preferable to the smaller cuff, which gives a falsely increased blood pressure, but neither is the method of choice. Auscultation is preferred to palpation.

Parents ask the nurse if there was something that should have been done during the pregnancy to prevent their child's cleft lip. Which statement should the nurse give as a response? a. "This is a type of deformation and can sometimes be prevented." b. "Studies show that taking folic acid during pregnancy can prevent this defect." c. "This is a genetic disorder and has a 25% chance of happening with each pregnancy." d. "The malformation occurs at approximately 5 weeks of gestation; there is no known way to prevent this."

D. "The malformation occurs at approximately 5 weeks of gestation; there is no known way to prevent this." Cleft lip, an example of a malformation, occurs at approximately 5 weeks of gestation when the developing embryo naturally has two clefts in the area. There is no known way to prevent this defect. Deformations are often caused by extrinsic mechanical forces on normally developing tissue. Club foot is an example of a deformation often caused by uterine constraint. Cleft lip is not a genetic disorder; the reasons for this occurring are still unknown. Taking folic acid during pregnancy can help to prevent neural tube disorders but not cleft lip defects.

The nurse is reviewing a client's prenatal history. Which prescribed medication does the nurse understand is not considered a teratogen and prescribed during pregnancy? a. Phenytoin (Dilantin) b. Warfarin (Coumadin) c. Isotretinoin (Accutane) d. Heparin sodium (Heparin)

D. Heparin Sodium (Heparin). Teratogens, agents that cause birth defects when present in the prenatal environment, account for the majority of adverse intrauterine effects not attributable to genetic factors. Types of teratogens include drugs (phenytoin [Dilantin], warfarin [Coumadin], isotretinoin [Accutane]). Heparin is the anticoagulant used during pregnancy and is not a teratogen. It does not cross the placenta.

A couple asks the nurse about the optimal time for genetic counseling. They do not plan to have children for several years. When should the nurse recommend they begin genetic counseling? a. As soon as the woman suspects that she may be pregnant b. Whenever they are ready to start their family c. Now, if one of them has a family history of congenital heart disease d. Now, if they are members of a population at risk for certain diseases

D. Now, if they are members of a population at risk for certain diseases. Persons who seek genetic evaluation and counseling must first be aware if there is a genetic or potential problem in their families. Genetic testing should be done now if the couple is part of a population at risk. It is not feasible at this time to test for all genetic diseases. The optimal time for genetic counseling is before pregnancy occurs. During the pregnancy, genetic counseling may be indicated if a genetic disorder is suspected. Congenital heart disease is not a single-gene disorder.

Using knowledge of child development, what approach is best when preparing a toddler for a procedure? Avoid asking the child to make choices. Plan for a teaching session to last about 20 minutes. Demonstrate on a doll how the procedure will be done. Show the necessary equipment without allowing child to handle it.

Demonstrate on a doll how the procedure will be done Prepare toddlers for procedures by using play. Demonstrate on a doll but avoid the child s favorite doll because the toddler may think the doll is really feeling the procedure. In preparing a toddler for a procedure, the child is allowed to participate in care and help whenever possible. Teaching sessions for toddlers should be about 5 to 10 minutes. Use a small replica of the equipment and allow the child to handle it.

The nurse is preparing a 9-year-old boy before obtaining a blood specimen by venipuncture. The child tells the nurse he does not want to lose his blood. What approach is best by the nurse? Explain that it will not be painful. Suggest to him that he not worry about losing just a little bit of blood. Discuss with him how his body is always in the process of making blood. Tell the child that he will not even need a Band-Aid afterward because it is a simple procedure.

Discuss with him how his body is always in the process of making blood School-age children can understand that blood can be replaced. Explain the procedure to him using correct scientific and medical terminology. The venipuncture will be uncomfortable. It is inappropriate to tell him it will not hurt. Even though the nurse considers it a simple procedure, the boy is concerned. Telling him not to worry will not allay his fears.

The nurse gives an injection in a patient s room. How should the nurse dispose of the needle? Remove the needle from the syringe and dispose of it in a proper container. Dispose of the syringe and needle in a rigid, puncture-resistant container in the patient s room. Close the safety cover on the needle and return it to the medication preparation area for proper disposal. Place the syringe and needle in a rigid, puncture-resistant container in an area outside of the patient s room.

Dispose of the syringe and needle in a rigid, puncture-resistant container in the patient's room All needles (uncapped and unbroken) are disposed of in a rigid, puncture-resistant, tamper-proof container located near the site of use. Consequently, these containers should be installed in the patient s room. Needles and syringes are disposed of uncapped and unbroken. A used needle should not be transported to an area distant from use for disposal.

A 7-year-old is identified as being at risk for skin breakdown. What intervention should the nursing care plan include? Massaging reddened bony prominences Teaching the parents to turn the child every 4 hours Ensuring that nutritional intake meets requirements Minimizing use of extra linens, which can irritate the child s skin

Ensuring that nutritional intake meets requirements Children who are hospitalized and NPO (taking nothing by mouth) for several days are at risk for nutritional deficiencies and skin breakdown. If NPO status is prolonged, parenteral nutrition should be considered. Massaging bony prominences can cause deep tissue damage. This should be avoided. Although parents can participate, turning the child is the nurse s responsibility. If the child is alert and can move, position shifts should be done more frequently. If the child does not move, the nurse should reposition every 2 hours. The number of linens is not an issue. The child should not be dragged across the sheet. Children should be lifted and moved to avoid friction and shearing.

A 10-year-old child requires daily medications for a chronic illness. Her mother tells the nurse that the child continually forgets to take the medicine unless reminded. What nursing action is most appropriate to promote adherence to the medication regimen? Establish a contract with her, including rewards. Suggest time-outs when she forgets her medicine. Discuss with her mother the damaging effects of her rescuing the child. Ask the child to bring her medicine containers to each appointment so they can be counted.

Establish a contract with her, including rewards Many factors can contribute to the child s not taking the medication. The nurse should resolve those issues such as unpleasant side effects, difficulty taking medicine, and time constraints before school. If these factors do not contribute to the issue, then behavioral contracting is usually an effective method to shape behaviors in children. Time-outs provide negative reinforcement. If part of a contract, negative consequences can work, but they need to be structured. Discussing with her mother the damaging effects of her rescuing the child is not the most appropriate action to encourage compliance. For a school-age child, parents should refrain from nagging and rescuing the child. This child is old enough to partially assume responsibility for her own care. If the child brings her medicine containers to each appointment so they can be counted, this will help determine if the medications are being taken, but it will not provide information about whether the child is taking them by herself.

An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is which? Ask her why she wants to know. Determine why she is so anxious. Explain in simple terms how it works. Tell her she will see how it works as it is used

Explain in simple terms how it works. School-age children require explanations and reasons for everything. They are interested in the functional aspect of all procedures, objects, and activities. It is appropriate for the nurse to explain how equipment works and what will happen to the child so that the child can then observe during the procedure. The nurse should respond positively for requests for information about procedures and health information. By not responding, the nurse may be limiting communication with the child. The child is not exhibiting anxiety in asking how the blood pressure apparatus works, just requesting clarification of what will occur.

FLACC pain scale

F: Faces. L: Legs. A: Activity. C: Cry C: Consolability

Because children younger than 5 years are egocentric, the nurse should do which when communicating with them? Focus communication on the child. Use easy analogies when possible. Explain experiences of others to the child. Assure the child that communication is private.

Focus communication on the child. Because children of this age are able to see things only in terms of themselves, the best approach is to focus communication directly on them. Children should be provided with information about what they can do and how they will feel. With children who are egocentric, analogies, experiences, and assurances that communication is private will not be effective because the child is not capable of understanding.

What is an advantage of the ventrogluteal muscle as an injection site in young children? Easily accessible from many directions Free of significant nerves and vascular structures Can be used until child reaches a weight of 9 kg (20 lb) Increased subcutaneous fat, which provides sustained drug absorption

Free of significant nerves and vascular structures Being free of significant nerves and vascular structure is one of the advantages of the ventrogluteal site. In addition, it is considered less painful than the vastus lateralis. The major disadvantage is lack of familiarity by health professionals and controversy over whether the site can be used before weight bearing. The vastus lateralis is a more accessible site. The ventrogluteal muscle site has safely been used from newborn through adulthood. Clinical guidelines address the need for the child to be walking. The site has less subcutaneous tissue, which facilitates intramuscular deposition of the drug rather than subcutaneous.

A 16-year-old girl comes to the pediatric clinic for information on birth control. The nurse knows that before this young woman can be examined, consent must be obtained from which source? Herself Her mother Court order Legal guardian

Herself Contraceptive advice is one of the conditions that is considered medically emancipated. The adolescent is able to provide her own informed consent.

The nurse is interviewing the mother of an infant. The mother reports, I had a difficult delivery, and my baby was born prematurely. This information should be recorded under which heading? a. History b. Present illness c. Chief complaint d. Review of systems

History The history refers to information that relates to previous aspects of the childs health, not to the current problem. The difficult delivery and prematurity are important parts of the infants history. The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Unless the chief complaint is directly related to the prematurity, this information is not included in the history of the present illness. The chief complaint is the specific reason for the childs visit to the clinic, office, or hospital. It should not include the birth information. The review of systems is a specific review of each body system. It does not include the premature birth but might include sequelae such as pulmonary dysfunction.

A bone marrow biopsy will be performed on a 7-year-old girl. She wants her mother to hold her during the procedure. How should the nurse respond? Holding your child is unsafe. Holding may help your child relax. Hospital policy prohibits this interaction. Holding your child is unnecessary given the child s age.

Holding may help your child relax The mother s preference for assisting, observing, or waiting outside the room should be assessed, as well as the child s preference for parental presence. The child s choice should be respected. This will most likely help the child through the procedure. If the mother and child agree, then the mother is welcome to stay. Her familiarity with the procedure should be assessed and potential safety risks identified (mother may sit in chair). Hospital policies should be reviewed to ensure that they incorporate family-centered care.

Excessive sensitiveness

Hyperesthesia

Diminished sensation

Hypesthesia

When teaching a mother how to administer eye drops, where should the nurse tell her to place them? At the lacrimal duct On the sclera while the child looks to the outside In the conjunctival sac when the lower eyelid is pulled down Carefully under the eyelid while it is gently pulled upward

In the conjunctival sac when the lower eyelid is pulled down The lower eyelid is pulled down, forming a small conjunctival sac. The solution or ointment is applied to this area. The medication should not be administered directly on the eyeball. The lacrimal duct is not the appropriate placement for the eye medication. It will drain into the nasopharynx, and the child will taste the drug.

Division of the skin made with a sharp object

Incision

Torn or jagged wound

Laceration

The nurse is preparing to assess a 10-month-old infant. He is sitting on his fathers lap and appears to be afraid of the nurse and of what might happen next. Which initial actions by the nurse should be most appropriate? Initiate a game of peek-a-boo. Ask the infants father to place the infant on the examination table. Talk softly to the infant while taking him from his father. Undress the infant while he is still sitting on his fathers lap.

Initiate a game of peek-a-boo. Peek-a-boo is an excellent means of initiating communication with infants while maintaining a safe, nonthreatening distance. The child will most likely become upset if separated from his father. As much of the assessment as possible should be done with the child on the fathers lap. The nurse should have the father undress the child as needed during the examination.

Guidelines for intramuscular administration of medication in school-age children include what standard? Inject medication as rapidly as possible. Insert needle quickly, using a dartlike motion. Have the child stand if at all possible and if the child is cooperative. Penetrate the skin immediately after cleansing the site while the skin is moist.

Insert needle quickly, using a dartlike motion The needle should be inserted quickly in a dartlike motion at a 90-degree angle unless contraindicated. Inject medications slowly. Allow skin preparation to dry completely before the skin is penetrated. Place the child in a lying or sitting position.

The nurse is seeing an adolescent and the parents in the clinic for the first time. Which should the nurse do first? Introduce him- or herself. Make the family comfortable. Give assurance of privacy. Explain the purpose of the interview.

Introduce him- or herself. The first thing that nurses must do is to introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they specify a preferred name. Clarification of the purpose of the interview and the nurses role is the second thing that should be done. During the initial part of the interview, the nurse should include general conversation to help make the family feel at ease. The interview also should take place in an environment as free of distraction as possible. In addition, the nurse should clarify which information will be shared with other members of the health care team and any limits to the confidentiality.

The nurse has just collected blood by venipuncture in the antecubital fossa. What should the nurse do nextterm-23? Keep the child s arm extended while applying a Band-Aid to the site. Keep the child s arm extended and apply pressure to the site for a few minutes. Apply a Band-Aid to the site and keep the arm flexed for 10 minutes. Apply a gauze pad or cotton ball to the site and keep the arm flexed for several minutes.

Keep the child's arm extended and apply pressure to the site for a few minutes Applying pressure to the site of venipuncture stops the bleeding and aids in coagulation. Pressure should be applied before a bandage or gauze pad is applied.

A 14-year-old adolescent is hospitalized with cystic fibrosis. What nursing note entry represents best documentation of his breakfast meal? Tolerated breakfast well Finished all of breakfast ordered One pancake, eggs, and 240 ml OJ No documentation is needed for this age child.

One pancake, eggs, and 240mL OJ Specific information is necessary for hospitalized children. It is essential to be able to identify caloric intake and eating patterns for assessment and intervention purposes. That he tolerated breakfast well only provides information that the child did not become ill with the meal. Even if he finished all his breakfast, an evaluation cannot be completed unless the quantity of food ordered is known. Nutritional information is essential, especially for children with chronic illnesses.

An appropriate method for administering oral medications that are bitter to an infant or small child should be to mix them with which? Bottle of formula or milk Any food the child is going to eat One teaspoon of something sweet-tasting such as jam Carbonated beverage, which is then poured over crushed ice

One teaspoon of something sweet-tasting such as jam Mix the drug with a small amount (about 1 tsp) of sweet-tasting substance. This will make the medication more palatable to the child. The medication should be mixed with only a small amount of food or liquid. If the child does not finish drinking or eating, it is difficult to determine how much medication was consumed. Medication should not be mixed with essential foods and milk. The child may associate the altered taste with the food and refuse to eat this food in the future.

Abnormal sensation

Paresthesia

The nurse needs to take the blood pressure of a preschool boy for the first time. What action would be best in gaining his cooperation? Tell him that this procedure will help him get well faster. Take his blood pressure when a parent is there to comfort him. Explain to him how the blood flows through the arm and why the blood pressure is important. Permit him to handle the equipment and see the cuff inflate and deflate before putting the cuff in place.

Permit him to handle the equipment and see the cuff inflate and deflate before putting the cuff in place A preschooler is at the stage of preoperational thought. The nurse needs to explain the procedure in simple terms and allow the child to see how the equipment works. This will help allay fears of bodily harm. Blood pressure measurement is used for assessment, not therapy, and will not help him get well faster. Although the parent will be able to support the child, he may still be uncooperative. Also, the assessment of blood pressure may be needed before the parent is available. Explaining to a preschooler how the blood flows through the artery and why the blood pressure is important is too complex.

Parents are being taught how to feed their infant using a newly placed gastrostomy tube (G-tube). What is essential information for the parents to receive? Verify placement before each feeding. Use a syringe with a plunger to give the infant bolus feedings. Position the infant on the right side during and after the feeding. Beefy red tissue around the G-tube site must be reported to the practitioner.

Position the infant on the right side during and after the feeding Positioning on the right side during and after feedings helps minimize the risk of aspiration. It is not necessary to verify placement before each feeing. G-tubes are inserted into the stomach and sutured in place. If the tube is through the skin, it is in the stomach. Feedings should be given by gravity flow. The plunger may be used to initiate the feeding, but then the formula should be allowed to flow. Beefy red tissue around the G-tube site is normal granulation tissue that is expected.

A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for a lumbar puncture, what should the nurse do? Set up a tray with equipment the same size as for adults. Apply EMLA to the puncture site 15 minutes before the procedure. Prepare the child for conscious sedation being used for the procedure. Reassure the parents that the test is simple, painless, and risk free.

Prepare the child for conscious sedation being used for the procedure Because of the urgency of the child s condition, conscious sedation should be used for the procedure. Pediatric spinal trays have smaller needles than do adult trays. EMLA should be applied approximately 60 minutes before the procedure; the emergency nature of the spinal tap precludes its use. A spinal tap is not a simple procedure and does have associated risks; analgesia will be given for the pain.

The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which technique should be most helpful? Recommend that the child keep a diary. Provide supplies for the child to draw a picture. Suggest that the parent read fairy tales to the child. Ask the parent if the child is always uncommunicative.

Provide supplies for the child to draw a picture. Drawing is one of the most valuable forms of communication. Childrens drawings tell a great deal about them because they are projections of the childrens inner self. A diary should be difficult for a 6-year-old child, who is most likely learning to read. The parent reading fairy tales to the child is a passive activity involving the parent and child; it should not facilitate communication with the nurse. The child is in a stressful situation and is probably uncomfortable with strangers, not always uncommunicative.

Itching

Pruritus

Wound with a relatively small opening compared with the depth

Puncture

A 5-year-old child returns from the pediatric intensive care unit after abdominal surgery. The orders state to monitor vital signs every 2 hours. On assessment, the nurse observes that the child s heart rate is 20 beats/min less than it was preoperatively. What should be the nurse s next action? Follow the orders and check in 2 hours. Ask the parents if this is the child s usual heart rate. Recheck the pulse and blood pressure in 15 minutes. Notify the surgeon that the child is probably going into shock.

Recheck the pulse and blood pressure in 15 minutes In a 5-year-old child, this is a significant change in vital signs. The nurse should assess the child to see if his condition mirrors a drop in heart rate. The assessment and vital signs should be redone in 15 minutes to determine whether the child s condition is stable. When a disparity in vital signs or other assessment data is observed, the nurse should reassess sooner. Most parents will not know their child s heart rate. It is important to determine how the child is recovering from surgery. The nurse should collect additional information before notifying the surgeon. This includes blood pressure, respiratory rate, and pain status.

A child, age 7 years, has a fever associated with a viral illness. She is being cared for at home. What is the principal reason for treating fever in this child? Relief of discomfort Reassurance that illness is temporary Prevention of secondary bacterial infection Avoidance of life-threatening complications

Relief of discomfort The principal reason for treating fever is the relief of discomfort. Relief measures include pharmacologic and environmental intervention. The most effective is the use of pharmacologic agents to lower the set point. Although the nurse can reassure the child that the illness is temporary, the child is often uncomfortable and irritable. Intervention helps the child and family minimize the discomfort. Most fevers result from viral, not bacterial, infections. Few life-threatening events are associated with fever. The use of antipyretics does not seem to reduce the incidence of febrile seizures.

A 6-year-old boy is hospitalized for intravenous antibiotic therapy. He eats very little on his regular diet trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. What nursing action is the most appropriate? Request these favorite foods for him. Identify healthier food choices that he likes. Explain that he needs fruits and vegetables. Reward him with ice cream at the end of every meal that he eats.

Request these favorite foods for him Loss of appetite is a symptom common to most childhood illnesses. To encourage adequate nutrition, the nurse should request favorite foods for the child. The foods he likes provide nutrition and can be supplemented with additional fruits and vegetables. Ice cream and other desserts should not be used as rewards or punishment.

A nurse must do a venipuncture on a 6-year-old child. What consideration is important in providing atraumatic care? Use an 18-gauge needle if possible. Show the child the equipment to be used before the procedure. If not successful after four attempts, have another nurse try. Restrain the child completely.

Sow the child the equipment to be used before the procedure. To provide atraumatic care the child should be able to see the equipment to be used before the procedure begins. Use the smallest gauge needle that permits free flow of blood. A two-try-only policy is desirable, in which two operators each have only two attempts. If insertion is not successful after four punctures, alternative venous access should be considered. Restrain the child only as needed to perform the procedure safely; use therapeutic hugging.

An 11-month-old hospitalized boy is restrained because he is receiving intravenous (IV) fluids. His grandmother has come to stay with him for the afternoon and asks the nurse if the restraints can be removed. What nurse s response is best? Restraints need to be kept on all the time. That is fine as long as you are with him. That is fine if we have his parents consent. The restraints can be off only when the nursing staff is present.

That is fine as long as you are with him. The restraints are necessary to protect the IV site. If the child has appropriate supervision, restraints are not necessary. The nurse should remove the restraints whenever possible. When parents or staff members are present, the restraints can be removed and the IV site protected. Parental permission is not needed for restraint removal.

The nurses approach when introducing hospital equipment to a preschooler who seems afraid should be based on which principle? The child may think the equipment is alive. Explaining the equipment will only increase the childs fear. One brief explanation will be enough to reduce the childs fear. The child is too young to understand what the equipment does.

The child may think the equipment is alive. Young children attribute human characteristics to inanimate objects. They often fear that the objects may jump, bite, cut, or pinch all by themselves without human direction. Equipment should be kept out of sight until needed. Simple, concrete explanations about what the equipment does and how it will feel will help alleviate the childs fear. Preschoolers need repeated explanations as reassurance.

Which parameter correlates best with measurements of total muscle mass? a. Height b. Weight c. Skinfold thickness d. Upper arm circumference

Upper arm circumference Upper arm circumference is correlated with measurements of total muscle mass. Muscle serves as the bodys major protein reserve and is considered an index of the bodys protein stores. Height is reflective of past nutritional status. Weight is indicative of current nutritional status. Skinfold thickness is a measurement of the bodys fat content.

A 6-year-old child needs to drink 1 L of GoLYTELY in preparation for a computed tomography scan of the abdomen. To encourage the child to drink, what should the nurse do? Give him a large cup with ice so it tastes better. Restrict him to his room until he drinks the GoLYTELY. Use little cups and make a game to reward him for each cup he drinks. Tell him that if he does not finish drinking by a set time, the practitioner will be angry.

Use little cups and make a game to reward him for each cup he drinks One liter of GoLYTELY is difficult for many children to drink. By using small cups, the child will find the amount less overwhelming. Then a game can be made in which some type of reward (sticker, reading another page of a book) is given for each cup. A large cup of ice would make it more difficult because the child would see it as too much and ice adds additional fluid to be consumed. Negative reinforcement may work if the child wishes to be out of his room. A practitioner may or may not be angry if he does not finish drinking by a set time; this is a threat that may or may not be true. If the child is having difficulty drinking, this would most likely not be effective.

Which is considered a block to effective communication? Using silence Using clichs Directing the focus Defining the problem

Using clichs Using stereotyped comments or clichs can block effective communication. After the nurse uses such trite phrases, parents often do not respond. Silence can be an effective interviewing tool. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions. To be effective, the nurse must be able to direct the focus of the interview while allowing maximum freedom of expression. By using open-ended questions and guiding questions, the nurse can obtain the necessary information and maintain a relationship with the family. The nurse and parent must collaborate and define the problem that will be the focus of the nursing intervention.

A toddler is being sent to the operating room for surgery at 9 AM. As the nurse prepares the child, what is the priority intervention? Administering preoperative antibiotic Verifying that the child and procedure are correct Ensuring that the toddler has been NPO since midnight Informing the parents where they can wait during the procedure

Verifying that the child and procedure are correct The most important intervention is to ensure that the correct child is going to the operating room for the identified procedure. It is the nurse s responsibility to verify identification of the child and what procedure is to be done. If an antibiotic is ordered, administering it is important, but correct identification is a priority. Clear liquids can be given up to 2 hours before surgery. If the child was NPO (taking nothing by mouth) since midnight, intravenous fluids should be administered. Parents should be encouraged to accompany the child to the preoperative area. Many institutions allow parents to be present during induction.

A child has a central venous access device for intravenous (IV) fluid administration. A blood sample is needed for a complete blood count, hemogram, and electrolytes. What is the appropriate procedure to implement for this blood sample? Perform a new venipuncture to obtain the blood sample. Interrupt the IV fluid and withdraw the blood sample needed. Withdraw a blood sample equal to the amount of fluid in the device, discard, and then withdraw the sample needed. Flush the line and central venous device with saline and then aspirate the required amount of blood for the sample.

Withdraw a blood sample equal to the amount of fluid in the device, discard, and then withdraw the sample needed. The blood specimen obtained must reflect the appropriate hemodilution of the blood and electrolyte concentration. The nurse needs to withdraw the amount of fluid that is in the device and discard it. The next sample will come from the child s circulating blood. With a central venous device, the trauma of a separate venipuncture can be avoided. The blood sample will be diluted with either the IV fluid being administered or the saline.

What can the nurse suggest to families to reduce blood lead levels? (Select all that apply.) a.Do not store food in open cans. b.Ensure the child eats regular meals. c.Mix formula with hot water from the tap. d.Vacuum hard-surfaced floors and window wells. e.Wash and dry the child's hands and face frequently.

a, b, e

During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is which? a. A normal finding b. A sign of a possible visual defect and a need for vision screening c. An abnormal finding requiring referral to an ophthalmologist d. A sign of small hemorrhages, which usually resolve spontaneously

a. A normal finding A brilliant, uniform red reflex is an important normal finding. It rules out many serious defects of the cornea, aqueous chamber, lens, and vitreous chamber.

Where in the health history does a record of immunizations belong? a. History b. Present illness c. Review of systems d. Physical assessment

a. History The history contains information relating to all previous aspects of the childs health status. The immunizations are appropriately included in the history. The present illness, review of systems, and physical assessment are not appropriate places to record the immunization status.

Which data should be included in a health history? a. Review of systems b. Physical assessment c. Growth measurements d. Record of vital signs

a. Review of systems A review of systems is done to elicit information concerning any potential health problems. This further guides the interview process. Physical assessment, growth measurements, and a record of vital signs are components of the physical examination.

Which is the most frequently used test for measuring visual acuity? a. Snellen letter chart b. Ishihara vision test c. Allen picture card test d. Denver eye screening test

a. Snellen letter chart The Snellen letter chart, which consists of lines of letters of decreasing size, is the most frequently used test for visual acuity. The Ishihara Vision Test is used for color vision. The Allen picture card test and Denver eye screening test involve single cards for children ages 2 years and older who are unable to use the Snellen letter chart.

28. The nurse is testing an infants visual acuity. By which age should the infant be able to fix on and follow a target? a. 1 month b. 1 to 2 months c. 3 to 4 months d. 6 months

c. 3 to 4 months Visual fixation and ability to follow a target should be present by ages 3 to 4 months. One to 2 months is too young for this developmental milestone. If an infant is not able to fix and follow by 6 months, further ophthalmologic evaluation is needed.

20. What is the earliest age at which a satisfactory radial pulse can be taken in children? a. 1 year b. 2 years c. 3 years d. 6 years

b. 2 years Satisfactory radial pulses can be taken in children older than 2 years. In infants and young children, the apical pulse is more reliable.

Which explains the importance of detecting strabismus in young children? a. Color vision deficit may result. b. Amblyopia, a type of blindness, may result. c. Epicanthal folds may develop in the affected eye. d. Corneal light reflexes may fall symmetrically within each pupil.

b. Amblyopia, a type of blindness, may result. By the age of 3 to 4 months, infants are able to fixate on one visual field with both eyes simultaneously. In strabismus, or cross-eye, one eye deviates from the point of fixation. If misalignment is constant, the weak eye becomes lazy, and the brain eventually suppresses the image produced from that eye. If strabismus is not detected and corrected by age 4 to 6 years, blindness from disuse, known as amblyopia, may occur. Color vision is not the only concern. Epicanthal folds are not related to amblyopia. In children with strabismus, the corneal light reflex will not be symmetric for each eye.

The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the childs head (opisthotonos) with pain on flexion. Which is the most appropriate action? a. Ask the parent when the neck was injured. b. Refer for immediate medical evaluation. c. Continue assessment to determine the cause of the neck pain. d. Record head lag on the assessment record and continue the assessment of the child.

b. Refer for immediate medical evaluation. Hyperextension of the childs head with pain on flexion is indicative of meningeal irritation and needs immediate evaluation. No indication of injury is present. This situation is not descriptive of head lag.

Rectal temperatures are indicated in which situation? a. In the newborn period b. Whenever accuracy is essential c. Rectal temperatures are never indicated d. When rapid temperature changes are occurring

b. Whenever accuracy is essential Rectal temperatures are recommended when definitive measurements are necessary in infants older than age 1 month. Rectal temperatures are not done in the newborn period to avoid trauma to the rectal mucosa. Rectal temperature is an intrusive procedure that should be avoided whenever possible.

A child with cyanide poisoning has been admitted to the emergency department. What antidote does the nurse anticipate being prescribed for the child? a.Atropine b.Glucagon c.Amyl nitrate d.Naloxone (Narcan)

c

With the National Center for Health Statistics criteria, which body mass index (BMI)for-age percentiles should indicate the patient is at risk for being overweight? a. 10th percentile b. 75th percentile c. 85th percentile d. 95th percentile

c. 85th percentile Children who have BMI-for-age greater than or equal to the 85th percentile and less than the 95th percentile are at risk for being overweight. Children who are greater than or equal to the 95th percentile are considered overweight. Children whose BMI is between the 10th and 75th percentiles are within normal limits.

29. During an otoscopic examination on an infant, in which direction is the pinna pulled? a. Up and back b. Up and forward c. Down and back d. Down and forward

c. Down and back In infants and toddlers, the ear canal is curved upward. To visualize the ear canal, it is necessary to pull the pinna down and back to the 6 to 9 oclock range to straighten the canal. In children older than age 3 years and adults, the canal curves downward and forward. The pinna is pulled up and back to the 10 oclock position. Up and forward and down and forward are positions that do not facilitate visualization of the ear canal.

Where is the best place to observe for the presence of petechiae in dark-skinned individuals? a. Face b. Buttocks c. Oral mucosa d. Palms and soles

c. Oral mucosa Petechiae, small distinct pinpoint hemorrhages, are difficult to see in dark-skinned individuals unless they are in the mouth or conjunctiva.

When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet is which? a. Lacking in protein b. Indicating they live in poverty c. Providing sufficient amino acids d. Needing enrichment with meat and milk

c. Providing sufficient amino acids A diet that contains vegetables, legumes, and starches may provide sufficient essential amino acids even though the actual amount of meat or dairy protein is low. Combinations of foods contain the essential amino acids necessary for growth. Many cultures use diets that contain this combination of foods. It is not indicative of poverty. A dietary assessment should be done, but many vegetarian diets are sufficient for growth.

What is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child? a. Rinne test b. Weber test c. Pure tone audiometry d. Eliciting the startle reflex

c. Pure tone audiometry Pure tone audiometry uses an audiometer that produces sounds at different volumes and pitches in the childs ears. The child is asked to respond in some way when the tone is heard in the earphone. The Rinne and Weber tests measure bone conduction of sound. Eliciting the startle reflex may be useful in infants.

During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action? a. Recheck head control at next visit. b. Teach the parents appropriate exercises. c. Schedule the child for further evaluation. d. Refer the child for further evaluation if the anterior fontanel is still open.

c. Schedule the child for further evaluation. Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation. Head control is part of normal development. Exercises will not be effective. The lack of achievement of this developmental milestone must be evaluated.