NS223 FINAL

Which teaching topic is the priority for the nurse who is teaching the family of an infant diagnosed with osteogenesis imperfecta? 1. Cast care 2. Trunk and extremity support during everyday care 3. Postoperative spinal surgery care 4. Traction care

2. Trunk and extremity support during everyday care

Which is the priority teaching point for the nurse to include in the discharge instructions for the parents of a child who was admitted in a sickle-cell crisis? 1. Rapid weaning of pain medications 2. A diet high in protein 3. Adequate hydration 4. Restriction of activities

3. Adequate hydration

The telephone triage nurse receives a call from a parent who describes a crowing sound when the 18-month-old breathes and the child is hard to wake up. Which is the appropriate nursing action? 1. Making an appointment for the child to see the healthcare provider 2. Obtaining the history of the illness from the parent 3. Advising the parent to hang up and call 911 4. Reassuring the parent and providing instructions on home care for the child

3. Advising the parent to hang up and call 911

The nurse is working with children in hospice care. The mother of a young child with cancer talks with the nurse about the future holiday celebrations she will miss with her child. Which is the mother experiencing based on these data? 1. Actual loss 2. Perceived loss 3. Anticipatory loss 4. Loss

3. Anticipatory loss

A hospitalized 3-year-old child needs to have an IV restarted. The child begins to cry when carried into the treatment room by the mother. Which is an appropriate nursing diagnosis to address this situation? 1. Knowledge Deficit of the procedure 2. Fear related to the unfamiliar environment 3. Anxiety related to anticipated painful procedure 4. Ineffective Individual Coping related to an invasive procedure

3. Anxiety related to anticipated painful procedure

The nurse observes that over time, the parents of a child with a chronic condition have experienced a pattern of periodic grieving alternating with denial. Which will the nurse include in the child's updated plan of care? 1. Pathologic Grieving 2. Compassion Fatigue 3. Chronic Sorrow 4. Dysfunctional Parenting

3. Chronic Sorrow

Which side effect should the nurse include in the parent teaching for a child who is prescribed a baclofen pump for cerebral palsy? 1. Diarrhea 2. Hypertonia 3. Hypotonia 4. Restlessness

3. Hypotonia

A 4-year-old child is admitted to the hospital secondary to dehydration. Laboratory tests indicate a high hemoglobin and hematocrit, and the serum sodium is below normal levels. Which condition does the nurse suspect based on the current data? 1. Hypernatremia 2. Metabolic acidosis 3. Hypotonic dehydration 4. Isotonic dehydration

3. Hypotonic dehydration

The 4-year-old child is undergoing cardiac surgery. Which nursing action will reduce the child's stress in the preoperative period? Select all that apply. 1. Explain the procedure to the child in simple terms of what the child will see, hear, and feel while awake. 2. Explain to the child that the surgery will fix her "broken" heart. 3. Allow the parents to accompany the child to the surgical holding room and wait with the child. 4. Allow the child to hold onto their special "teddy bear" while awake. 5. Wait until the child is in the holding room to insert the Foley catheter.

1, 3, 4 -1. Explain the procedure to the child in simple terms of what the child will see, hear, and feel while awake. -3. Allow the parents to accompany the child to the surgical holding room and wait with the child. -4. Allow the child to hold onto their special "teddy bear" while awake.

Which will the nurse assess in the family of a 3-year-old child during a pediatric clinic visit scheduled due to regressive behavior? Select all that apply. 1. Change in parental marital status 2. Level of education for each parent 3. Health of child's siblings 4. Maternal depression 5. Child's exposure to communicable diseases

1, 3, 4 -change in parental marital status -health of child's siblings -maternal depression

Which are resources that enable families to develop and adapt to stressors? Select all that apply. 1. Education 2. Communication 3. Prior experiences 4. Problem solving 5. Adequate finances

1, 3, 5 -education -prior experiences -adequate finances

During a scheduled health maintenance visit for a 6-month-old infant the nurse asks, "Does the baby sit without assistance, and is the baby crawling?" Which process is the nurse using in this interaction? 1. Health promotion 2. Developmental surveillance 3. Health maintenance 4. Disease surveillance

2. Developmental surveillance

A 5-year-old child is hospitalized with a fractured femur. Which tool should the nurse use to assess this child's pain? 1. CRIES Scale 2. Faces Pain Rating Scale 3. SUN Scale 4. PIPP Scale

2. Faces Pain Rating Scale

While being comforted in the emergency department, the 6-year-old male sibling of a pediatric trauma victim blurts out to the nurse, "It's all my fault! When we were fighting yesterday, I told him I wished he was dead!" Which response by the nurse is most therapeutic? 1. Asking the child if he would like to sit down and drink some water 2. Sitting the child down in an empty room with markers and paper so that he can draw a picture 3. Reassuring the child that it is normal to get angry and say things that we do not mean, but that we have no control over whether an accident happens 4. Discussing the catheters, tubes, and equipment that the sibling requires, and explaining why they are needed

3. Reassuring the child that it is normal to get angry and say things that we do not mean, but that we have no control over whether an accident happens

Which is the rationale the nurse provides to the parents of an infant diagnosed with congestive heart failure (CHF) for the prescribed spironolactone? 1. Produces rapid diuresis 2. Blocks reabsorption of sodium and water in renal tubules 3. Spares potassium 4. Promotes vascular relaxation

3. Spares potassium

Which vaccine reaction, noted by the mother during a telephone conversation with a nurse, would require activation of emergency medical services? 1. A few hives are noted around the injection site. 2. The child is running a slight temperature. 3. The child has swelling of the face. 4. Fever and joint pains occurring within hours of the vaccination.

3. The child has swelling of the face.

The nurse is speaking with a preschool-age child whose sibling recently died. Which feelings should the nurse anticipate from the preschool-age child? 1. The child may feel that his or her bad behavior caused the sibling's death as a punishment. 2. The child may feel that the sibling died as a result of a fight. 3. The child may feel that having bad thoughts about the sibling caused the death. 4. The child may feel that the sibling died because the parents did not like that sibling.

3. The child may feel that having bad thoughts about the sibling caused the death.

The nurse is preparing to administer a vaccine to a 14-month-old toddler. Which assessment factor would warrant a delay in the scheduled vaccination during the well-child visit? 1. The child is allergic to a substance in the vaccine. 2. The child has a low-grade fever and a runny nose. 3. The child received a dose of immune globulin 2 months ago. 4. The child is on antibiotics.

3. The child received a dose of immune globulin 2 months ago.

The nurse is administering packed red blood cells to a child with sickle-cell disease (SCD). When should the nurse monitor the child closely due to the risk of reaction? 1. Six hours after the transfusion is given. 2. At the end of the administration of the transfusion. 3. The first 20 mL of blood administered. 4. Never; children with SCD do not have reactions.

3. The first 20 mL of blood administered

An adolescent is admitted to the eating disorders unit with a 2-year history of anorexia nervosa. Assessment data indicate that the adolescent has recently sustained additional weight loss and electrolyte imbalances. Which is the priority when planning care for this client? 1. Individual counseling 2. Family therapy 3. Regulation of antidepressant drugs 4. Nutritional support

4

Separation anxiety is one of the major stressors of hospitalization for a toddler. How can the nurse best limit the amount of separation anxiety that the hospitalized toddler will experience? a. Encourage parental involvement in the child's care and suggest rooming in if possible. b. Encourage the parents to leave the child's room when care is being provided. c. Encourage the parents to limit the time they hold their child. d. Reduce the amount of time spent with the child when the parents are not present.

a. Encourage parental involvement in the child's care and suggest rooming in if possible.

Which nursing diagnosis is the highest priority for a child undergoing chemotherapy, experiencing nausea, and vomiting? a. Fluid and Electrolyte Imbalance b. Body Image Disturbances c. Alterations in Skin Integrity d. Alterations in Nutrition

a. Fluid and Electrolyte Imbalance

Which intervention would be appropriate when a nurse is caring for a child with acute postinfectious glomerulonephritis (APIGN)? a. Screen family members for strep throat. b. Offer a high-protein diet. c. Maintain strict fluid restriction. d. Monitor the child for hyperactivity.

a. Screen family members for strep throat.

Which information obtained during a nursing assessment of a 3-year-old child indicates a need for parent education? Hint: Nutrition a. The child watches cartoons on television while eating. b. The parents expect the child to eat at the table for supper. c. The child knows how to pour liquids from a small pitcher. d. The child only wants to eat pizza and/or chicken fingers.

a. The child watches cartoons on television while eating.

The neonatal nurse explains to new parents that infants are at greater risk for fluid and electrolyte imbalance than older children are. Which parent comment would indicate that further education is needed? a. "Compared to an adult, an infant has little body water for reserve." b. "Infants maintain their temperature by losing heat through their heads." c. "Infants have a higher metabolic rate than older children do." d. "Infants lose water through their skin, and they have a larger proportion of skin surface area than older children do."

b. "Infants maintain their temperature by losing heat through their heads."

The nurse caring for a 13-year-old has identified imagery as a way to help the client with pain management. Which instructions could the nurse use to help the client use imagery? a. "Take some slow, deep breaths." b. "Think about your favorite place to go in the summer." c. "Relax while I rub your shoulders." d. "Count to 10 very slowly."

b. "Think about your favorite place to go in the summer."

A child is diagnosed with severe combined immunodeficiency. The nurse considers that dietary instruction to the parents is effective if which food is included in the child's diet? a. Grilled cheese b. Chicken fingers and milkshakes c. Tuna salad and whole wheat bread d. Hamburger and skim milk

b. Chicken fingers and milkshakes (diet high in protein & calories)

A nurse is taking care of four different pediatric clients. Which child is at greatest risk for dehydration? 1. 7-year-old child with migraine headaches 2. 4-year-old child with a broken arm 3. 2-year-old child with cellulitis of the left leg 4. 18-month-old child with tachypnea

4. 18-month-old child with tachypnea

At which age will the nurse begin to calculate body mass index (BMI) as a part of the nursing assessment process? 1. 12 months 2. 18 months 3. 2 years 4. 4 years

3. 2 years

Which is the priority nursing diagnosis for nurse to use when planning care for a school-age child who must wear a brace for correction of scoliosis? 1. Impaired Gas Exchange, Risk for 2. Altered Growth and Development, Risk for 3. Impaired Skin Integrity, Risk for 4. Impaired Mobility, Risk for

3. Impaired Skin Integrity, Risk for

The nurse administers IV morphine to a 4-year-old postoperative client. Which assessment finding requires further evaluation by the nurse? 1. Pulse decreased from 136 to 104 2. Blood pressure dropped from 110/72 to 90/55 3. Respiratory rate went from 42 to 16 4. Child pulls away from nurse who wants to assess surgical site

3. Respiratory rate went from 42 to 16

A nurse is providing care for a pediatric client in the intensive care unit (ICU) who has been on opioids for an extended period of time. Which assessment finding indicates to the nurse that the child is experiencing withdrawal symptoms related to the opioid weaning process? 1. Hyperactive deep tendon reflexes, vomiting, and abdominal cramps. 2. Bradycardia and pallor. 3. Decreased blood pressure and drowsiness. 4. Voracious appetite and hypotonicity.

1. Hyperactive deep tendon reflexes, vomiting, and abdominal cramps.

A child who has not had a tetanus immunization steps on a rusty nail. Which term should the nurse use to identify the tetanus immunization when teaching the parents about the vaccine? 1. Toxoid 2. Live virus 3. Killed virus 4. Recombinant

1. Toxoid

The nurse is assessing an infant brought to the clinic because of diarrhea. The infant is alert but has dry mucous membranes. Which additional assessment data indicates to the nurse that the infant is experiencing an early to moderate stage of dehydration? 1. Bradycardia 2. Tachycardia 3. Increased blood pressure 4. Normal fontanels

2. Tachycardia

An 11-month-old is diagnosed with a rare and fatal form of cancer. Which initial reaction by the parents does the nurse consider normal? a. "There has to be a cure; are you sure of the diagnosis?" b. "My wife drank two glasses of wine during her pregnancy!" c. "I knew we weren't ready for this; so, what do we do now?" d. "What are we going to do without her?"

a. "There has to be a cure; are you sure of the diagnosis?"

Which strategy by the nurse is best when communicating with a 3-year-old? a. Avoid telling the toddler about the hernia repair procedure too far in advance. b. Talk and sing frequently during care. c. Make sure to speak in a high-pitched voice to ensure the toddler pays attention. d. Teach the toddler to count backwards from 10 in order to relax before the procedure.

a. Avoid telling the toddler about the hernia repair procedure too far in advance.

When assessing an 18-month-old child, which technique should the nurse plan to use? a. Examine the child on the parent's lap. b. Restrain the child on the examining table. c. Allow the child to sit on the examining table. d. Have the child lie in a supine position on the examining table.

a. Examine the child on the parent's lap.

What is the most appropriate nursing diagnosis for an adolescent who smokes? a. Knowledge Deficit regarding dangers of smoking related to developmental focus on the present b. Impaired Social Interaction related to altered thought processes c. Risk for Injury related to altered sensorium and perception d. Hopelessness related to stressful home environment

a. Knowledge Deficit regarding dangers of smoking related to developmental focus on the present

A 16-year-old female has been admitted to the hospital because of a serious respiratory infection with a diagnosis of possible tuberculosis. She has been placed on respiratory isolation in a private room. Knowing that peers are important, what should the nurse suggest? a. Maintaining contact with her friends by telephone b. Drawing pictures of her feelings to give to her peers c. Placing the child in a room with a roommate of the same age d. Having friends visit her often

a. Maintaining contact with her friends by telephone

Which intervention by the nurse is most important when taking care of a child with severe dehydration? a. Monitor weight daily. b. Monitor for crackles in the lungs. c. Monitor level of consciousness. d. Monitor serum sodium levels.

a. Monitor weight daily.

A child with sickle cell anemia (SCA) requires a blood transfusion. Which intravenous solution should the nurse administer before and after the transfusion? a. Normal saline b. D5W 0.45 NS c. 0.45% NS d. D5W

a. Normal saline

A nurse is planning to teach a prenatal class. Which topic is most appropriate at this time? a. Nutrition b. Physical activity c. Oral health d. Sleep patterns

a. Nutrition

A parent is concerned that his 4-year-old will eat only Cheerios and chicken nuggets. What is the best anticipatory guidance that the nurse can offer this parent? a. Offer chicken nuggets and Cheerios with other foods at mealtimes. b. Make the child sit at the table until she eats all her food. c. Give the child the desired food between mealtimes. d. Encourage the child to drink at least 24 ounces of juice a day.

a. Offer chicken nuggets and Cheerios with other foods at mealtimes.

A child is diagnosed with severe combined immunodeficiency deficiency syndrome. The nurse's priority interventions are directed toward which objective? a. Prevention of infection b. Maintenance of skin integrity c. Management of body image concerns d. Maintenance of cardiac function

a. Prevention of infection

Which response by the school nurse to a 16-year-old would be appropriate when the boy tells the nurse he smokes? a. "If you continue to smoke, you will get lung cancer and die." b. "We need to discuss how smoking can affect your health." c. "You are hurting your family with your secondhand smoke." d. "Did you know that smoking can stunt your growth?"

b. "We need to discuss how smoking can affect your health."

A 6-year-old postop for appendectomy complains of pain of 8 in her abdomen based on the FACES pain scale. The nurse notes the child laughing as she asks for pain medication. What is the appropriate action by the nurse? a. Tell the child to do deep-breathing exercises taught preoperatively. b. Administer the pain medication as ordered. c. Explain to the child that she should only ask for medication when she really hurts. d. Get the child's parents to determine the child's pain.

b. Administer the pain medication as ordered.

A preschool-age child is to undergo several painful procedures. Which technique is the most appropriate for the nurse to use in preparing the child? a. Allow a family member to explain the procedure to the child. b. Explain the procedure in simple terms. c. Allow the child to practice injections on a favorite doll. d. Allow the child to watch an educational video.

b. Explain the procedure in simple terms.

Which nursing diagnosis is the most appropriate for a child with sickle cell anemia (SCA)? a. Pain b. Impaired Gas Exchange c. Ineffective Coping d. Alteration in Nutrition

b. Impaired Gas Exchange

A child with nephrotic syndrome is placed on corticosteroids. About which side effects of corticosteroids should the nurse educate the family? a. Impaired balance b. Moon face c. Decreased appetite d. Hair loss

b. Moon face

The nurse notes that a 6-month-old infant who weighed 7 pounds at birth now weighs 15 pounds. What is the nurse's evaluation of the infant's current weight? a. The infant should be hospitalized for failure to thrive. b. The infant needs weekly follow-up to assess weight. c. The infant has been consuming more calories than needed. d. The infant's weight is appropriate for his age.

d. The infant's weight is appropriate for his age.

Which is the most appropriate anticipatory guidance to give parents relative to food allergies in infants? a. Document episodes of fussiness following eating. b. Instruct parents to read all baby food labels carefully. c. Allow 3-5 days between the introductions of new foods. d. Instruct the parents on how to make their own baby food.

c. Allow 3-5 days between the introductions of new foods.

Which pain-assessment tool is the most appropriate for a 14-year-old client? a. FLACC behavioral pain assessment scale b. FACES pain rating scale c. Numeric scale d. Poker chip tool

c. Numeric scale

A child with hemophilia states that he wants to participate in sports. Which sport should the nurse recommend as most appropriate for the child? a. Baseball b. Swimming c. Running d. Biking

b. Swimming

Which toy is most age-appropriate for a 2-year-old? a. Mobile b. Toy vacuum cleaner c. Nesting cups d. Playhouse

b. Toy vacuum cleaner

While trying to inform a 5-year-old child about what will occur during an upcoming CT scan, the nurse notices that the child is engaged in a collective monologue, talking about a new puppy. Which response by the nurse is age appropriate? 1. "You must be so excited to have a new puppy! They are so much fun. Now let me tell you again about going downstairs in a wheelchair to a special room." 2. Redirect the child by saying, "Please stop talking about your puppy. I need to tell you about your CT scan." 3. "I'll come back when you are ready to talk with me more about your CT scan." 4. Ignore the information regarding the puppy and state, "I need to teach you about going to the special room later today."

1. "You must be so excited to have a new puppy! They are so much fun. Now let me tell you again about going downstairs in a wheelchair to a special room."

The pediatric nurse would expect that patient-controlled analgesia (PCA) would be most appropriate for which client? 1. 12-year-old client who is postoperative for spinal fusion for scoliosis 2. 10-year-old client who has a fractured femur and concussion from a bike accident 3. 5-year-old client who is postoperative for tonsillectomy 4. Developmentally delayed 16-year-old client who is postoperative for bone surgery.

1. 12-year-old client who is postoperative for spinal fusion for scoliosis

Which neonate requires a close nursing assessment for the development of retinopathy of prematurity (ROP)? 1. 28-weeks'-gestation infant who has been on long-term oxygen and weighed 1400 g 2. 32-weeks'-gestation infant of African heritage with a congenital heart defect who needed no oxygen and weighed 1850 g 3. 28-weeks'-gestation female infant who was on short-term oxygen, weighed 1420 g, and was treated with phototherapy 4. 36-weeks'-gestation, small-for-gestational-age infant who was in an oxyhood for 12 hours and weighed 1800 g

1. 28-weeks'-gestation infant who has been on long-term oxygen and weighed 1400 g

The child is admitted to the hospital unit newly diagnosed with retinoblastoma. Which clinical manifestation does the nurse anticipate upon assessment? 1. A white reflex 2. Blue-tinged sclerae 3. A red reflex 4. Yellow-tinged sclerae

1. A white reflex

A nurse is providing education to a group of new mothers regarding immunity and infection. Which information regarding the development of immunity should the nurse include in the teaching session? 1. Acquired through immunization or exposure to the natural disease 2. Acquired through exposure to diseases from family members 3. Acquired through diseases from other children 4. Newborns being born with diseases already in their systems

1. Acquired through immunization or exposure to the natural disease

The nursing action is most appropriate when performing a procedure on a toddler-age child? 1. Allowing the child to cry or scream 2. Performing the procedure in the child's hospital bed 3. Asking the child if it is okay to start the procedure 4. Asking the mother to restrain the child during the procedure

1. Allowing the child to cry or scream

The nurse is providing care for the family of a child who is diagnosed with acquired immunodeficiency syndrome (AIDS). Which priority nursing diagnosis should the nurse include in the plan of care? 1. Anticipatory Grieving 2. Risk for Impaired Parenting 3. Compromised Family Coping 4. Parental Role Conflict

1. Anticipatory Grieving

Which nursing action is appropriate when treating a school-age child, diagnosed with hemophilia, for a superficial wound above the knee? 1. Applying pressure to the area 2. Applying a warm, moist pack to the area 3. Performing some passive range-of-motion to the affected leg 4. Keeping the affected extremity in a dependent position

1. Applying pressure to the area

A toddler is prescribed digoxin (Lanoxin) for cardiac failure. Which should the nurse instruct the toddler's parents to monitor for as a manifestation associated with digoxin toxicity? 1. Bradycardia 2. Tinnitus 3. Ataxia 4. Hypotension

1. Bradycardia

A parent is concerned about her 8-year-old child's recent behavior and calls the nurse for advice. According to the parent, her child is constantly crying, is not sleeping well, has withdrawn from activities, and does not want to attend school. Which should the nurse explore in more detail with the parent? 1. Bullying 2. Sexual abuse 3. Lead poisoning 4. Drug abuse

1. Bullying

A 5-year-old child with a history of hypopituitarism presents with complaints of right hip and leg pain. Which prescribed medication for the diagnosis should the nurse identify as the cause for the current symptoms? 1. Daily growth hormone 2. Insulin before meals and bedtime 3. DDAVP (desmopressin) at bedtime 4. Cortisone injections

1. Daily growth hormone

A 9-month-old infant who is not sitting independently has been diagnosed with ataxic cerebral palsy (CP). Which clinical manifestations would the nurse expect to see in the baby? 1. Hypotonia and muscle instability 2. Hypertonia and persistence primitive reflexes 3. Tremors and exaggerated posturing 4. Hemiplegia and hypertonia

1. Hypotonia and muscle instability

As a result of opioid administration, a child's respirations are slow and shallow. Which should the nurse anticipate when assessing the child's arterial blood gas? 1. Increased PCO2 and respiratory acidosis 2. Decreased PCO2 and respiratory alkalosis 3. Low pH and low PCO2 4. High pH and high PCO2

1. Increased PCO2 and respiratory acidosis

A nurse is providing information to a group of new mothers. Which rationale, indicating increased susceptibility for infant infection, should the nurse include in the teaching session? 1. Low levels of antibodies 2. High levels of maternal antibodies to diseases to which the mother has been exposed 3. Passive transplacental immunity from maternal immunoglobulin G 4. Exposure to microorganisms during the birth process

1. Low levels of antibodies

Which is the rationale for why parents should be allowed to be present with their children during a medical procedure? 1. Parents want to support their child before, during, and immediately after the procedure. 2. Parents want to ensure that nothing goes wrong with the child. 3. Parents are interested because they are also in the medical field. 4. Parents want to ensure that the correct medication is being used.

1. Parents want to support their child before, during, and immediately after the procedure.

Which clinical manifestation should the nurse monitor for when assessing a pediatric client who is diagnosed with a basilar skull fracture? 1. Periorbital ecchymosis 2. Subdural hematoma 3. Protruding bone 4. Epidural hematoma

1. Periorbital ecchymosis

The emergency department (ED) nurse is talking with a preschooler about the death of the child's parents in a motor vehicle crash. Which should the nurse take into consideration when formulating the client's plan of care? 1. Preschool-age children often believe that death is their fault. 2. Preschool-age children believe death is permanent. 3. Preschool-age children engage in reality-based thinking. 4. Preschool-age children may believe the parents will not come back home.

1. Preschool-age children often believe that death is their fault.

The nurse is taking care of a postoperative school-age child. The child's mother requests that the child not receive narcotics because she is afraid the child will become addicted. The nurse should explain that children who do not receive adequate pain control will be at risk for which complication? 1. Respiratory 2. Urinary 3. Cardiac 4. Bowel

1. Respiratory

Which teaching topic should the nurse include in the discharge instructions for the family of child diagnoses with sickle-cell disease to prevent crisis? 1. Respiratory infection and dehydration 2. Mid-range altitudes 3. Weight loss without dehydration 4. Overhydration

1. Respiratory infection and dehydration

Which clinical manifestation does the nurse anticipate for a pediatric client who is admitted with congestive heart failure (CHF)? 1. Tachycardia 2. Weight loss 3. Hypertension 4. Bradycardia

1. Tachycardia

The pediatric clinic has set a goal that 95% or more of the children attending the clinic will be fully immunized. Which should the clinic nurses teach the families to meet this goal? 1. The benefits of immunizations outweigh the risks of communicable diseases. 2. Immunizations should be completed by the time the child starts school. 3. Once a child receives a vaccination, that individual has lifelong immunity against that disease. 4. Vaccinations are 100% safe.

1. The benefits of immunizations outweigh the risks of communicable diseases.

The nurse is providing care to a child diagnosed with hemophilia who states, "I am going to join a bike club at school." Which recommendation should the nurse give to the child? 1. Wear knee pads, elbow pads, and a helmet while bicycling. 2. Consider a swim club instead of the bicycling club. 3. Do not join the club. 4. Participate only in the social activities of the club.

1. Wear knee pads, elbow pads, and a helmet while bicycling.

A female client arrived by life flight to the hospital after experiencing multiple traumas in a .motor vehicle crash involving a suspected drunk driver. Which statement is most important for the nurse to make to the parents before they see their child? 1. "You should press charges against the drunk driver." 2. "Your child's condition is very critical; her face is swollen, and she might not look like herself." 3. "Your child's leg was crushed, and might have to be amputated." 4. "Don't worry, everything will be okay. We will take excellent care of your child."

2. "Your child's condition is very critical; her face is swollen, and she might not look like herself."

The school nurse is planning a smoking prevention program for middle school students. Which is most likely to be effective in preventing this population from smoking? 1. A demonstration of the pathophysiology of the effects of smoking tobacco on the body given by the school's biology teacher 2. A talk on the importance of not smoking given by a local high school basketball star 3. Colorful posters with catchy slogans displayed throughout the school 4. A pledge campaign during which students sign contracts saying that they will not use tobacco products

2. A talk on the importance of not smoking given by a local high school basketball star

The mother of a dying 3-year-old child posts on Facebook: "Family and friends. Michael's heart is giving out. Looks like it will be tonight. He is surrounded by family and not in pain. I treasure every minute of being his mother. Pray for us." Which stage of grieving, according to Kubler-Ross, is the mother experiencing? 1. Denial 2. Acceptance 3. Bargaining 4. Depression

2. Acceptance

Which nursing actions allow a child to acquire active immunity against a disease? 1. Administering a dose of immunoglobulins 2. Administering a killed virus vaccine 3. Administering a toxoid vaccine 4. Administering antibiotic therapy 5. Administering antiviral therapy

2. Administering a killed virus vaccine 3. Administering a toxoid vaccine

The nurse is preparing to administer a prescribed, as needed, antiemetic drug for a child who is diagnosed with cancer. Which action by the nurse is most appropriate? 1. Administering the drug only if the child is nauseated 2. Administering the drug prophylactically prior to the next dose of chemotherapy 3. Administering the drug after the next dose of chemotherapy 4. Administering the drug only if the child is experiencing diarrhea

2. Administering the drug prophylactically prior to the next dose of chemotherapy

The mother of a child admitted to the intensive care unit (ICU) appears very angry and tells the nurse no one is providing information about the child. Which response by the nurse is most appropriate? 1. Asking the mother to leave if the behavior continues 2. Apologizing for the mother's perception and assure the mother that the staff will keep her informed. 3. Offering to ask the healthcare provider to come and talk with her 4. Telling the mother her behavior will upset the child

2. Apologizing for the mother's perception and assure the mother that the staff will keep her informed.

A school-age child diagnosed with congenital heart block codes in the emergency department. The parents witness this and stare at the resuscitation scene unfolding before them. Which is the best nursing intervention in this situation? 1. Asking the parents to help bag the child 2. Asking the parents to sit near the child's face and touch their child 3. Asking the parents to stand at the foot of the cart to watch 4. Asking the parents to leave the room

2. Asking the parents to sit near the child's face and touch their child

A child is being prepared for surgery. The parents request to be present during anesthesia induction. Which response by the nurse is most appropriate? 1. Telling the parents the names of all the medications that will be administered 2. Explaining what the parents will see and hear during induction 3. Telling the parents they will be upset to see the child under anesthesia 4. Ignoring the request and focusing on the child

2. Explaining what the parents will see and hear during induction

An adolescent experiencing status asthmaticus is rushed to the emergency department by ambulance. The parents arrive and ask to see their child. The triage nurse at the reception desk knows that the adolescent was pronounced dead on arrival. Which is the best action by the triage nurse at this time? 1. Ask the parents to please take a seat in the waiting room. 2. Immediately escort the parents to a quiet, private room. 3. Tell the parents that they must wait because only the healthcare provider can talk with them. 4. Immediately tell the parents, "I'm sorry, but your child didn't make it."

2. Immediately escort the parents to a quiet, private room.

The 17-month-old toddler, diagnosed with terminal cancer, is experiencing constant pain. Which prescription does the nurse anticipate from the healthcare provider for this toddler? 1. Patient-controlled analgesia (PCA) with the parents controlling the button that administers the dosage 2. Intravenously administered opioids on a scheduled basis 3. Intravenously administered opioids on a prn basis 4. Orally administered opioids on a prn basis

2. Intravenously administered opioids on a scheduled basis

Which action should the nurse include when providing education regarding methods to enhance health promotion during a scheduled health maintenance visit for a 4-year-old child? 1. Recognizing that food jags are common 2. Involving the child in snack selection and preparation 3. Encouraging the use of a highchair with a safety strap 4. Recommending the child consumes high-fat foods

2. Involving the child in snack selection and preparation

A child with human immunodeficiency virus (HIV) is diagnosed with oral candidiasis. Which should the nurse include in the plan of care related to oral care based on this information? 1. Listerine 2. Normal saline 3. Viscous lidocaine 4. Scope

2. Normal saline

The nurse is preparing to perform a heel stick on a neonate. Which complementary therapy should the nurse implement to decrease pain during this quick but painful procedure? 1. Holding the newborn 2. Providing a sucrose pacifier to the newborn 3. Massaging the newborn 4. Swaddling the newborn

2. Providing a sucrose pacifier to the newborn

A nurse is assessing an 11-month-old infant, and notes that the infant's height and weight are at the 5th percentile on the growth chart; the infant was previously plotted at the 25th percentile. Psychosocial history reveals that the parents are separated and are planning to divorce. Which is the priority when planning this infant's care? 1. Parental anxiety 2. Risk for failure to thrive 3. Excessive nutritional intake 4. Risk for injury

2. Risk for failure to thrive

An adolescent client diagnosed with cystic fibrosis suddenly becomes noncompliant with the medication regimen. Which nursing intervention would most likely improve compliance? 1. Give the client a computer-animated game that presents information on the management of cystic fibrosis. 2. Set up a meeting with other adolescents with the cystic fibrosis who have been managing their disease effectively. 3. Arrange for the primary healthcare provider to sit down and talk to the client about the risks related to noncompliance with medications. 4. Discuss with the client's parents that privileges, such as a cell phone, can be taken away if compliance fails to improve.

2. Set up a meeting with other adolescents with the cystic fibrosis who have been managing their disease effectively.

A nurse assesses the height and weight measurements on an infant and documents these measurements at the 75th percentile. The nurse notes that the measurements 2 months ago were at the 25th percentile. Which interpretation of these data by the nurse is accurate? 1. The infant is not gaining enough weight. 2. The infant has gained a significant amount of weight. 3. These measurements most likely are inaccurate. 4. The previous measurements were most likely inaccurate.

2. The infant has gained a significant amount of weight.

The nurse is having difficulty coping with the impending death of a child. Who is the best resource for the nurse to consult during this difficult situation? 1. Other staff nurses 2. Hospice nurses 3. Unit nurse manager 4. Nurse's spouse

2. hospice nurses

The nurse is leading a recovery group of parents who have lost a child. As the opening topic for the night's discussion, the nurse reviews information about the grief process to the parents and talks about how different people grieve. Which parental statement indicates the need for more education regarding the grieving process? 1. "I understand that everyone grieves differently." 2. "Looking back, I realize why I became so angry when the doctors didn't cure my daughter." 3. "It's been 6 months since my son died, so why isn't my wife ready to move on with our lives?" 4. "I'm glad you described some common grief reactions. I thought I was going crazy for a while."

3. "It's been 6 months since my son died, so why isn't my wife ready to move on with our lives?"

The nurse is providing nutritional guidance to the parents of a school-age child. Which comment by a parent would prompt the nurse to provide further education? 1. "We use separate utensils for food preparation and for eating." 2. "We allow our child to drink only pasteurized apple cider." 3. "We let our child sample cookie dough while making cookies." 4. "We always wash our hands well before any food preparation."

3. "We let our child sample cookie dough while making cookies."

The nurse is presenting a program on healthy eating habits to the parents of children attending the clinic. Which parental comment indicates the need for more information about safe food preparation? 1. "We always wash our hands well before any food preparation." 2. "We use separate utensils for preparing raw meat and for preparing fruits, vegetables, and other foods." 3. "We take the meat out of the freezer and then allow it to thaw on the counter for 2 to 3 hours before cooking it thoroughly." 4. "If our baby doesn't drink all the formula in his bottle, we throw the rest out."

3. "We take the meat out of the freezer and then allow it to thaw on the counter for 2 to 3 hours before cooking it thoroughly."

The nurse is caring for a child in the pediatric intensive care unit (PICU). The parents have expressed anger over the nursing care their child is receiving. Which nursing action is most appropriate? 1. Explaining to the parents that their anger is affecting their child, and they will not be allowed to visit the child until they calm down 2. Asking the healthcare provider to talk with the family 3. Acknowledging the parents' concerns and collaborating with them regarding the care of their child 4. Calling the hospital chaplain to sit with the family

3. Acknowledging the parents' concerns and collaborating with them regarding the care of their child

The nurse is conducting a physical assessment for a preschool-age child. When plotting the child's body mass index (BMI) the nurse notes that the child's is at the 90th percentile. Which action by the nurse is appropriate? 1. Referring the child to a nutritionist 2. Conducting a developmental assessment 3. Assessing the child's level of activity 4. Checking a blood glucose level

3. Assessing the child's level of activity

Which finding, noted during the newborn admission assessment, would lead the nurse to suspect unilateral congenital hip dysplasia? 1. Lordosis 2. Trendelenburg sign 3. Asymmetry of the gluteal and thigh fat folds 4. Telescoping of the affected limb

3. Asymmetry of the gluteal and thigh fat folds

The nurse collects the weight and height measurements of a child, and calculates the child's body mass index (BMI) to be in the 10th percentile. Previous assessments indicate that the child's BMI was also in the 10th percentile. Which should the nurse include in the discussion of this child's BMI with the parents? 1. Undernutrition 2. Inconsistent growth 3. Consistent growth 4. Overnutrition

3. Consistent growth

An adolescent presents in the emergency department (ED) with confusion. The healthcare provider suspects diabetic ketoacidosis (DKA). A stat serum glucose is done, and the result is 7l5 mg/dL. Which clinical manifestations does the nurse anticipate upon assessment for this client? 1. Tachycardia, dehydration, and abdominal pain 2. Sweating, photophobia, and tremors 3. Dry mucous membranes, blurred vision, and weakness 4. Dry skin, shallow rapid breathing, and dehydration

3. Dry mucous membranes, blurred vision, and weakness

A mother brings in her 4-month-old infant for a routine checkup and vaccinations. The mother reports that her child was exposed to the flu. Which nursing action is accurate based on the current data? 1. Withhold the DTaP vaccination but give the others as scheduled. 2. Give the infant the flu vaccination but withhold the others. 3. Give the vaccinations as scheduled. 4. Withhold the vaccinations.

3. Give the vaccinations as scheduled.

An analgesic is prescribed for a postsurgical pediatric client to be administered every 3 to 4 hours. Which can occur if the nurse is delayed in administering the prescribed analgesic? 1. Decrease in the chance of withdrawal symptoms 2. Decrease in the chance of addiction 3. Increase in the chance of breakthrough pain 4. Increase in the child's pain tolerance

3. Increase in the chance of breakthrough pain

A preschool-age child is admitted to the pediatric unit for surgery. The parents request to stay with their child. Which is the best response by the nurse? 1. Tell the parents they can stay in the hospital but not on the unit. 2. Read the rules and regulations of rooming in with the child. 3. Let the parents know they are allowed to stay with the child. 4. Explain to the parents why they cannot stay with the child.

3. Let the parents know they are allowed to stay with the child.

Which live virus vaccines should the nurse teach to parents as being used to decrease the risk of communicable diseases? Select all that apply. 1. Poliovirus 2. Tetanus 3. Measles 4. Varicella 5. Hepatitis B

3. Measles 4. Varicella

The nurse is caring for a child just admitted with diabetic ketoacidosis (DKA). Which healthcare provider prescription should the nurse question? 1. Neurologic checks hourly 2. Insert urinary catheter and measure output hourly 3. NPH insulin IV at 0.1 unit/kg per hour 4. Stat serum electrolytes

3. NPH insulin IV at 0.1 unit/kg per hour

The parents have requested to be present during their child's procedure. How should the nurse plan for this request? 1. Explain in detail, using medical terms, what will occur. 2. Explain to the family that it is not permitted for family members to be present. 3. Prepare family members for what they should anticipate and what is expected of them. 4. Prepare the family to speak with the healthcare provider.

3. Prepare family members for what they should anticipate and what is expected of them.

Which adolescent behavior, reported by a parent, would cause the nurse to suspect possible substance abuse? 1. Becoming very involved with friends and in activities related to basketball 2. Becoming moody, crying, and weeping one minute and then cheerful and excited the next 3. Receiving numerous detentions for sleeping in class 4. Wearing baggy, oversized clothing and dyeing hair black

3. Receiving numerous detentions for sleeping in class

The nurse is planning care for a child with acquired immune deficiency syndrome (AIDS). Which vaccines should be avoided in the child with AIDS? 1. Inactivated polio vaccine 2. Tetanus toxoid vaccination 3. Varicella vaccine 4. Acellular pertussis vaccine

3. Varicella vaccine

The nurse learns that a newborn is diagnosed with phenylketonuria (PKU). Which is the most appropriate way to inform the newborn's parents about this diagnosis? 1. Calling the parents to provide the diagnosis over the phone 2. Mailing a certified letter explaining the diagnosis and requesting the parents make a pediatric office appointment 3. Planning a group meeting for all parents whose children received the diagnosis in the last two months 4. Scheduling an appointment for the parents to see the healthcare provider in person to discuss the diagnosis

4. Scheduling an appointment for the parents to see the healthcare provider in person to discuss the diagnosis

Which urine specific gravity, and corresponding pH, should the nurse include in a goal statement for a pediatric client receiving chemotherapy in the treatment of cancer? 1. Specific gravity 1.030 and pH 7.5 2. Specific gravity 1.005 and pH 6 3. Specific gravity 1.030 and pH 6 4. Specific gravity 1.005 and pH 7.5

4. Specific gravity 1.005 and pH 7.5

While making rounds, the nurse observes all of the following client behaviors. Which child should the nurse further evaluate for postoperative pain? 1. The 6-month-old in deep sleep. 2. The 2-year-old who is cooperative when the nurse takes vital signs. 3. The 4-year-old who is actively watching cartoons. 4. The 14-month-old who is thrashing his arms and legs.

4. The 14-month-old who is thrashing his arms and legs.

A teacher states to the school nurse, "I have a student who will often just stare at me for 15 seconds after asking a question; then the student blinks and asks me to repeat the question. Should I be concerned?" Which should the nurse include in the response to the teacher? 1. The child has a crush on the teacher. 2. The child has increased intracranial pressure. 3. The child may have had a head injury. 4. The child is experiencing absence seizures.

4. The child is experiencing absence seizures.

During shift report, the night nurse reports that a terminally ill child has developed tolerance to the prescribed morphine. Which concept should the nurse use when planning care for this child? 1. The child is physically dependent on morphine. 2. The child is addicted to morphine. 3. The child is showing physical signs of withdrawal. 4. The child will need more medication to achieve the same effect.

4. The child will need more medication to achieve the same effect.

The parents of an infant diagnosed with sickle-cell disease ask, "How did our child get this disease? Neither one of us has it." Which should the nurse consider when responding to the parents? 1. The father is not the biologic father of the infant. 2. The mother of the child has the trait, but the father does not. 3. The father of the child has the trait, but the mother does not. 4. The mother and the father of the child have the sickle-cell trait.

4. The mother and the father of the child have the sickle-cell trait.

Which statement regarding what was found during the nurse's daily check of the vaccine refrigerator would cause concern about the potency of the vaccines? 1. The vaccine was frozen as labeled. 2. The vaccines have been stored in a refrigerator where the temperature has been maintained between 35 and 46° F. 3. The vaccine's expiration date expires within the next month. 4. The vaccine is stored in the door of the refrigerator

4. The vaccine is stored in the door of the refrigerator

While taking the history of a 10-year-old child, the parents admit to owning firearms. Which should the nurse suggest to enhance the child's safety based on this information? 1. Keeping all the guns put away and out of the child's reach 2. Taking the child to a shooting range for lessons on how to use a gun properly 3. Storing the guns and ammunition in the same place 4. Using a gun lock on all firearms in the house

4. Using a gun lock on all firearms in the house

When assessing the food choices of a 4-year-old boy, the nurse learns that the child loves certain foods and has a normal weight and BMI. Which responses by the parent would indicate a need for nutritional teaching? Select all that apply. Hint: Nutrition a. "I give him all the milk he wants because he is a picky eater." b. "He won't eat all vegetables, but he will eat carrots and celery for a snack." c. "I give him an extra dessert most days when he is being good." d. "We have fun preparing foods together when I get home from work." e. "I give him an extra dessert most days when he is being good."

A, C, E -"I give him all the milk he wants because he is a picky eater." -"I give him an extra dessert most days when he is being good." -"I give him an extra dessert most days when he is being good."

Facilitating health-promotion activities with parents is an important role of the nurse. Which interventions are included in this role? (Select all that apply.) a. Support breastfeeding during the first year of life. b. Help parents understand the immunization schedule. c. Assist in identifying strategies to initiate with "difficult"-temperament infants. d. Encourage parents not to smoke around the infant. e. Teach parents about anticipated developmental milestones.

A, C, E -support breastfeeding during the 1st year of life -assist in identifying strategies to initiate w/ "difficult" temperament infants -teach parents about anticipated developmental milestones

A 4-year-old tells the nurse that she is bad and that is why she is in the hospital. What is the nurse's most appropriate response? a. "What did you do that makes you feel like you are bad?" b. "Don't be silly." c. "You are here so we can help you feel better, not because of anything you might have done." d. "Let's call your mom and see what she has to say about it."

c. "You are here so we can help you feel better, not because of anything you might have done."

At each healthcare visit, the nurse plots the infant's weight, length, and head circumference on a growth curve. Which growth pattern would necessitate a further inquiry into the infant's growth and development? a. An infant whose weight increases from the 75th percentile at 6 months to the 80th percentile at 9 months b. An infant whose length was at the 50th percentile at 2 months of age and who is at the 25th percentile at 4 months of age c. A 1-month-old infant whose birth weight was at the 25th percentile and whose current weight is at the 5th percentile d. An infant whose head circumference was at the 75th percentile at 4 months and who remains at the 75th percentile at 6 months

c. A 1-month-old infant whose birth weight was at the 25th percentile and whose current weight is at the 5th percentile

The nurse asks a 6-year-old male client to rate his pain using the FACES pain-rating scale. The child is 12 hours postoperative for an appendectomy. The child chooses the first face, indicating that he does not have any pain, but the child's mother reports that just before the nurse entered the room, the child stated that his stomach was hurting badly. What is the most appropriate initial action by the nurse? a. Ask the mother to report any more complaints of pain to the nurse. b. Ask the child why he told his mother he had pain but rates his pain as a 0 on the pain scale. c. Administer a dose of prescribed pain medication to the child. d. Reassess the child in 1 hour.

c. Administer a dose of prescribed pain medication to the child.

Which intervention should the nurse suggest to the parents of a 12-month-old as the most effective way to reduce the incidence of early-childhood caries? a. Encourage parents to give the child a bottle of juice at bedtime. b. Advise the parents to begin regular visits to the dentist. c. Advise the parents to provide a pacifier instead of a bottle at bedtime. d. Encourage parents to brush the child's teeth daily.

c. Advise the parents to provide a pacifier instead of a bottle at bedtime.

Which nursing intervention is most developmentally appropriate for a hospitalized 10-year-old? a. Encourage the child to play with safe medical equipment. b. Encourage dependency on the child's parents while the child is hospitalized. c. Allow the child to assist with dressing changes. d. Obtain a complete health history from the child.

c. Allow the child to assist with dressing changes.

6-year-old child is to receive regularly scheduled immunizations. The parent states that the child is not feeling well and asks the nurse to defer the immunizations until next week. What is the best response by the nurse? a. Ask whether the child has missed school. b. Give the parent an immunization appointment for next week. c. Check the child's temperature. d. Ask whether the child has ever had a reaction to immunizations.

c. Check the child's temperature.

A father refuses the measles, mumps, and rubella (MMR) immunizations for his child because he does not want the child to suffer pain or injury, and he believes that the MMR vaccine injection might cause autism. What is the priority nursing diagnosis for this father? a. Risk for Infection related to incomplete immunization series b. Risk for Injury related to vaccine reaction c. Knowledge Deficit (parent): Potential Side Effects of Vaccines related to lack of correct information d. Acute Pain related to injection and associated anxiety

c. Knowledge Deficit (parent): Potential Side Effects of Vaccines related to lack of correct information

The parents of a 17-year-old male are concerned about his recent attitude changes, physical changes, and lack of interest in eating. Which intervention should the nurse consider first? a. Refer to a family counselor, so the family can work together on the changes. b. Ask the parents whether they have alcohol in the home. c. Tell the physician to order drug screens to check for substance abuse. d. Ask the teen privately whether he is using any substances such as drugs or alcohol.

d. Ask the teen privately whether he is using any substances such as drugs or alcohol.

The nurse is providing care for an 8-year-old client with a 2-year history of juvenile rheumatoid arthritis (JRA). The child takes nonsteroidal anti-inflammatory drugs (NSAIDs) on a regular basis to help control discomfort. What is the most appropriate nursing diagnosis for this client? a. Knowledge Deficit: Pain Management related to lack of previous teaching b. Coping Deficit related to discomfort associated with JRA c. Acute Pain related to JRA d. Chronic Pain related to JRA

d. Chronic Pain related to JRA

Nursing assessment of a 14-year-old reveals a BMI in the 90th percentile and a lifestyle that includes spending 4 hours a day playing video games and eating supper while watching television. What is the priority nursing diagnosis for this adolescent? a. Fatigue related to malnutrition b. Disturbed Body Image related to distorted perception of body size and shape c. Delayed Growth and Development related to inappropriate intake d. Imbalanced Nutrition: More than Body Requirements related to excessive intake and sedentary lifestyle

d. Imbalanced Nutrition: More than Body Requirements related to excessive intake and sedentary lifestyle

Which nursing intervention is most important for the family of a premature infant of 26 weeks' gestational age with Down syndrome who is not expected to survive? a. Encourage the parents to join the hospital's support group for children with Down syndrome. b. Orient the parents to the high-tech environment of the neonatal intensive care unit. c. Refer the family to social services to receive assistance for respite care. d. Support the family in anticipatory grieving.

d. Support the family in anticipatory grieving.

A preschooler's response to hospitalization includes the fear of bodily injury or mutilation. How can the nurse best reduce this fear? a. Give thorough explanations of procedures to the child. b. Ask the parents to restrain the child for procedures because the child trusts them. c. Avoid any discussion of impending procedures with the child. d. Use Band-Aids or bandages after invasive procedures to reassure the child that his body will not leak and that body parts will not fall out.

d. Use Band-Aids or bandages after invasive procedures to reassure the child that his body will not leak and that body parts will not fall out.

A child is diagnosed with the HIV. The child's mother expresses concern about transmission at the daycare setting. What should the nurse teach the family regarding handling soiled diapers? a. Use gowns, gloves, and masks. b. Use gowns and gloves. c. Use gowns and goggles. d. Use standard precautions.

d. Use standard precautions.

A 17-year-old male taking codeine after surgery has a history of myocarditis. For which side effect does the nurse carefully monitor? a. Nausea and vomiting b. Constipation c. Sedation d. Respiratory depression

d. respiratory depression

The parents of a child who is critically injured wish to stay in the room while the child is receiving emergency care. Which nursing action is most appropriate in this situation? 1. Asking the healthcare provider if the parents can stay with the child 2. Allowing the parents to stay with the child 3. Escorting the parents to the waiting room and assuring them that they can see their child soon 4. Telling the parents that they do not need to stay with the child

2. Allowing the parents to stay with the child

A new school counselor asks the school nurse to present an educational program for the parents of young adolescents. Which item would be a priority for inclusion in the program? (Select all that apply.) a. Signs and symptoms of substance abuse b. Signs of depression c. Driver's education classes d. Opportunities available in the community to promote physical activity e. The current clothing styles, so the children can "fit in"

A, B, D -s/s of SA -s/s of depression -opportunities available in the community to promote physical activity

When assessing the food choices of a 9-year-old boy, the nurse learns that the child eats his lunch from the school cafeteria. Which responses by the child would indicate a need for nutritional teaching? (Select all that apply.) a. "I eat all the food they give me." b. "I don't get the vegetables they have, but have carrots after school as a snack." c. "I like to get extra dessert most days because it is so good." d. "If I try to eat all the food they give me, I don't have much time at recess."

B, C, D -"I don't get the vegetables they have, but have carrots after school as a snack." -"I like to get extra dessert most days because it is so good." -"If I try to eat all the food they give me, I don't have much time at recess."

The nurse is discussing the risks and benefits of vaccines with a family and must secure signed, informed consent for the children to be immunized. The nurse emphasizes that which reaction to vaccines is very rare? a. Encephalopathy b. Maculopapular rash c. Urticaria around the injection site d. Fever of 100°F (37.8°C)

a. Encephalopathy

Which behavioral responses and verbal descriptions of pain are characteristic of a preschooler? (Select all that apply.) a. Holds body very still when talking to the nurse. b. Points to where the hurt is. c. Cries and screams, unable to describe the type of pain. d. Strikes out physically when painful procedures are performed. e. States, "I'll try to be brave."

b, d

The parent of a child undergoing chemotherapy asks the nurse why the child must wear a mask when in public places. Which response by the nurse would be most appropriate? a. "Chemotherapy causes dry mouth, and the mask will help contain moisture." b. "Chemotherapy decreases immune system function, increasing the risk of acquiring an infection." c. "Chemotherapy kills cancer cells, and your child might spread those cells to others." d. "Chemotherapy makes the oral mucous membranes deteriorate and makes them susceptible to infection."

b. "Chemotherapy decreases immune system function, increasing the risk of acquiring an infection."

When discussing an infant's growth with parents, the nurse explains the term "percentile." Which statement by a parent indicates appropriate understanding of the term? a. "You said my baby is at the 50th percentile for weight, so that means he is only half of what he should be at his age." b. "Since my baby is at the 50th percentile for height, that means only 5 out of 10 babies would be longer than he is." c. "My baby is at the 95th percentile for weight, so that must mean she will probably be overweight like I am when she gets older." d. "Being at the 95th percentile for head circumference means my baby's brain is growing at almost the perfect size of 100 percent for his age."

b. "Since my baby is at the 50th percentile for height, that means only 5 out of 10 babies would be longer than he is."

A mother is concerned that her 5-month-old infant spits out his rice cereal. She thinks he dislikes it. What is the nurse's best response to the mother? a. "You should try placing the cereal in an infant feeder." b. "This is a normal response in some babies when they are first fed from a spoon." c. "Try wheat cereal and see if the baby likes it better." d. "Your child is not ready for solid foods. Try again in 2 months."

b. "This is a normal response in some babies when they are first fed from a spoon."

The nurse assesses a 10-year-old male client with multiple fractures shortly after the child arrives on the unit from the emergency department. The nurse attempts to assess the child's pain using a number scale and then a FACES scale. The child responds, "I do not know, I just hurt bad!" What is the most appropriate action by the nurse? a. Explain the scale and tell the child that he needs to rate his pain. b. Administer the prescribed dose of intravenous morphine. c. Reassess the child in 30 minutes to see whether he will give a rating of his pain. d. Give the prescribed dose of oral acetaminophen with codeine.

b. Administer the prescribed dose of intravenous morphine.

A 14-year-old has been diagnosed with insulin-dependent diabetes. Which technique is most appropriate in order to facilitate coping with this diagnosis? a. Warn the teen of the consequences of noncompliance. b. Introduce the adolescent to another teenager who is successfully managing his diabetes. c. Give the adolescent specific instructions. d. Encourage increased dependence on the teen's parents for several weeks.

b. Introduce the adolescent to another teenager who is successfully managing his diabetes.

An infant in the neonatal intensive care unit must undergo numerous painful procedures. Which complementary therapy to decrease pain during the procedures is most appropriate? a. Massage b. Sucrose pacifier c. Imagery d. Swaddling

b. Sucrose pacifier

Which of the following is the priority goal of nursing interventions related to pain control and pain management? a. The child receives analgesic medication. b. The child reports experiencing reduced pain and improved comfort. c. The child is allowed to rest between painful procedures. d. The child is easily distracted during painful procedures.

b. The child reports experiencing reduced pain and improved comfort.

A gas explosion at a nearby home has worried the parents of a 6-year-old and a 10-year-old. You provide them information about creating a family fire escape plan. Which statement indicates that the parents need further education about emergency preparedness in the home? a. "We changed all the batteries in our smoke alarm last month." b. "We made a game of teaching the children how to cover their faces with a towel in case of a fire." c. "We live in a single-level home, so we'd have no trouble getting out of the house in case of a fire." d. "We have a plan to meet by the street lamp out front in case we all have to leave the house."

c. "We live in a single-level home, so we'd have no trouble getting out of the house in case of a fire."

The nurse is expecting the admission of a child with severe isotonic dehydration. Which intravenous fluid prescription does the nurse anticipate for this child? 1. 0.9% normal saline (NS) 2. D5 0.2% (¼) normal saline 3. D5W 4. Albumin

1. 0.9% normal saline (NS)

A 4-year-old client with intractable seizures has been on a ketogenic diet for the last 6 months, with a decrease in seizure activity. This child is now admitted to the pediatric unit with left-sided pain. Which possible complication to this diet does the nurse suspect? 1. Appendicitis 2. Bowel obstruction 3. Urinary tract infection 4. Kidney stones

4. Kidney stones

A child with a history of seizures arrives in the emergency department (ED) in status epilepticus. Which is the priority nursing action? 1. Take vital signs. 2. Establish an intravenous line. 3. Perform rapid neurologic assessment. 4. Maintain patent airway.

4. Maintain patent airway.

Which assessment data would cause the nurse to suspect that a newborn requires further testing for cystic fibrosis? 1. Rectal prolapse 2. Constipation 3. Steatorrheic stools 4. Meconium ileus

4. Meconium ileus

Which clinical manifestations should the nurse expect when assessing a pediatric client who is diagnosed with Legg-Calvé-Perthes disease? Select all that apply. 1. Limited abduction of the affected hip 2. Asymmetry of thigh fat folds 3. Telescoping of the thigh 4. Muscle weakness 5. Atrophy of the muscles

4. Muscle weakness 5. Atrophy of the muscles

Which is the priority nursing assessment when providing care for an infant at risk for dehydration? 1. Urine output 2. Urine specific gravity 3. Vital signs 4. Daily weight

4. Daily weight

The nurse is teaching a mother of a young child with a newly diagnosed seizure disorder. The child is prescribed valproic acid (Depakote) for control of seizures. Which parental statement indicates the need for further education? 1. "I will not use carbonated beverages to dilute his medication." 2. "I will give his medicine on an empty stomach so he will absorb it better." 3. "I will not let him chew his tablet." 4. "I will bring him to the physician's office for regular blood work to check bleeding times."

2. "I will give his medicine on an empty stomach so he will absorb it better."

Which support groups should the nurse include in a bereavement package for a family who suddenly lost an adolescent in a motor vehicle crash? Select all that apply. 1. Compassionate Friends 2. First Candle 3. Al Anon 4. Infant Loss Support 5. Rachel's Vineyard

1, 2 -Compassionate friends -First Candle

Which complementary pain management interventions should the nurse include in the plan of care for a pediatric client who is experiencing chronic pain? Select all that apply. 1. Hypnosis 2. Guided imagery 3. Patient-controlled analgesia (PCA) 4. Fentanyl patch 5. EMLA cream

1, 2 1. Hypnosis 2. Guided imagery

Which nursing actions are developmentally appropriate when caring for a hospitalized school-age child? Select all that apply. 1. Knocking on the school-age child's hospital room door prior to entering 2. Giving clear instructions about details of treatment 3. Providing brochures regarding sexuality 4. Offering medical equipment to play with prior to a procedure 5. Using toys for distraction during a painful procedure

1, 2 -Knocking on the school-age child's hospital room door prior to entering -Giving clear instructions about details of treatment

The nurse is planning care for a preschool-age child who is intellectually disabled and is scheduled for surgery the next day. Which should the nurse consider when choosing a pain assessment tool? Select all that apply. 1. The child's language skills 2. The child's ability to understand the concept of more and less 3. The child's ability to sit for a 10-minute evaluation 4. The child's ability to perceive pain 5. The child's ability to understand pain

1, 2 -The child's language skills -The child's ability to understand the concept of more and less

Which distraction techniques should the nurse to use for a school-age child during a painful procedure? Select all that apply. 1. Blowing bubbles 2. Music therapy 3. Guided imagery 4. Hypnosis 5. Sucrose solution

1, 2, 3 1. Blowing bubbles 2. Music therapy 3. Guided imagery

The nurse is teaching the parents of a 6-month-old infant about the introduction of solid foods. Which foods will the nurse include in the teaching session? Select all that apply. 1. Rice cereal 2. Fruits 3. Vegetables 4. Meats 5. Nut products

1, 2, 3 -rice cereal (at 4-6mo) -fruits -veggies

Which nursing actions will allow a family to further develop resilience when faced with an illness of a child? Select all that apply. 1. Teaching skills to provide care 2. Suggesting adaptations related to discipline 3. Providing positive reinforcement 4. Recommending the use of defensive coping strategies 5. Focusing on the weaknesses

1, 2, 3 -teaching skills to provide care -suggesting adaptations r/t discipline -providing positive reinforcement

Which concepts will the nurse use when conducting client teaching to a family regarding Dietary Reference Intake (DRI) in the United States (U.S.)? Select all that apply. 1. Estimated Average Requirement (EAR) 2. Recommended Daily Allowance (RDA) 3. Adequate Intake (AI) 4. Upper Intake (UI) 5. Reference Nutrient Intake (RNI)

1, 2, 3, 4 -Estimated Average Requirement (EAR) -Recommended Daily Allowance (RDA) -Adequate Intake (AI) -Upper Intake (UI)

The nurse is planning a teaching session for the parents of a child who is diagnosed with simple partial seizures. Which causes should the nurse include when teaching the parents? Select all that apply. 1. Lesions 2. Cysts 3. Tumor 4. Brain abscesses 5. Brain trauma

1, 2, 3, 4 1. Lesions 2. Cysts 3. Tumor 4. Brain abscesses

The nurse is teaching the mother of a newborn how the immune system functions. Which statement regarding the process that occurs when healthy children are exposed to infection indicates accurate understanding of the information presented? 1. "Children who are exposed to infection naturally develop antibodies." 2. "Children who are exposed to infection are found to be healthier." 3. "Children who are exposed to infection will acquire terminal illnesses." 4. "Children who are exposed to infection will have weakened immune systems."

1. "Children who are exposed to infection naturally develop antibodies."

A school-age child is admitted to the hospital with a fractured femur and head trauma. The child was not wearing a helmet while riding a new bicycle on the highway, and collided with a car. Which nursing diagnoses should the nurse include in the plan of care with regard to the child's parents? Select all that apply. 1. Compromised Family Coping related to the critical injury of the child 2. Parental Role Conflict related to child's injuries and pediatric intensive care unit (PICU) policies 3. Guilt related to lack of child supervision and safety precautions 4. Knowledge Deficit related to home care of fractured femur 5. Anger related to feelings of helplessness

1, 2, 3, 5 -1. Compromised Family Coping related to the critical injury of the child -2. Parental Role Conflict related to child's injuries and pediatric intensive care unit (PICU) policies -3. Guilt related to lack of child supervision and safety precautions -5. Anger related to feelings of helplessness

Which topics should the nurse include in a discussion with parents of a terminally ill child regarding parental feelings that may occur upon the child's death? Select all that apply. 1. Loneliness 2. Guilt 3. Anger 4. High energy 5. Depression

1, 2, 3, 5 -Loneliness -Guilt -Anger -Depression

Which nursing diagnoses should the nurse include in the plan of care for a pediatric client diagnosed with cerebral palsy? Select all that apply. 1. Risk for Constipation 2. Impaired Tissue Integrity 3. Impaired Verbal Communication 4. Acute Pain 5. Risk for Delayed Development

1, 2, 3, 5 1. Risk for Constipation 2. Impaired Tissue Integrity 3. Impaired Verbal Communication 5. Risk for Delayed Development

The nurse is providing care to a child who is nearing death. Which nursing actions may offer the family support? SATA 1. Using active listening techniques 2. Looking the parents in the eye when talking 3. Refusing to cry while in the child's room 4. Offering to call and notify family 5. Avoiding being in the room to allow the family to grief

1, 2, 4 -1. Using active listening techniques -2. Looking the parents in the eye when talking -4. Offering to call and notify family

Which pediatric diagnoses require the nurse to include interventions to treat chronic pediatric client pain in the plan of care? Select all that apply. 1. Juvenile idiopathic arthritis 2. Sickle cell disease 3. Attention deficit hyperactivity disorder (ADHD) 4. Cancer 5. Human immunodeficiency virus (HIV)

1, 2, 4 1. Juvenile idiopathic arthritis 2. Sickle cell disease 4. Cancer

The pediatric nurse is working as a first responder within the community after a tornado. Which nursing actions are appropriate? Select all that apply. 1. Providing first aid to the walking wounded 2. Assessing for panic reactions 3. Allowing a child to leave the scene unaccompanied by an adult 4. Administering immunizations 5. Discussing the situation with the local media

1, 2, 4 -providing 1st aid to the walking wounded -assessing for panic reactions -admin immunizations

The nurse is preparing to administer an intramuscular injection to a toddler-age client. Which is the most appropriate statement by the nurse prior to this procedure? 1. "It is all right to cry. After we are done, you can go to the box and pick out your favorite sticker." 2. "We will give you your shot when your mommy comes back." 3. "I will wipe your skin with a magic wipe and then hold the needle like this and say 'one, two, three, go' and give you your shot. Are you ready?" 4. "This is a magic sword that will give you your medicine and make you all better."

1. "It is all right to cry. After we are done, you can go to the box and pick out your favorite sticker."

A school-age child is admitted to the hospital in a sickle-cell crisis. Which actions should the nurse include in the plan of care to address the child's pain? 1. Administering opioid analgesics, per order 2. Administering nonsteroidal anti-inflammatory drugs (NSAIDs), per order 3. Applying cold packs to affected joints, prn 4. Encouraging oral fluid intake 5. Maintaining bed rest

1, 2, 4, 5 1. Administering opioid analgesics, per order 2. Administering nonsteroidal anti-inflammatory drugs (NSAIDs), per order 4. Encouraging oral fluid intake 5. Maintaining bed rest

Which vaccines should the nurse prepare to administer to a 6-month-old infant during a scheduled well-child visit? Select all that apply. 1. DTaP vaccine 2. Hib vaccine 3. HPV4 vaccine 4. MMR vaccine 5. PCV13 vaccine

1, 2, 5 1. DTaP vaccine 2. Hib vaccine 5. PCV13 vaccine

The mother of an immunocompromised child expresses concern that her child will "catch" a disease from the scheduled vaccination. Which vaccines should be administered to this child as they carry no risk for acquiring the infection? 1. Toxoid 2. Killed virus vaccine 3. Live virus vaccine 4. Attenuated vaccine 5. Immunoglobulins

1, 2, 5 1. Toxoid 2. Killed virus vaccine 5. Immunoglobulins

A 6-year-old child is hospitalized for a surgical procedure. The parents ask if the child's four siblings can visit. Which response by the nurse is the most appropriate? 1. "Let's plan their visit for a time when the child has received pain medication." 2. "Only those siblings over 16 will be allowed to visit." 3. "I don't think the other children should visit because it might scare them to see their sibling so sick." 4. "Very young children shouldn't visit as they may carry germs."

1. "Let's plan their visit for a time when the child has received pain medication."

Which parental statements during the nutrition assessment for a toddler would cause the nurse concern? Select all that apply. 1. "My child drinks 20 ounces of fat-free milk each day." 2. "My child drinks 6 ounces of 100% fruit juice each day." 3. "We eat at fast-food restaurants several times each week." 4. "We only give our child pasteurized fruit juices." 5. "My child likes to drink water with snacks."

1, 3 -"My child drinks 20 ounces of fat-free milk each day." -"We eat at fast-food restaurants several times each week."

The nurse is educating the parents of a 2-month-old infant when to contact the healthcare provider. Which statements by the parents indicate the need for further instruction? Select all that apply. 1. "We will contact the doctor if our baby does not have a bowel movement each day." 2. "We will contact the doctor if our baby is vomiting." 3. "We will contact the doctor if our baby has a temperature greater than 99°F." 4. "We will contact the doctor if our baby does finish each bottle." 5. "We will contact the doctor if our baby develops a skin rash."

1, 3, 4 -"We will contact the doctor if our baby does not have a bowel movement each day." -"We will contact the doctor if our baby has a temperature greater than 99°F." -"We will contact the doctor if our baby does finish each bottle."

The nurse is providing care to a child who is diagnosed with Legg-Calvé-Perthes disease. Which parental statement regarding the child's care required further teaching from the nurse? 1. "We're glad this will only take about 6 weeks to correct." 2. "We understand abduction of the affected leg is important." 3. "We know to watch for areas on the skin that the brace might rub." 4. "We understand swimming is a good sport for Legg-Calvé-Perthes."

1. "We're glad this will only take about 6 weeks to correct."

Which defense mechanisms should the nurse include in the parental teaching session regarding common pediatric responses to a life-threatening illness? Select all that apply. 1. Regression 2. Anticipating 3. Denial 4. Repression 5. Bargaining

1, 3, 4, 5 -regression -denial -repression -bargaining

The nurse is providing information to an adolescent newly diagnosed with diabetes. Which clinical manifestations of diabetic ketoacidosis (DKA) should the nurse include in the teaching session? Select all that apply. 1. Change in mental status 2. Tachycardia 3. Fruity breath odor 4. Rapid, shallow respirations 5. Abdominal pain

1, 3, 5 1. Change in mental status 3. Fruity breath odor 5. Abdominal pain

Which nursing actions are developmentally appropriate when providing care to a hospitalized toddler-age child? Select all that apply. 1. Using a crib mobile for distraction during a procedure 2. Having a potty-chair available 3. Allowing self-feeding opportunities 4. Showing equipment that will be used during the scheduled surgery 5. Assessing drawings to determine concerns

2, 3 -Having a potty-chair available -Allowing self-feeding opportunities

Which infection control measures should the nurse include in the discharge instructions for the family of a child who is immunodeficient? Select all that apply. 1. "It is important that your child does not share cups with other members of the family." 2. "You should avoid washing your child's utensils in the dishwasher." 3. "You should allow your child to eat fresh fruit with the skin intact." 4. "It is important that everyone practices hand hygiene before touching your child." 5. "You should use alcohol wipes to cleanse your child's diaper area."

1, 4 -"It is important that your child does not share cups with other members of the family." -"It is important that everyone practices hand hygiene before touching your child."

Which preventative strategies should the nurse include in a teaching session for a mother whose infant is at risk for febrile seizures? Select all that apply. 1. Increasing oral intake of fluids 2. Administering dose-appropriate aspirin 3. Providing a sponge bath with cold water 4. Decreasing oral fluid intake 5. Patting the child dry after a tepid bath

1, 5 1. Increasing oral intake of fluids 5. Patting the child dry after a tepid bath

Which clinical manifestations should the nurse expect when assessing a pediatric client who is diagnosed with congenital hip dysplasia (CHD)? Select all that apply. 1. Limited adduction of the affected hip 2. Asymmetry of thigh fat folds 3. Telescoping of the thigh 4. Muscle weakness 5. Atrophy of the muscles

2, 3 2. Asymmetry of thigh fat folds 3. Telescoping of the thigh

The nurse administers the flu vaccine to a school-age child. Which should the nurse include in the documentation for the administration of this vaccine? Select all that apply. 1. The date of the last flu vaccine 2. The site of the vaccination 3. The lot and serial number of the vaccine 4. The date and time of administration. 5. Who assisted in restraining the child

2, 3, 4 -2. The site of the vaccination -3. The lot and serial number of the vaccine -4. The date and time of administration.

Which nonpharmacologic interventions are appropriate for the nurse to use when treating pediatric clients in pain? Select all that apply. 1. Regional nerve block 2. Cutaneous stimulation 3. Application of heat 4. Electroanalgesia 5. Use of EMLA cream

2, 3, 4 2. Cutaneous stimulation 3. Application of heat 4. Electroanalgesia

The parents of a 4-month-old child learn that there will be long-term consequences due to the head injury sustained in a motor vehicle accident, including intellectual disability and cerebral palsy. The parents express anger at the diagnosis and project that anger on the nursing staff. Which responses by the nursing staff are appropriate? Select all that apply. 1. Referring the family to the hospital administrator 2. Recognizing that the parents' anger is a normal response to the news 3. Continuing to provide physical and emotional care to the child and family 4. Offering hospital resources to the parents in addition to continued nursing support 5. Explaining to the family that you are sorry about their child's injury but suggest they transfer the child to another hospital for their own comfort

2, 3, 4 -Recognizing that the parents' anger is a normal response to the news -Continuing to provide physical and emotional care to the child and family -Offering hospital resources to the parents in addition to continued nursing support

Which functions of the adrenal hormone aldosterone should the nurse include in a teaching session for a pediatric client diagnosed with alterations in adrenal function? Select all that apply. 1. Stimulates bone development 2. Increases sodium ion reabsorption 3. Stimulates secondary sexual characteristics 4. Increases potassium excretion by the kidneys 5. Activates the sympathetic nervous system

2, 4 2. Increases sodium ion reabsorption 4. Increases potassium excretion by the kidneys

The parents of a 2.5-year-old boy are concerned about their child's finicky eating habits. While counseling the parents, which statements by the nurse would be accurate? Select all that apply. 1. "Nutritious foods should be made available at all times of the day so that the child is able to 'graze' whenever he is hungry." 2. "The child is experiencing physiologic anorexia, which is normal for this age group." 3. "A general guideline for food quantity at a meal is one quarter cup of each food per year of age." 4. "It is more appropriate to assess a toddler's nutritional demands over a 1-week period rather than a 24-hour one." 5. "The toddler should drink 16 to 24 ounces of milk daily."

2, 4, 5 -"The child is experiencing physiologic anorexia, which is normal for this age group." -"It is more appropriate to assess a toddler's nutritional demands over a 1-week period rather than a 24-hour one." -"The toddler should drink 16 to 24 ounces of milk daily."

Which clinical manifestations should the nurse monitor for when conducting a scoliosis screening for a school-age child? Select all that apply. 1. Lordosis 2. Prominent scapula 3. Pain 4. A one-sided rib hump 5. Uneven shoulders and hips

2, 4, 5 2. Prominent scapula 4. A one-sided rib hump 5. Uneven shoulders and hips

The clinic administrator has suggested that the nurse teach all children newly diagnosed with diabetes in a single class to save nursing time. The children recently diagnosed range in age from 6 to 15. Which is the rationale for the nursing staff to continue with more than one group session? 1. Freud's theory of psychosexual development, which states that the 6-year-old child's sexual energy is at rest while the adolescent has developed mature sexuality. 2. Erikson's psychosocial theory, which discusses how children learn to relate to others. 3. Piaget's cognitive development theory, which says the 6-year-old child learns by concrete examples, while the 15-year-old adolescent can think abstractly. 4. Kohlberg's theory, which says the young children are conventional in their thinking and will want to learn to please others, while older children can internalize values and will learn for their own principles

3

There has been an outbreak of communicable diseases in the community. To reduce parental anxiety, the nurse presents information about disease at the school's Parent Teacher Association meeting. Which vectorborne diseases, not communicable from person to person, should the nurse include in the teaching session? Select all that apply. 1. Measles 2. Whooping cough 3. Rocky Mountain spotted fever 4. West Nile virus 5. Lyme disease

3, 4, 5 3. Rocky Mountain spotted fever 4. West Nile virus 5. Lyme disease

A pediatric client diagnosed with cancer is to receive 2 months of chemotherapy that is separated by a 6-week period. The mother asks why the child cannot receive the medication for 2 months straight. Which rationale should the nurse include when responding to the client's mother? 1. Prevention of nausea and vomiting from the drugs 2. Schedule requirement of the infusion center 3. Decrease incidence of heart failure 4. Allows normal cells to repair themselves while the cancer cells die

4. Allows normal cells to repair themselves while the cancer cells die

Which statement by the parent of a preschool-age child would indicate the need for further teaching regarding pain management? 1. "I will call the office tomorrow if the pain medicine is not relieving the pain." 2. "I can expect my child to have some pain for the next few days." 3. "Because my child just had surgery today, I can expect the pain level to be higher tomorrow." 4. "I will plan to give my child pain medicine around the clock for the next day or so."

3. "Because my child just had surgery today, I can expect the pain level to be higher tomorrow." (inc pain is s/s of complication)

Which parental statement indicates correct understanding regarding pancreatic enzyme administration in the treatment of cystic fibrosis? 1. "I will administer this medication 4 times each day." 2. "I will administer this medication twice each day." 3. "I will administer this medication with meals and snacks." 4. "I will administer this medication every 6 hours around the clock."

3. "I will administer this medication with meals and snacks."

The nurse is caring for a child who has been sedated for a painful procedure. Which is the priority nursing action? 1. Placing the child on a cardiac monitor 2. Allowing parents to stay with the child 3. Monitoring pulse oximetry 4. Assessing the child's respiratory effort

4. Assessing the child's respiratory effort

A neonate with a meningomyelocele is to have surgery in the morning. Which nursing action is appropriate for this neonate? 1. Applying a diaper to prevent contamination of sac 2. Positioning the newborn in a side-lying position 3. Encouraging the mother to hold the newborn because she will not be able to pick him up after surgery 4. Positioning the newborn in a prone position

4. Positioning the newborn in a prone position

A child is receiving a nucleoside reverse transcriptase inhibitor for human immunodeficiency virus (HIV). Which laboratory value should the nurse include in the plan of care as needing to monitor? 1. Glucose 2. Sodium 3. Potassium 4. Red blood cell count

4. Red blood cell count

The mother of a 6-year-old boy who has recently had surgery for the removal of his tonsils and adenoids complains that he has begun sucking his thumb again. Which defense mechanism will the nurse include when responding to the mother? 1. Repression 2. Rationalization 3. Fantasy 4. Regression

4. Regression

A nurse is planning care for a child with human immunodeficiency virus (HIV). Which is the priority nursing diagnosis for this child? 1. Ineffective Peripheral Tissue Perfusion 2. Ineffective Thermoregulation 3. Risk for Fluid Volume Deficit 4. Risk for Infection

4. Risk for Infection

A 3-year-old child, recently hospitalized for the exacerbation of a chronic illness, presents for a follow-up appointment at the pediatric clinic. The child's mother states, "He was potty trained before the hospital stay but now he is having daily accidents." Which response by the nurse is most appropriate? 1. "This is probably a reaction to the antibiotics and will disappear when the antibiotics are finished." 2. "Urinary incontinence is a common symptom of progression of cystic fibrosis. Be sure to notify the healthcare provider of this change." 3. "The child may have a urinary tract infection and needs to be evaluated." 4. "Children often regress after hospitalization. Be patient and remind him to go to the bathroom frequently."

4. "Children often regress after hospitalization. Be patient and remind him to go to the bathroom frequently."

A parent says to a nurse, "How do you know when my baby needs these screening tests the doctor just mentioned?" Which response by the nurse is most appropriate? 1. "Screening tests are done in the newborn nursery, and from these results, additional screening tests are ordered throughout the first 2 years of life." 2. "Screening tests are done at each office visit." 3. "Screening tests are most often done when the doctor suspects something is wrong with the child." 4. "Screening tests are administered at the ages when a child is most likely to develop a condition."

4. "Screening tests are administered at the ages when a child is most likely to develop a condition."

The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis) immunization for a 6-month-old infant. Which nursing action is accurate to safely administer this vaccine to the infant? 1. Administering the vaccine by ID (intradermal) injection 2. Administering the vaccine by SQ (subcutaneous) injection 3. Administering the vaccine by IM (intramuscular) injection 4. Administering the vaccine via a nasal spray

4. Administering the vaccine via a nasal spray (DTaP admin via IM injection)

The nurse is planning care for a pediatric client who has a fractured femur and requires a spica cast after being involved in a motor vehicle accident. The client's adolescent brother was driving the car, which was a total loss. The client's father lost his job 3 weeks ago and the mother has just accepted a temporary waitress job. Which is an appropriate nursing diagnosis for this child, and family, based on the current data? 1. Interrupted Family Processes related to a child with significant disability requiring alteration in family functioning. 2. Risk for Caregiver Role Strain related to a child with a newly acquired disability and the associated financial burden. 3. Impaired Social Interaction (parent and child) related to the lack of family or respite support. 4. Compromised Family Coping related to multiple simultaneous stressors.

4. Compromised Family Coping related to multiple simultaneous stressors.

The parents of a 2-year-old child who sustained severe head trauma from falling out of a second-story window are arguing in the pediatric intensive care unit (PICU), and are blaming each other for the child's accident. Which is the best nursing diagnosis for this family? 1. Impaired Parenting related to protecting the child 2. Anxiety related to the critical care unit environment 3. Hopelessness related to the child's deteriorating condition 4. Compromised Family Coping related to the child's critical injury

4. Compromised Family Coping related to the child's critical injury

During a 4-month-old infant's well-child checkup, the nurse discusses introduction of solid foods into the infant's diet. Although the nurse recommends delaying the introduction of many foods into the diet, which food(s) will the nurse discuss delaying because they increase the risk for food allergy? 1. Honey 2. Carrots, beets, and spinach 3. Pork 4. Cow's milk, eggs, and peanuts

4. Cow's milk, eggs, and peanuts

The nurse is doing a follow-up home visit to a family who lost their 3-month-old infant to SIDS 8 weeks ago. The mother answers the door in her nightgown, with hair uncombed. During the interview, the mother states: "I don't see the point of getting dressed each day." Which stage of grief will the nurse document based on the current data? 1. Recovery 2. Yearning, pining 3. Hostile 4. Disorganization

4. Disorganization

A 6-year-old postoperative client's IV infiltrates and has to be restarted immediately for medication. There is no time for placing local anesthetic cream on the skin. Which complementary therapy would be helpful when placing this IV? 1. Restraints 2. Moderate sedation 3. Anesthesia 4. Distraction

4. Distraction

Which aspect of an emergency medical services system (EMS) indicates the providers are prepared to provide emergency care to children? 1. Listing hospitals in the area that treat children 2. Having pediatric-sized equipment and supplies 3. Placing small stretchers in emergency vehicles 4. Educating staff related to assessment and treatment of children of all ages

4. Educating staff related to assessment and treatment of children of all ages

An adolescent diagnosed with type 1 diabetes mellitus (DM) is prescribed dietary restrictions and daily insulin injections. Which behavior does the nurse anticipate from the adolescent upon return to school? 1. Administering medication in front of peers 2. Teaching peers about the diagnosis 3. Acknowledging the condition to classmates 4. Exhibiting poor adherence to the prescribed treatment plan

4. Exhibiting poor adherence to the prescribed treatment plan

A mother refuses to have her child immunized with the measles, mumps, and rubella (MMR) vaccine because she believes that letting her infant get these diseases will help him fight off other diseases later in life. Which is an appropriate response by the nurse? 1. Telling the mother that by not immunizing the child she may be exposing pregnant women to the virus, which could cause fetal harm 2. Honoring the mother's request because she is the parent 3. Telling the mother that she is wrong and should have her child immunized 4. Explaining the potential complications of measles, mumps, and rubella infections

4. Explaining the potential complications of measles, mumps, and rubella infections

The nurse is caring for a postoperative toddler-age child. Which pain assessment tool should the nurse use to assess this child's pain? 1. Poker Chip Tool 2. Oucher Scale 3. Faces Pain Rating Scale 4. FLACC Behavioral Pain Assessment Scale

4. FLACC Behavioral Pain Assessment Scale

A child diagnosed with cancer is prescribed chemotherapy. Recent laboratory data show a low white blood cell (WBC) count. Which prescription should the nurse anticipate based on the current data? 1. Epoetin alfa (Epogen) 2. Ondansetron (Zofran) 3. Oprelvekin (Neumega) 4. Filgrastim (Neupogen)

4. Filgrastim (Neupogen)

During a natural disaster, a child diagnosed with hemophilia is injured and bleeding internally. Which blood product should the nurse plan to administer if the appropriate factor is not available? 1. Platelets 2. Whole blood 3. Packed cells 4. Fresh or fresh frozen plasma

4. Fresh or fresh frozen plasma

A child has a planned hospitalization in a few weeks, and the client and family appear very stressed. Which nursing action will minimize the stress for the client and family? 1. Telling the client and family that everything will be fine 2. Explaining to the client and family how the child will benefit from the surgery 3. Telling the client and family that the surgeon is very good 4. Giving a tour of the hospital unit or surgical area to the client and family

4. Giving a tour of the hospital unit or surgical area to the client and family

When teaching a pregnant client about antibodies that are passed from mother to newborn, which antibody should the nurse include? 1. IgM 2. IgA 3. IgD 4. IgG

4. IgG

The nurse is planning health promotion activities for a toddler-age child during a scheduled health maintenance visit. Which action by the nurse is appropriate during this visit? 1. Connecting developmental skills with risks for injury 2. Recognizing that childcare attendance increases the risk for communicable disease 3. Planning education for treatment of common disease processes 4. Illustrating developmental progression on a screening tool

4. Illustrating developmental progression on a screening tool

While assessing the development of a 9-month-old client, the nurse asks the mother if the child actively looks for toys when they are placed out of sight. Which is the nurse assessing with this question to the parent? 1. Transductive reasoning 2. Conservation 3. Centration 4. Object permanence

4. Object permanence

The nurse is providing information regarding infant nutrition to parents during a well-child visit. Which of the following growth and development milestones must be achieved prior to introducing soft finger foods into an infant's diet? (Select all that apply.) a. The infant drinks formula every 4 hours during the day. b. The infant is able to sit up with support. c. The infant has developed the pincer grasp. d. The extrusion reflex no longer is present. e. The infant has several primary teeth.

B, C, D -infant is able to sit up w/ support -infant has developed the pincer grasp

The nurse teaches a parent of a child with sickle cell anemia (SCA) about recommended immunizations for the child. Which immunizations would be recommended? (Select all that apply.) a. Synagist b. Pneumococcal c. Hib d. MMR e. Influenza

B, C, D, E b. Pneumococcal c. Hib d. MMR e. Influenza

A 6-month-old infant is admitted with severe dehydration. Effectiveness of therapy is evaluated with which assessment measures? (Select all that apply.) a. Documenting abdominal girth every shift b. Documenting mucous membrane moisture every shift c. Daily weights each day on a rotating shift d. Recording intake and output accurately e. Evaluating level of consciousness continuously

B, D, E -Documenting mucous membrane moisture every shift -Recording intake and output accurately -Evaluating level of consciousness continuously

Nutritional assessment of a 10-year-old indicates the following findings. Which does the nurse recognize as a risk alert? (Select all that apply.) a. A BMI in the 25th percentile b. Eating an apple and an orange every day for a snack c. Having been diagnosed with asthma d. Eating one vegetable a day, generally at suppertime e. Playing basketball 5-6 days a week

C, D -have been dx w/ asthma -eating one vegetable a day, generally at suppertime

A mother is complaining to the nurse that her 16-year-old son who plays varsity football has been "eating too much junk." Which comment by the nurse is appropriate? a. "Because your son is so active, he might need three thousand or more calories daily." b. "Two thousand calories are more than enough to support his needs." c. "Talk to him about the benefits of good nutrition and stopping all fast food intake." d. "Discuss the need for him to add fruits and vegetables to his diet."

a. "Because your son is so active, he might need three thousand or more calories daily."

The parent of a child diagnosed with sickle cell anemia (SCA) asks the nurse about air travel with the child. Which is the best response by the nurse? a. "Flying at high altitudes can be associated with less available oxygen, causing more red blood cells to assume the sickle shape." b. "Flying does not pose any particular risks for the child with SCA." c. "Flying will present a risk for infection secondary to crowds." d. "Air travel is not recommended, because it will increase the child's risk for dehydration."

a. "Flying at high altitudes can be associated with less available oxygen, causing more red blood cells to assume the sickle shape."

The nurse is preparing a 4-year-old for surgery. Which technique is most appropriate? a. Allow the child to handle safe medical equipment. b. Limit the teaching to one 1-hour session. c. Explain to the child that she will be put to sleep for the procedure. d. Use an anatomically correct doll to explain the procedure.

a. Allow the child to handle safe medical equipment.

A father was the driver of a car involved in an accident that severely injured his only child. The father is yelling angrily at the nurses and doctors in the emergency department, calling them stupid and incompetent. Which is the best nursing diagnosis applying to the father? a. Anger related to the crisis of child's condition b. Anger related to the incompetence of physicians and nurses c. Guilt related to the father's role in the accident d. Anger related to lack of trust in the nurse

a. Anger related to the crisis of child's condition

A parent tells the nurse, "I just don't think my child will make it this time. We have had so many hospitalizations, but this time is different." Which nursing diagnosis is consistent with this statement? a. Anticipatory Grieving related to child's deteriorating health status b. Knowledge Deficit related to a complex-condition management plan c. Compromised Family Coping related to prolonged condition management d. Risk for Impaired Parenting related to stress with many hospitalizations

a. Anticipatory Grieving related to child's deteriorating health status

The family of a hospitalized child with leukemia believes that the child will be cured by prayer alone and plans to take the child home. Which nursing intervention will address this barrier to care? a. Assess the family's understanding of leukemia. b. Communicate the parents' request to the child's primary healthcare provider. c. Evaluate the home for wheelchair accessibility. d. Demonstrate respect for the family's wishes

a. Assess the family's understanding of leukemia.

A new mother has questions about breastfeeding and infant formulas. She asks the nurse what the best kind of milk is for her full-term baby. What is the best recommendation by the nurse? a. Breast milk for the first year b. Breast milk with human milk fortifier for the first 3 months c. Iron-fortified formula for 6 months d. Breast milk alternated with iron-fortified formula for the first 6 months

a. Breast milk for the first year

The nurse is assessing an adolescent. The nurse notes that the teen has bloodshot eyes and dilated pupils and has lost weight. What should the nurse suspect based on these assessment findings? a. Drug abuse b. Suicidal ideations c. Smoking d. Intoxication

a. Drug abuse

The nurse is planning a class on safety for a group of middle school-age children. Which safety intervention is the most important for the nurse to include in the class? a. Helmet use when riding a bike b. Use of a helmet and kneepads with indoor roller-skating c. Use of knee pads when Rollerblading d. Need for elbow pads when riding a scooter

a. Helmet use when riding a bike

Which intervention would not be included in the preoperative plan of care for an infant with an omphalocele? a. Push the exposed abdominal contents back into the abdomen. b. Administer intravenous fluids. c. Assess for signs of other congenital anomalies. d. Care for the infant in a radiant warmer.

a. Push the exposed abdominal contents back into the abdomen.

A mother refuses to have her child receive any immunizations, based on her religious beliefs. What is the priority nursing diagnosis when planning health teaching for this family? a. Risk for Infection related to incomplete immunization series b. Knowledge Deficit (parent) related to potential side effects of vaccines c. Acute Pain related to injection and associated anxiety d. Risk for Injury related to vaccine reaction

a. Risk for Infection related to incomplete immunization series

A 5-year-old is showing signs of respiratory depression after receiving a dose of morphine postop surgical repair of a fracture to the right arm. For what signs and symptoms does the nurse observe? a. Small pupils and shallow breathing b. Tachypnea and sweating c. Vomiting and anxiety d. Delirium and hallucinations

a. Small pupils and shallow breathing

A 3-year-old child is being discharged from the hospital following treatment for an acute illness. The child is scheduled to return to the clinic in 1 week to have blood drawn by venipuncture to reassess electrolyte values. The child's parents ask whether there is anything they can do prior to arriving at the clinic to decrease the child's discomfort from the procedure. What is the most appropriate response by the nurse? a. Reassure the parents that the procedure is not painful. b. Suggest therapeutic play prior to the procedure. c. Obtain a prescription for EMLA or Ela-max from the primary healthcare provider and instruct the parents how and when to apply the medication. d. Suggest that the parents reassure the child that the procedure will not hurt.

c. Obtain a prescription for EMLA or Ela-max from the primary healthcare provider and instruct the parents how and when to apply the medication.

At a 2-year-old's checkup, measurement of weight indicates that the infant has lost 4 pounds since his last checkup. What should the nurse do first? a. Plot the weight on a growth chart. b. Assess the child for signs of malnutrition. c. Reweigh the child. d. Ask the mother about the child's daily intake.

c. Reweigh the child.

The nurse is caring for a postoperative 14-year-old female on the pediatric unit. Which consideration is most significant in planning care for this child? a. The child will want her mother with her at all times. b. The child of this age will be glad to miss school. c. The child of this age is learning to become independent. d. The child is not going to be concerned with her body image while hospitalized.

c. The child of this age is learning to become independent.

The nurse is evaluating the effectiveness of client-controlled analgesia for a 10-year-old client. Which outcome is the best indicator that this delivery of pain medication is effective? a. The child naps at frequent intervals. b. The child presses the button on a regular basis. c. The child reports a pain level of 0 on a 0-to-10 scale. d. There is no evidence of respiratory depression.

c. The child reports a pain level of 0 on a 0-to-10 scale.

Which statement made by the grandmother of a 7-month-old infant during a health visit would indicate that more teaching regarding nutrition was needed? a. "He seems to know that it is time to eat when we put him in his high chair." b. "He is a little young to use a spoon the right way, but I still let him try." c. "I don't worry if he only takes a few bites of a new food at each meal." d. "I am going to make sure that this grandchild is not a picky eater. I give him whatever we are eating."

d. "I am going to make sure that this grandchild is not a picky eater. I give him whatever we are eating."

10-year-old child has just received his first immunization of influenza vaccine. His lips begin to swell, and he states, "It feels like my throat is closing shut and my chest is tight when I breathe." Which reaction does the nurse recognize that the child is experiencing? a. A local allergic reaction to the influenza vaccine injection b. A common systemic allergic reaction to immunization c. An anxiety reaction due to receiving an injection d. A life-threatening reaction to the influenza vaccine

d. A life-threatening reaction to the influenza vaccine

A preschool-age child undergoing chemotherapy experiences nausea and vomiting. Which action would best encourage the child to eat? a. Offer fluids only between meals. b. Administer tube feedings. c. Offer small, frequent meals. d. Allow the child to choose what to eat for meals.

d. Allow the child to choose what to eat for meals.