Peds: Exam 1

A 3-year-old admitted to the hospital with croup has the following vital signs: heart rate 90, respiratory rate 44, blood pressure 100/52, and temperature 98.8°F (37.1°C). The parents ask the nurse if these vital signs are normal. The nurse ' s best response is: 1. "Your son's blood pressure is elevated, but the other vital signs are within the normal range." 2. "Your son's temperature is elevated, but the other vital signs are within the normal range." 3. "Your son's respiratory rate is elevated, but the other vital signs are within the normal range." 4. "Your son's heart rate is elevated, but the other vital signs are within the normal range."

3. A normal respiratory rate for a child from 3 to 6 years is 20 to 30 breaths per minute.

26. Which medication is most important to have available in all clinics and offices if immunizations are administered? 1. Diphenhydramine (Benadryl) injection. 2. Diphenhydramine (Benadryl) liquid. 3. Epinephrine 1 : 1000 injection. 4. Epinephrine 1 : 10,000 injection.

3. Epinephrine 1 : 1000 injection would be the drug of choice for subcutaneous injection if a severe allergic reaction occurs in an office or clinic setting.

16. Which statement by the parent of a newborn diagnosed with galactosemia demonstrates successful teaching? 1. "This is a rare disorder that usually does not affect future children." 2. "Our newborn looks normal; he may not have galactosemia." 3. "Our newborn may need to take penicillin and other medications to prevent infection." 4. "Penicillin and other drugs that contain lactose as fillers need to be avoided."

4. Many drugs, such as penicillin, contain unlabeled lactose as filler and need to be avoided.

During an adolescent ' s initial physical assessment, the nurse notes signs and symptoms of nutritional deficit. Which assessment led the nurse to this initial conclusion? 1. Protein level within normal limits. 2. Blood pressure is 110/66. 3. Hair and nails are brittle and dry. 4. Teeth appear to be eroded.

3. Dry and brittle hair and nails are common among people who have a nutritional deficit.

35. Which would be the most appropriate injury prevention/safety teaching for an adolescent? 1. Inquire which are the favorite sports, discuss the teen's knowledge and application of appropriate safety principles. 2. Tell the teen to be careful performing sports activities because every sport has the potential for injury. 3. Tell the teen not to let friends encourage drinking, smoking, or taking drugs. 4. Ask the mother what sports the teen plays and if a helmet is worn with contact sports.

1. Adolescence is a time of need for independence and learning to make appropriate decisions. Safety is always a concern, and tying a safety discussion to the teen ' s interest in sports will help keep him safe. The nurse needs to inquire about and build on the teen ' s interests and knowledge.

Which method is the most effective way to present an educational program on abstinence to adolescents? 1. Use peer-led programs that emphasize the consequences of unprotected sexual contact. 2. Teach students methods to resist peer pressure. 3. Offer students the opportunity to care for a simulator infant for 1 week. 4. Offer statistics, pamphlets, and films discussing the consequences of unprotected sexual contact.

1. Adolescents are most concerned with what their peers think and feel. They are most receptive to information that comes from another adolescent.

2. Which would be the priority nursing intervention for a newly admitted child with Kawasaki disease? 1. Continuous cardiovascular and oxygen-saturation monitoring. 2. Vital signs every 4 hours until stable. 3. Strict intake and output monitoring hourly. 4. Begin aspirin therapy after fever has resolved.

1. Cardiovascular manifestations of Kawasaki disease are the major complications in pediatric clients. Continuous cardiac monitoring is required to alert the nurse of any cardiovascular complications. Decreased oxygen saturation and respiratory changes have been shown to be early indicators of potential complications.

11. Expected nursing assessments of a newborn with suspected cystic fibrosis would include which of the following? Select all that apply. 1. Observe frequency and nature of stools. 2. Provide chest physical therapy. 3. Observe weight gain. 4. Assess parents 'compliance with fluid restrictions. 5. Assess respiratory system frequently.

1. Cystic fibrosis is inherited as an autosomal-recessive trait, causing exocrine gland dysfunction. About 7% to 10% of newborns with cystic fibrosis present with meconium ileus, so assessing stool frequency and consistency is important. 3. Assessing weight is important in newborns because they can lose up to 10% of their birth weight, and it can take up to 2 weeks for them to regain their birth weight.

A 5-year-old boy has always been one of the shortest children in class. His mother tells the school nurse that her husband is 6′ tall and she is 5′ 7″. What should the nurse tell the child's mother? 1. He is expected to grow about 2 inches every year from ages 6 to 9 years. 2. He is expected to grow about 3 inches every year from ages 6 to 9 years. 3. He should be seen by an endocrinologist for growth-hormone injections. 4. His growth should be re-evaluated when he is 7 years old.

1. During the school-age years, a child grows approximately 2 inches per year.

15. Which intervention should the nurse implement for a newborn diagnosed with galactosemia? 1. Eliminate all milk and lactose-containing foods. 2. Encourage breastfeeding as long as possible. 3. Encourage lactose-containing formulas. 4. Avoid feeding soy-protein formula to the newborn.

1. Galactosemia is a rare autosomal recessive disorder involving an inborn error of carbohydrate metabolism. The hepatic enzyme galactose-1-phosphate uridyl transferase is absent, causing the failure of galactose to be converted into glucose. Glucose builds up in the bloodstream, which can result in liver failure, cataracts, and renal tubular problems. Treatment of galactosemia involves eliminating all milk and lactose containing foods, including breast milk and formulas.

Which should the nurse recommend to the parents of a 9-year-old hospitalized following a bicycle injury? To prevent future injury, their child should: 1. Wear safety equipment while riding bicycles. 2. Read educational material on bicycle safety. 3. Watch a video on bicycle safety. 4. Ride his bike in the presence of adults.

1. Safety equipment is essential for bicycling, skateboarding, and participating in contact sports. Most injuries occur during the school-age years, when children are more active and participate in contact sports.

8. Which signs and symptoms would the nurse expect to assess in a child with rheumatic fever? 1. Ankle and knee joint pain. 2. Negative group A beta streptococcal culture. 3. Large red "bulls eye"-appearing rash. 4. Stiff neck with photophobia.

1. Joint pain or arthritis is the most common symptom of acute rheumatic fever (60% to 80% of fi rst attacks). The joint pain usually occurs in two or more large joints (ankle, knee, wrist, or elbow).

A 4-year-old is hospitalized for an ASD repair. The parents have decided to go home for a few hours to spend time with their other children. The child asks when her mommy and daddy will be back. The nurse's best response is: 1. "Your mommy and daddy will be back after your nap." 2. "Your mommy and daddy will be back at 6:00 p.m." 3. "Your mommy and daddy will be back later this evening." 4. "Your mommy and daddy will be back in 3 hours."

1. Preschoolers understand time in relation to events.

32. A 10-month-old is carried into the emergency department by her parents after she fell down 15 stairs in her walker. Which would be your highest priority nursing intervention? 1. Assess airway while simultaneously maintaining cervical spine precautions. 2. Assess airway, breathing, and circulation simultaneously. 3. Prepare for diagnostic radiological testing to check for any injuries. 4. Obtain venous access and draw blood for testing.

1. Priority nursing intervention with pediatric trauma patients is airway 3. There is a very small incidence of infants developing intussusception, signaled by the onset of bloody stools or diarrhea after receiving oral rotavirus vaccine.

A 13-year-old boy is hospitalized for a femur fracture. He was hit by a car while he and his friends were racing bikes near a major intersection. The child's parents are concerned about his judgment. The nurse should tell the parents that the behavior is: 1. Typical of young teens. 2. Related to hormonal surges during adolescence. 3. An isolated incident and will not likely happen again. 4. Related to teen rebellion.

1. The brains of young teens are not completely developed, which often leads to poor judgment and impulse control.

What can a nurse do to reinforce a 5-year-old's intellectual initiative when he asks about his upcoming surgery? 1. Answer the child's questions about his upcoming surgery in simple terms. 2. Provide the child with a book that has vivid illustrations about his surgery. 3. Tell the child he should wait and ask the doctor his questions. 4. Tell the child that she will answer his questions at a later time.

1. The child is taking the initiative to ask questions, as all preschoolers do, and the nurse should always answer those questions as appropriately and accurately as possible.

Which statement by the mother of an 18-month-old would lead the nurse to believe that the child should be referred for further evaluation for developmental delay? 1. "My child is able to stand but is not yet taking steps independently." 2. "My child has a vocabulary of approximately 15 words." 3. "My child is still sucking his thumb." 4. "My child seems to be quite wary of strangers."

1. The child should be walking independently by 15 to 18 months. Because this toddler is 18 months and not walking, a referral should be made for a developmental consult.

A 4-year-old hospitalized with FTT has orders for daily weights, strict intake and output, and calorie counts. Which action by the nurse would be a concern? 1. The nurse weighs the child every morning after breakfast. 2. The nurse weighs the child with no clothing except for undergarments. 3. The nurse sits with the child while the child eats her meals. 4. The nurse weighs the child using the same scale every morning.

1. The child should be weighed every day on the same scale before eating. Her weight will not be an accurate reflection if she is fed prior to being weighed.

24. Which would be the nurse ' s best response if a mother asks if her baby still needs the Hib vaccine because he already had Hib? 1. "Yes, it is recommended that the baby still get the Hib vaccine." 2. "No, if he has Hib, he will not need to receive the vaccine." 3. "Let me take a nasal swab first; if it is negative, he will receive the Hib vaccine." 4. "The physician will order a blood test, and depending on results, your child may need the vaccine."

1. The infant needs the Hib vaccine to ensure protection against many serious infections caused by Hib, such as bacterial meningitis, bacterial pneumonia, epiglottitis, septic arthritis, and sepsis.

9. The parents of a 12-month-old with HIV are concerned about his receiving routine immunizations. What will the nurse tell them about immunizations? 1. "You are concerned about your child receiving immunizations. Let me explain why your child will not receive routine immunizations today." 2. "Your child will receive the recommended vaccines today." 3. "Your child is not severely immunocompromised, but I would still be concerned about his receiving routine immunizations." 4. "Your child may develop infections if he gets his routine immunizations. Your child will not be immunized today."

1. The nurse acknowledges a client's fears and then discusses the concerns to clarify any misconceptions. Immunizations and influenza vaccine are recommended to prevent infection. Immunocompromised HIV-infected children should not receive the varicella and MMR live vaccines.

Which fi nding would the nurse consider abnormal when performing a physical assessment on a 6-month-old? 1. Posterior fontanel is open. 2. Anterior fontanel is open. 3. Beginning signs of tooth eruption. 4. Able to track and follow objects.

1. The posterior fontanel should close between 6 and 8 weeks of age.

A 16-year-old is having a discussion with the nurse about the teen ' s recent diagnosis of lupus. In explaining the child's prognosis, the nurse uses the knowledge that adolescents are: 1. Preoccupied with thoughts of the here and now. 2. Able to understand and imagine possibilities for the future. 3. Capable of thinking only in concrete terms. 4. Overly concerned with past events and relationships.

2. Adolescents are becoming abstract thinkers and are able to imagine possibilities for the future.

An 18-year-old with a rash and itching in the groin area is concerned that he has contracted a sexually transmitted disease and does not want his parents to find out. The nurse's best response is: 1. "We will need to contact your parents to let them know." 2. "We will not contact your parents regarding this visit." 3. "Who would you like us to contact about your visit here today?" 4. "We cannot promise that the hospital will not contact your parents."

2. An adolescent has every right to privacy as long as the situation is not life threatening.

20. Which intervention might the nurse anticipate in a 2-day-old infant diagnosed with maple syrup urine disease? 1. High-protein, high-amino acid diet. 2. Low-protein, limited-amino acid diet. 3. Low-protein, low-sodium diet. 4. Phenylalanine-restricted diet.

2. A child with maple syrup urine disease will be on a low-protein, limited-amino acid diet for life. Patients need a diet high in thiamine.

Which toy is the best choice for a 12-month-old? 1. Baby doll. 2. Musical rattle. 3. Board book. 4. Colorful beads.

2. A musical rattle is the perfect toy for this child. Infants have short attention spans and enjoy auditory and visual stimulation.

7. Which would be the priority intervention for a child diagnosed with chickenpox (varicella) who was prescribed diphenhydramine (Benadryl) for itching? 1. Give a warm bath with mild soap before lotion application. 2. Avoid Caladryl lotion while taking diphenhydramine (Benadryl). 3. Apply Caladryl lotion generously to decrease itching. 4. Give a cool shower with mild soap to decrease itching.

2. Caladryl lotion contains diphenhydramine (Benadryl), and the child would be at risk for toxicity if the Caladryl is applied to open lesions.

Which stressor is common in hospitalized toddlers? Select all that apply. 1. Social isolation. 2. Interrupted routine. 3. Sleep disturbances. 4. Self-concept disturbances. 5. Fear of being hurt.

2. Common stressors of the hospitalized toddler include interrupted routine, sleep pattern disturbances, and fear of being hurt. 3. Common stressors of the hospitalized toddler include interrupted routine, sleep pattern disturbances, and fear of being hurt. 5. Common stressors of the hospitalized toddler include interrupted routine, sleep pattern disturbances, and fear of being hurt.

17. Which signs and symptoms would the nurse expect to assess in a newborn with congenital hypothyroidism? 1. Preterm, diarrhea, and tachycardia. 2. Post-term, constipation, and bradycardia. 3. High-pitched cry, colicky, and jittery. 4. Lethargy, diarrhea, and tachycardia.

2. Congenital hypothyroidism clinical manifestations may include bradycardia, constipation, poor feeding, lethargy, jaundice prolonged for more than 2 weeks, cyanosis, respiratory difficulties, hoarse cry, large anterior/posterior fontanels, post-term, and birth weight greater than 4000 g.

A 4-year-old boy has been hospitalized because he fell down the stairs. His mother is crying and states, "This is all my fault." Which is the nurse's best response? 1. "Accidents happen. You shouldn't blame yourself." 2. "Falls are one of the most common injuries in this age-group." 3. "It may be a good idea to put a gate on the stairs." 4. "Your son should be proficient at walking down the stairs by now."

2. Falls are one of the most common injuries, and it may make the parent feel better to know that this is common.

To obtain an adolescent's health information, the nurse should: 1. Interview the adolescent using direct questions. 2. Gather information during a casual conversation. 3. Interview the adolescent only in the presence of the parents. 4. Gather information only from the parents.

2. Frequently adolescents will share more information when it is gathered during a casual conversation.

30. What would be the best plan of care for a newborn whose mother ' s hepatitis B antigen status is unknown? 1. Give the infant the hepatitis B vaccine within 12 hours of birth. 2. Give the infant the hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth. 3. Give the infant the hepatitis B vaccine within 24 hours of birth. 4. Give the infant the hepatitis B vaccine and hepatitis B immune globulin within 24 hours of birth.

2. Infants born to mothers of unknown hepatitis B antigen status should be given the hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth.

Which statements by an infant's mother lead the nurse to believe that she needs further education about the nutritional needs of a 6-month-old? Select all that apply. 1. "I will continue to breastfeed my son and will give him oatmeal cereal two times a day." 2. "I will start my son on fruits and gradually introduce vegetables." 3. "I will start my son on carrots and will introduce one new vegetable every few days." 4. "I will not give my son any more than 4 to 6 ounces of baby juice per day." 5. "I will make sure my son gets cereal three times a day."

2. Infants should be started on vegetables prior to fruits. The sweetness of fruits may inhibit infants from taking vegetables. 4. Infants can be given fruit juice by 6 months of age, but it is recommended not to exceed 4 to 6 ounces per day. 5. Infants need another source of iron by 4 to 6 months of age, so cereal is introduced twice a day.

13. Which teaching would be important to discuss with the family of a newborn with PKU? 1. Studies have shown that children with PKU outgrow the disease. 2. Consumption of decreased amounts of protein and dairy products is advised. 3. High-protein and high-dairy products consumption must be maintained. 4. Exclusive breastfeeding is encouraged for maximal nutrition for the child.

2. Many high-protein foods such as meats and dairy products are restricted or eliminated from the diet because of their high phenylalanine content.

Which foods would the nurse recommend to the mother of a 2-year-old with iron deficiency anemia? 1. 32 oz of whole cow's milk per day. 2. Meats, eggs, and green vegetables. 3. Fruits, whole grains, and rice. 4. 8 oz of juice, three times per day.

2. Meat, eggs, and green vegetables are excellent sources of iron.

The mother of an 11-month-old with iron-deficiency anemia tells the nurse that her infant is currently taking iron and a multivitamin. Which statement made by the mother should be of concern to the nurse? 1. "I give the iron and multivitamin at the same time each morning." 2. "I give the iron and multivitamin in the morning 6-oz bottle." 3. "I give the iron and multivitamin 2 hours before I feed the morning bottle." 4. "I give the iron and multivitamin in oral syringes toward the back of the cheek."

2. Medications should never be mixed in a large amount of food or formula because the parent cannot be sure that the child will take the entire feeding. Formula decreases the absorption of iron.

A child with a newly applied left leg cast initially feels fine, then starts to cry and tells his mother his leg hurts. Which assessment would be the nurse's first priority? 1. Cast integrity. 2. Neurovascular integrity. 3. Musculoskeletal integrity. 4. Soft tissue integrity.

2. Neurovascular integrity should be assessed first and frequently because neurovascular compromise may cause serious consequences. Neurovascular integrity should be assessed using the 5 Ps: increased Pain out of proportion with injury, Pallor of extremity, Paresthesia, Pulselessness at distal part of extremity, and Paralysis post cast application.

A first-time mother brings in her 5-day-old baby for a well-child visit. The nurse weighs the infant and reports a weight of 7 lb 5 oz to the mother. The mother looks concerned and tells the nurse that her baby weighed 7 lb 10 oz when she was discharged 4 days ago. The nurse's best response to the mother is: 1. "I will let the doctor know, and he will talk with you about possible causes of your infant's weight loss." 2. "A weight loss of a few ounces is common among newborns, especially for breastfeeding mothers." 3. "I can tell you are a first-time mother. Don't worry; we will find out why she is losing weight." 4. "Maybe she isn't getting enough milk. How often are you breastfeeding her?"

2. Newborns can lose up to 10% of their birth weight without concern but should regain their birth weight by 2 weeks of age.

36. Which assessment is most important after any injury in a child? 1. History of loss of consciousness and length of unconsciousness. 2. Serial assessments of level of consciousness. 3. Initial neurological assessment. 4. Initial vital signs and oxygen saturation level.

2. Serial assessments of level of consciousness are the most important observations of a child after any injury. That information tells you if the child ' s condition is changing.

19. Which statement from parents of a newborn diagnosed with Tay-Sachs disease indicates successful understanding of the long-term prognosis? 1. "If we give our baby a proper diet, early intervention, and physical therapy, he can live to adulthood." 2. "He will have normal development for about 6 months before progressive developmental delays occur." 3. "With intense physical therapy and early intervention, we can prevent developmental delays." 4. "If we give our baby a lactose-free diet for life, we can minimize developmental delays and learning disabilities."

2. Tay-Sachs disease is a genetic disorder in which the infant has normal development for the fi rst 6 months. After 6 months, developmental delays and neurological worsening occur. Dietary restriction or providing physical therapy does not change the outcome.

Which activity can the nurse provide for a 9-year-old to encourage a sense of industry? 1. Allow the child to choose what time to take his medication. 2. Provide the child with the homework his teacher has sent. 3. Allow the child to assist with his bath. 4. Allow the child to help with his dressing change.

2. The school-age child is focused on academic performance; therefore, the child can achieve a sense of industry by completing his homework and staying on track with his classmates.

A 16-year-old male is hospitalized for cystic fibrosis. He will be an inpatient for 2 weeks while he receives IV antibiotics. Which action taken by the nurse will most enhance his psychosocial development? 1. Fax the teen's teacher and have her send in his homework. 2. Encourage the teen's friends to visit him in the hospital. 3. Encourage the teen's grandparents to visit frequently. 4. Tell the teen he is free to use his phone to call or text friends.

2. Teens are most concerned about being like their peers. Having the teen's friends visit will help him feel he is still part of the school and social environment.

Which reaction would a nurse expect when giving a preschooler immunizations? 1. The child remains silent and still. 2. The child cries and tells the nurse that it hurts. 3. The child tries to stall the nurse. 4. The child remains still while telling the nurse that she is hurting him.

2. The common response of a 5-year old is to cry and protest during an immunization.

The mother of a newborn asks the nurse when the infant will receive the first hepatitis B immunization. Which is the nurse ' s best response? 1. "Babies receive the hepatitis B vaccine only if their mother is hepatitis B-positive." 2. "The first dose of the hepatitis B vaccine will be given prior to discharge today." 3. "The first dose of hepatitis B vaccine is given at 1 year of age." 4. "Babies receive their first hepatitis B vaccine at 6 months of age."

2. The first dose of hepatitis B vaccine is recommended between birth and 2 months. In most hospitals, newborns are given the vaccine prior to discharge.

37. Which is the most appropriate nursing intervention when caring for a child newly admitted with a mild head concussion and no cervical spine injury? 1. Keep head of bed fl at, side rails up, and safety measures in place. 2. Elevate head of bed, side rails up, and safety measures in place. 3. Observe drainage from any orifice and notify the physician immediately. 4. Continually stimulate the child to keep awake to check neurological status.

2. The head of the bed should be elevated to decrease intracranial pressure. Side rails should be up to help ensure the child stays in bed, and age-appropriate safety measures should be instituted.

28. Which would be the priority intervention for the newborn of a mother positive for hepatitis antigen? 1. The newborn should be given the first dose of hepatitis B vaccine by 2 months of age. 2. The newborn should receive the hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth. 3. The newborn should receive the hepatitis B vaccine and hepatitis B immune globulin within 24 hours of birth. 4. The newborn should receive hepatitis B immune globulin within 12 hours of birth.

2. The newborn should receive both hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth to prevent hepatitis B infection.

The nurse is going to give a 6-month-old a dose of ceftriaxone (Rocephin) IM. What must the nurse do when the 1.5-mL dose arrives from the pharmacy? 1. Administer the injection into the deltoid muscle. 2. Divide the dose into two injections. 3. Administer the injection into the dorsogluteal muscle. 4. Give dose as a single injection into the vastus lateralis muscle.

2. The nurse should not deliver more than 1 mL per IM injection to a 6-month-old.

A mother requests that her child receive the varicella vaccine at the 9-month well-child checkup. The nurse tells the mother that: 1. Children who are vaccinated will likely develop a mild case of the disease. 2. The vaccine cannot be given at that visit. 3. The vaccine will be administered after the physician examines the child. 4. A booster vaccination will be needed at 18 months of age.

2. The nurse should not give the vaccine. The varicella vaccine is not usually administered prior to 1 year of age unless there are extenuating circumstances.

4. An 18-month-old is discharged from the hospital after having a febrile seizure secondary to exanthem subitum (roseola). On discharge, the mother asks the nurse if her 6-year-old twins will get sick. Which teaching about the transmission of roseola would be most accurate? 1. The child should be isolated in the home until the vesicles have dried. 2. The child does not need to be isolated from the older siblings. 3. Administer acetaminophen to the older siblings to prevent seizures. 4. Monitor older children for seizure development.

2. The route of roseola transmission is unknown, and the disease is more commonly seen in children 6 months to 3 years of age, so siblings do not need to be isolated.

21. What would be the priority nursing action on finding the varicella vaccine at room temperature on the shelf in the medication room? 1. Ensure the varicella vaccine's integrity is intact; if intact, follow the five rights of medication administration. 2. Do not administer this batch of vaccine. 3. Ensure the varicella vaccine's integrity is intact; if intact, give the vaccine after verifying proper physician orders. 4. Ask the mother if the child has had any prior reactions to varicella.

2. The varicella vaccine integrity cannot be assured if the vaccine is at room temperature, so do not administer.

A 9-year-old girl builds a clubhouse in her backyard. She hangs a sign outside her clubhouse that has "No boys allowed" printed on it. The child's parents are concerned that she is excluding their neighbor's son, and they are upset. What should the school nurse tell the child's parents? 1. Her behavior is cause for concern and should be addressed. 2. Her behavior is common among school-age children. 3. Her feelings about boys will subside within the next year. 4. They should have their daughter speak with the school counselor.

2. This is common behavior. Girls of 9 and 10 generally prefer to have friends who are of the same gender.

39. What would be the most appropriate advice to give to the parent of a child with slight visual blurring after being hit in the face with a basketball? 1. "Apply ice, observe for any further eye complaints, and bring him back if he has increased pain." 2. "Take him to the emergency department to ensure that he does not have any internal eye damage." 3. "Call your pediatrician if he starts vomiting, is hard to wake up, or has worsening eye blurring." 4. "Observe any further eye complaints, headaches, dizziness, or vomiting, and if worsening occurs, take him to your pediatrician."

2. This type of eye injury is considered blunt force trauma to the eyes, and the child should be evaluated medically for assessment and prevention of eye damage. Slight blurring could indicate eye injuries, such as detached retina and hyphema, which need immediate medical intervention.

6. Which would be the priority intervention for a child suspected of having varicella (chickenpox)? 1. Contact precautions. 2. Contact and droplet respiratory precautions. 3. Droplet respiratory precautions. 4. Universal precautions and standard precautions.

2. Varicella (chickenpox) is highly contagious. Contact and droplet respiratory precautions should be started immediately because the primary source of transmission is secretions of the respiratory tract (droplet) and also by contaminated objects.

23. Which nursing intervention should take place prior to all vaccination administrations? 1. Document the vaccination to be administered on the immunization record and medical record. 2. Provide the vaccine information statement handout and answer all questions. 3. Administer the most painful vaccination first, and then alternate injection sites. 4. Refer to the vaccination as "baby shots" so that the parent understands the baby will be receiving an injection.

2. Written information about the vaccine should always be given prior to any immunization administered as well as allowing time for questions.

The best method to explain a procedure to a hospitalized preschool-age child is to: 1. Show the child a pamphlet with pictures showing the procedure. 2. Have the 5-year-old next door tell the 4-year-old about the experience. 3. Demonstrate the procedure on a doll. 4. Show the child a video of the procedure.

3. A 4-year-old child understands in very concrete and simple terms. Therefore, medical play is an excellent method for helping to understand the procedure.

Which is the best method of distraction for an 8-year-old who is having surgery later today to insert a central line and is NPO? 1. Use the telephone to call friends. 2. Watch television. 3. Play a board game. 4. Read the central-line pamphlet he was given.

3. A board game is the optimal choice because school-age children enjoy being engaged in an activity with others that will require some skill and challenge.

Which nursing action would help foster a hospitalized 3-year-old's sense of autonomy? 1. Let the child choose what time to take the oral antibiotics. 2. Allow the child to have a doll for medical play. 3. Allow the child to administer her own dose of cephalexin (Keflex) via oral syringe. 4. Let the child watch age-appropriate videos.

3. Allowing preschoolers to participate in actions of which they are capable is an excellent way to enhance their autonomy.

An adolescent has a diagnosis of new-onset diabetes. What would most influence a teenager's food choices as he begins to make changes in his diet? 1. Parents and their dietary choices. 2. Cultural background. 3. Peers and their dietary choices. 4. Television and other forms of media influence.

3. As a teen, the child is most influenced by his peers. Teens long to be like others around them.

Which should the nurse teach the parents is one of the most common causes of injury and death for a 9-month-old infant? 1. Poisoning. 2. Child abuse. 3. Aspiration. 4. Dog bites.

3. Aspiration is a common cause of injury and death among children of this age. These children often find small objects lying on the floor and place them in their mouths. Older siblings are often responsible for leaving small objects around.

A 12-month-old boy weighed 8 lb 2 oz at birth. Understanding developmental milestones, what should the nurse caring for the child expect the current weight to be? 1. 16 lb 4 oz 2. 20 lb 5 oz 3. 24 lb 6 oz 4. 32 lb 8 oz

3. Children should triple their birth weight by 12 months of age.

1. The mother of a 3-week-old infant tells the nurse she is residing in a homeless shelter and is concerned about her baby ' s mild cough, poor appetite, low-grade fever, weight loss, and fussiness over the past 2 weeks. Which nursing intervention would be the nurse ' s highest priority? 1. Weigh the baby to have an accurate weight using standard precautions. 2. Reassure the mother that the baby may only have a cold, which can last a few weeks. 3. Immediately initiate droplet face-mask precautions and isolate the infant. 4. Take a rectal temperature while completing the assessment using standard precautions.

3. Children with tuberculosis may have a history of living in a crowded home or could be homeless. Other symptoms may include a cough, cold symptoms, low grade fever, fussiness, poor appetite, and exposure to a person with tuberculosis. Initiation of droplet precautions and isolation of the infant would be warranted in this situation.

33. Which would be the most appropriate discharge instructions for a child with a right wrist sprain 3 hours ago? 1. "You should rest, elevate the wrist above the heart, apply heat wrapped in a towel, and use the sling when walking." 2. "You can use the wrist, but stop if it hurts; elevate the wrist when not in use and use the sling when walking." 3. "You should rest, apply ice wrapped in a towel, elevate the wrist above the heart, and use the sling when walking." 4. "You do not have to take any special precautions; do not use any movements that cause pain and apply alternate heat and ice, each wrapped in a towel."

3. For the first 24 hours, rest, ice, compression, and elevation (RICE) are recommended for acute injury.

A 13-year-old tells the nurse that he is worried because his breasts are growing. They hurt, and he is embarrassed to take his shirt off during gym class. What should the nurse tell him? 1. "The pediatrician will draw some blood to find out why your breasts are growing." 2. "It is just a slight hormonal imbalance that can be easily corrected with medication." 3. "This is a normal condition of puberty that will resolve within a year or two." 4. "This is a rare finding that occurs in about 5% of boys during puberty."

3. Gynecomastia and breast tenderness are common for about a third of boys during middle puberty. Gynecomastia usually resolves in 2 years.

How can the nurse best facilitate the trust relationship between infant and parents while the infant is hospitalized? The nurse should: 1. Encourage the parents to remain at their child's bedside as much as possible. 2. Keep parents informed about all aspects of their child's condition. 3. Encourage the parents to hold their child as much as possible. 4. Advise the parents to participate actively in their child's care.

3. Having parents hold their child while in the hospital is an excellent means of building the trust relationship. Infants are most secure when they are being held, patted, and spoken to.

A 6-month-old male is at his well-child checkup. The nurse weighs him, and his mother asks if his weight is normal for his age. The nurse's best response is: 1. "At 6 months, his weight should be approximately three times his birth weight." 2. "Each child gains weight at his or her own pace." 3. "At 6 months, his weight should be approximately twice his birth weight." 4. "At 6 months, a child should weigh about 10 lb more than his or her birth weight."

3. Infants should double their birth weight by 4 to 6 months of age.

10. After airway, breathing, and circulation have been assessed and stabilized, which intervention should the nurse implement for a child diagnosed with encephalitis? 1. Assist with a lumbar puncture and give reassurance. 2. Obtain a throat culture, then begin antibiotics. 3. Perform initial and serial neurological assessments. 4. Administer antibiotics and antipyretics.

3. Initial and serial neurological assessments would be a priority nursing intervention in a child with a neurological problem. These assessments monitor for changes in neurological status.

What should the nurse do to prevent separation anxiety in a hospitalized toddler? 1. Assume the parental role when parents are not able to be at the bedside. 2. Encourage the parents to always remain at the bedside. 3. Establish a routine similar to that of the child ' s home. 4. Rotate nursing staff so the child becomes comfortable with a variety of nurses.

3. It is very important to try to maintain a child ' s home routine both when parents are present and when they have to leave the hospital. This will increase the child ' s sense of security and decrease anxiety.

Which statements would indicate to the nurse that a school-age child is not developmentally on track for age? Select all that apply. 1. The child is able to follow a four- to five-step command. 2. The child started wetting the bed on admission to the hospital. 3. The child has an imaginary friend named Kelly. 4. The child enjoys playing board games with her sister. 5. The child is not able to follow rules.

3. Most school-age children do not have imaginary friends. This is much more common for children of 3 and 4 years of age. 4. Most school-age children do enjoy playing board games. 5. Most school-age children like rules and understand the consequences of not obeying them.

Which nursing action is most appropriate to gain information about how a child is feeling? 1. Actively attempt to make friends with the child before asking about her feelings. 2. Ask the child's parents what feelings she has expressed in regard to her diagnosis. 3. Provide the child with some paper to draw a picture of how she is feeling. 4. Ask the child direct questions about how she is feeling.

3. Often children will include much more detail about their feelings in drawings. They will often express things in pictures they are unable to verbalize.

12. Which treatment would the nurse anticipate for a 2-week-old boy diagnosed with PKU? 1. There is no treatment or special diet. 2. A high-phenylalanine diet. 3. A low-phenylalanine diet. 4. The mother would be advised not to breastfeed the infant.

3. PKU is inherited as an autosomal recessive trait. The enzyme phenylalanine hydroxylase controlling the conversion of phenylalanine to tyrosine is missing. A low-phenylalanine diet is the treatment to prevent brain damage.

The nurse is instructing a new breastfeeding mother in the need to provide her premature infant with an adequate source of iron in her diet. Which statement reflects a need for further education of the new mother? 1. "I will use only breast milk or an iron-fortified formula as a source of milk for my baby until she is at least 12 months old." 2. "My baby will need to have iron supplements introduced when she is 4 months old." 3. "I will need to add iron supplements to my baby's diet when she is 2 months old." 4. "When my baby begins to eat solid foods, I should introduce iron-fortified cereals to her diet."

3. Premature infants have iron stores from the mother that last approximately 2 months, so it is important to introduce an iron supplement by 2 months of age. Full-term infants have iron stores that last approximately 4 to 6 months.

Which action is a developmentally appropriate method for eliciting a 4-year-old's cooperation in obtaining the blood pressure? 1. Have the child's parents help put on the blood pressure cuff. 2. Tell the child that if he sits still, the blood pressure machine will go quickly. 3. Ask the child if he feels a squeezing of his arm. 4. Tell the child that measuring the blood pressure will not hurt.

3. Preschool children enjoy games, and it is a good way to elicit their assistance and cooperation during a procedure.

Which technique should the nurse suggest to the mother of an 8-year-old who does not want to complete her chores? 1. Grounding. 2. Time-out. 3. Reward system. 4. Spanking.

3. School-age children usually respond very well to a reward system and often enjoy the rewards so much that they will continue chores without continual reminders.

The mother of a 15-year-old is frustrated because he spends much of his weekend time sleeping. Which is the nurse's best response to the mother's frustration? 1. "Your son may be trying to catch up on the sleep missed during the week." 2. "Developmental theorists believe that teens require more sleep as they begin to integrate new roles into their lives." 3. "Teens require more sleep because of the rapid physical growth that is occurring." 4. "Teens require more sleep because of the increase in their social obligations."

3. Teens require more sleep because of the rapid physical growth that occurs during adolescence.

The nurse realizes that a 3½-year-old's mother needs further education about the Denver Developmental Screening Test when she states: Select all that apply. 1. "It screens for gross motor skills." 2. "It screens for fine motor skills." 3. "It screens for intelligence level." 4. "It screens for language development." 5. "It screens for school readiness."

3. The Denver Developmental Screening Test does not test a child's level of intelligence. 5. The Denver Developmental Screening Test evaluates children from 1 month to 6 years and is used to screen gross motor skills, fine motor skills, language development, and personal/social development not school readiness.

The nurse is using the FLACC scale to rate the pain level in a 9-month-old. Which is the nurse ' s best response to the father ' s question of what the FLACC scale is? 1. "It estimates a child ' s level of pain utilizing vital sign information." 2. "It estimates a child ' s level of pain based on parents 'perception." 3. "It estimates a child ' s level of pain utilizing behavioral and physical responses." 4. "It estimates a child ' s level of pain utilizing a numeric scale from 0 to 5."

3. The FLACC scale utilizes behavioral and physical responses of the child to measure the child ' s level of pain. The scale utilizes facial expression, leg position, activity, intensity of cry, and level of consolability.

The parents of a newborn are asking the nurse how to use the infant car seat and where it should be placed in their vehicle. Which is the most appropriate action by the nurse? 1. Give the parents a pamphlet explaining how to install the car seat. 2. Accompany the parents to the car and show them how to install the car seat. 3. Contact the hospital's car-seat safety officer and ask the officer to accompany the parents to the car for car-seat installation. 4. Show the parents a video on car-seat installation and safety and ask if they are comfortable with the information.

3. The car-seat safety officer is the best choice, as that individual would have the needed information and certification to help the family.

31. When discharging a newborn, which injury prevention instruction would be of highest priority to tell the parents? 1. "Place safety locks on all medicine cabinets and household cleaning supplies." 2. "Transport the infant in the front seat when driving alone so that you can see the baby." 3. "Never leave the baby unattended on a raised, unguarded area." 4. "Place safety guards in front of any heating appliance, stove, fireplace, or radiator."

3. The highest priority in newborn injury prevention is never to leave the baby unattended on a raised, unguarded surface. Involuntary reflexes may cause assessment while maintaining cervical spine precautions. If the airway is compromised, immediate corrective action should be taken prior to assessment of breathing.

29. Which instruction would be of highest priority for the mother of an infant receiving his first oral rotavirus vaccine? 1. "Call the physician if he develops a fever or cough." 2. "Call the physician if he develops fever, redness, or swelling at the injection site." 3. "Call the physician if he develops a bloody stool or diarrhea." 4. "Call the physician if he develops constipation and irritability."

3. The highest priority in newborn injury prevention is never to leave the baby unattended on a raised, unguarded surface. Involuntary reflexes may cause the infant to move and fall.

The mother of a 13-year-old girl tells the nurse that she is concerned because her daughter has gained 10 lb since she began puberty. The child's mother asks the nurse for advice about what to do about her daughter's weight gain. Which should the nurse do? 1. Provide the child's mother with some pamphlets on nutrition and healthy eating. 2. Provide the child's mother with information about a new exercise program for teens. 3. Inform the child's mother that it is common for teen girls to gain weight during puberty. 4. Inform the child's mother that her daughter will likely gain another 5 to 10 lb in the next year.

3. The nurse should tell the child ' s mother that this is a normal finding in teenage girls as they enter puberty.

The mother of 10-year-old fraternal twins tells the nurse at their well-child checkup that she is concerned because her daughter has gained more weight and height than her twin brother. The mother is concerned that there is something wrong with her son. The nurse's best response is: 1. "I understand your concern. I will talk with the physician, and we can draw some lab work." 2. "Let me ask you whether your son has been ill lately." 3. "It is normal for girls to grow a little taller and gain more weight than boys at this age." 4. "It is normal for you to be concerned, but I am sure your son will catch up with your daughter eventually."

3. This is the appropriate response. The nurse understands that it is normal for girls to grow taller and gain more weight than boys near the end of middle childhood.

The mother of a child who is 2 years 6 months in age has arranged a play date with the neighbor and her child who is 2 years 9 months old. During the play date the two mothers should expect that the children will do which of the following? 1. Share and trade their toys while playing. 2. Play with one another with little or no conflict. 3. Play alongside one another but not actively with one another. 4. Only play with one or two items, ignoring most of the other toys.

3. Toddlers engage in parallel play. They often play alongside another child, but they rarely engage in activities with the other child.

The nurse is assessing the pain level in an infant who just had surgery. The infant's parent asks which vital sign changes are expected in a child experiencing pain. The nurse's best response is: 1. "We expect to see a child's heart rate decrease and respiratory rate increase." 2. "We expect to see a child's heart rate and blood pressure decrease." 3. "We expect to see a child's heart rate and blood pressure increase." 4. "We expect to see a child's heart rate increase and blood pressure decrease."

3. When a child is experiencing pain, the normal physiological response is for the heart rate, respiratory rate, and blood pressure to increase.

An 8-day-old was admitted to the hospital with vomiting and dehydration. The newborn's heart rate is 170, respiratory rate is 44, blood pressure is 85/52, and temperature is 99°F (37.2°C). What is the nurse ' s best response to the parents who ask if the vital signs are normal? 1. "The blood pressure is elevated, but the other vital signs are within normal limits." 2. "The temperature is elevated, but the other vital signs are within normal limits." 3. "The respiratory rate is elevated, but the other vital signs are within normal limits." 4. "The heart rate is elevated, but the other vital signs are within normal limits."

4. A normal heart rate for a child from birth to 1 month is 90 to 160.

3. Which clinical assessment of a neonate with bacterial meningitis would warrant immediate intervention? 1. Irritability. 2. Rectal temperature of 100.6°F (38.1°C). 3. Quieter than usual. 4. Respiratory rate of 24 breaths per minute.

4. A normal neonate ' s respiratory rate is 30 to 60 breaths per minute. Neonates ' respiratory systems are immature, and the rate may initially double in response to illness. If no immediate interventions are begun when there is respiratory distress, a neonate ' s respiratory rate will slow down, respiratory distress will worsen, and, eventually, respiratory arrest will occur. Neonates with slower or faster-than-normal respiratory rates are true emergency cases; they require identification of the cause of distress.

38. Which is the most appropriate teaching to the parents of a child in the emergency department after a near-drowning if the child is awake, alert, and has no respiratory distress? 1. "Your child will most likely be discharged, and you should watch for any cough or trouble breathing." 2. "Your child will need to have a preventive tube for breathing and ventilation to ensure the lungs are clear." 3. "Your child will be fine, but sometimes antibiotics are started as a preventive." 4. "Your child will most likely be admitted for at least 24 hours and observed for respiratory distress or any swelling of the brain."

4. Any child who has had a near-drowning experience should be admitted for observation. Even if a child does not event, complications can occur within 24 hours after the event. Respiratory compromise and cerebral edema can be delayed complications.

18. Which families would be appropriate to refer for genetic counseling? 1. Parents with a macrosomic infant. 2. Parents with neonatal abstinence syndrome infants. 3. Couple with a history of planned abortions. 4. Couple with a history of multiple miscarriages.

4. Couples with a history of multiple miscarriages, stillbirths, or infertility should be referred for genetic counseling to try to determine the cause of their problems with maintaining a pregnancy.

According to developmental theories, which important event is essential to the development of the toddler? 1. The child learns to feed self. 2. The child develops friendships. 3. The child learns to walk. 4. The child participates in being potty-trained.

4. Developmental theorists such as Erickson and Freud believe that toilet training is the essential event that must be mastered by the toddler.

A 2-year-old admitted to the hospital 2 days ago has been crying and is inconsolable much of the time. The nurse's best response to the child's parents who are concerned about this behavior is that the child is in the: 1. Detachment phase of separation anxiety, which is normal for children during hospitalization. 2. Despair stage of separation anxiety, which is normal for children during hospitalization. 3. Bargaining stage of separation anxiety, which is normal for children during hospitalization. 4. Protest stage of separation anxiety, which is normal for children during hospitalization.

4. During the protest stage of separation anxiety, children are often inconsolable and often cry more than they do when they are at home. These children also frequently ask to go home.

Which statement accurately describes the best method for assessing a 12-month-old? 1. The nurse should assess the child on the examining table. 2. The nurse should assess the child in a head-to-toe sequence. 3. The nurse should have the child's parent assist in holding her down. 4. The nurse should assess the child while she is in her parent's lap.

4. Infants are most secure when in proximity to the parent. The parent ' s lap is an excellent place to assess the child.

Which approach should the nurse use to gather information from a child brought to the ED for suspected child abuse? 1. Promise the child that her parents will not know what she tells the nurse. 2. Promise the child that she will not have to see the suspected abuser again. 3. Use correct anatomical terms to discuss body parts. 4. Tell the child that the abuse is not her fault and that she is a good person.

4. Many young children believe abuse or illness is their fault, so they shouldbe reminded they are not to blame. Many children this age believe they have acquired a disease or have been abused because they are bad people.

What information should a school nurse include in a discussion on nutrition with a fourth-grade class? 1. The number of calories that a fourth-grade child should consume in a day. 2. A list of high-calorie foods that all fourth-graders should avoid. 3. How to read food labels so that children know which foods are good for them. 4. A list of nutritious foods with basic scientific information about how they affect the body organs and systems.

4. Reviewing nutritious choices keeps the lesson on a positive note, and school-age children are very interested in how food affects their bodies. They are capable of understanding basic medical terminology.

Which statement accurately describes how the nurse should approach an 11-year-old to do a physical assessment? 1. Ask the child's parents to remain in the room during the physical exam. 2. Auscultate the heart, lungs, and abdomen first. 3. Explain that the physical exam will not hurt. 4. Explain what the nurse will be doing in basic understandable terms.

4. School-age children are capable of understanding basic functions of the body and can understand what the nurse will be doing if explained in basic terms.

14. Which teaching is most important for a child with PKU? 1. The child is able to eat a quarter-pound hamburger and drink a milkshake daily. 2. If the child wants soda, diet soda is preferred over milk or dairy products. 3. The child may have ice cream in an unlimited quantity once a week. 4. Diet soda or anything with the sweetener aspartame should be avoided.

4. The artificial sweetener aspartame (NutraSweet, Equal) should be avoided because it is converted to phenylalanine in the body.

The mother of an adolescent complains that he has had some recent behavioral changes. He comes home from school every day, closes his door, and refrains from interaction with his family. The nurse's best response to the mother is: 1. "You should speak with your son and ask him directly what is wrong with him." 2. "You should set limits with your son and tell him that this is unacceptable behavior." 3. "Your son's behavior is abnormal, and he is going to need a psychiatric referral." 4. "Your son's behavior is normal. You should listen to him without being judgmental."

4. The child's behavior is typical of a teen's response to developmental and psychosocial changes of adolescence.

27. Which is the nurse's best response to the mother of a 2-month-old who is going to get IPV immunization when the mother tells the nurse the older brother is immunocompromised? 1. "Your baby should not be immunized because your immunocompromised son could develop polio." 2. "Your baby should receive the oral poliovirus vaccine instead so that your immunocompromised son does not get sick." 3. "You should separate your 2-month-old child from the immunocompromised son for 7 to 14 days after the IPV." 4. "Your baby can be immunized with the IPV; he will not be contagious."

4. The infant should be immunized as recommended and will not shed the poliovirus.

5. The pregnant mother of a child diagnosed with erythema infectiosum (fifth disease) is crying, and says, "I am afraid. Will my unborn baby die? I have a planned cesarean section next week." Which statement would be the most therapeutic response? 1. "Let me get the physician to come and talk with you." 2. "I understand. I would be afraid, too." 3. "Would you like me to call your obstetrician to have you seen as soon as possible?" 4. "I understand you are afraid. Can we talk about your concerns?"

4. There is less risk of fetal death in the second half of the pregnancy. It is more therapeutic to acknowledge a client ' s fears. After acknowledging her fears, the appropriate response would be to discuss concerns and clarify any misconceptions.

Which comment should the parent of a 2½-year-old expect from the toddler about a new baby brother? 1. "When the baby takes a nap, will you play with me?" 2. "Can I play with the baby?" 3. "The baby is so cute. I love him." 4. "It is time to put him away so we can play."

4. This is a typical statement that would be made by a toddler. Toddlers are very egocentric and do not consider the needs of the other child.

22. Which would be the most therapeutic response for the mother of a 6-month-old who tells the nurse she does not want her infant to have the DTaP vaccine because the infant had localized redness the last time she received the vaccine? 1. "I will let the physician know, and we will not administer the DTaP vaccination today." 2. "Every child has that allergic reaction, and your child will still get the DTaP today." 3. "I will let the physician know that you refuse further immunizations for your daughter." 4. "Would you mind if we discussed your concerns?"

4. This is the therapeutic response— discussing the mother ' s concerns about the immunizations and local reactions.

25. What would be the nurse's best response if the foster mother of a 15-month old with an unknown immunization history comes to the clinic requesting immunizations? 1. "Your foster child will not receive any immunizations today." 2. "Your foster child will receive the MMR, Hib, IPV, and hepatitis B vaccines." 3. "Your foster child could have harmful effects if we revaccinate with prior vaccines." 4. "Your foster child will receive only the Hib and DTaP vaccines today."

4. Vaccines routinely due at 15 months include Hib and DTaP. To catch up missed immunizations, the nurse would need the child's immunization record to verify what he has received.

A 3-year-old is attending her grandfather's funeral. Her parents told her that her grandfather is in heaven with God. Which statement describes a 3-year-old child's understanding of spirituality? 1. "The body is here with us on Earth, and the spirit is in heaven." 2. "He is in heaven. Is this heaven?" 3. "The spirit is no longer in his body." 4. "He won't need his body in heaven."

Three-year-old children are literal thinkers. The child's parents told her that Grandpa was in heaven. She sees his body, so she thinks they are all in heaven.