Final Review Q's, NCLEX Worksheets

The practitioner changes the medications for the child with asthma to salmeterol (Serevent). The mother asks the nurse what this drug will do. The nurse explains that salmeterol (Serevent) is used to treat asthma because the drug produces which characteristic? 1. Decreases inflammation 2. Decreases mucous production 3. Controls allergic rhinitis 4. Dilates the bronchioles

4. Dilates the bronchioles Salmeterol (Serevent) is a long-acting beta2-agonist that acts by bronchodilating. Steroids are anti-inflammatory, anticholinergics decrease mucous production, and antihistamines control allergic rhinitis.

A child is diagnosed with a Wilms tumor. Which nursing action is most appropriate prior to surgery? 1. Careful bathing and handling 2. Monitoring of behavioral status 3. Maintenance of strict isolation 4. Administration of packed RBCs

1. Careful bathing and handling The tumor should never be palpated; careful bathing and handling are an important nursing consideration. Palpating the tumor can cause a piece of the tumor to dislodge. The child's behavior will not be affected with a Wilms tumor. The tumor does not cause excessive lowering of WBCs or RBCs, so strict isolation or administration of packed RBCs is not usually a nursing intervention.

The nurse is caring for a pediatric client diagnosed with eczema. Which topical medication order does the nurse anticipate for this client? 1. Corticosteroid 2. Retinoid 3. Antifungal 4. Antibacterial

1. Corticosteroid Topical corticosteroid is used to reduce inflammation when the child has eczema. Topical retinoid is used for acne. Topical antifungal is used for dermatophytoses. Topical antibacterial would be used for problems such as burns

A pediatric client is hospitalized with a severe case of impetigo contagiosa. Which antibiotic does the nurse anticipate the healthcare provider will order for this client? 1. Dicloxacillin (Pathocil) 2. Rifampin (Rifadin) 3. Sulfamethoxazole and trimethoprim (Bactrim) 4. Metronidazole (Flagyl)

1. Dicloxacillin (Pathocil) A systemic antibiotic will be given for severe impetigo because it is a bacterial infection. Dicloxacillin is used in treatment of skin and soft-tissue infections. It is specific for treating staphylococcal infections. Rifampin is an antitubercular agent, sulfamethoxazole and trimethoprim are used as a prophylaxis against Pneumocystis carinii pneumonia (PCP), and metronidazole is used to treat anaerobic and protozoic infections.

The nurse is providing care to a preschool-age client who was admitted to the medical-surgical unit after an acute asthma attack. Which interventions foster a family-centered focus to client care? Select all that apply. 1. Discussing rooming in with the parents of the client 2. Allowing the client to "cry it out" after the parents leave for the evening 3. Providing comfort items from home, such as a blanket 4. Maintaining strict visitation for the family 5. Discussing what to expect during the hospital stay

1. Discussing rooming in with the parents of the client 3. Providing comfort items from home, such as a blanket 5. Discussing what to expect during the hospital stay Family-centered care principles that are used in the hospital setting include rooming in, providing comfort items from home, and discussing what to expect. Allowing the child to "cry it out" and maintaining strict visitation for the family are not family-centered principles.

The nurse is performing the initial assessment of a child newly diagnosed Kawasaki disease. Which symptoms would the nurse expect to assess with this child? 1. Dry, swollen, fissured lips 2. Nonpalpable lymph nodes 3. Conjunctivitis with exudates 4. Cyanosis of the hands and feet

1. Dry, swollen, fissured lips Dry, swollen, fissured lips are symptoms of Kawasaki disease. Lymph nodes can be palpable, conjunctivitis is present but without exudates, and hands and feet are typically erythematous.

The nurse is providing education to a group of student nurses regarding disorders of the endocrine system that can cause short stature. Which disorders will the nurse include in the educational session? Select all that apply 1. Hypothyroidism 2. Turner syndrome 3. Type 1 diabetes mellitus 4. Diabetes insipidus 5. Cushing syndrome

1. Hypothyroidism 2. Turner syndrome 5. Cushing syndrome

The nurse is providing education to a pediatric client diagnosed with diabetes. The client will be playing soccer over the summer. Which change in the client's management will the nurse explore during this education session? 1. Increased food intake 2. Decreased food intake 3. Increased need for insulin 4. Decreased risk of insulin reaction

1. Increased food intake Increased physical activity requires adequate caloric intake to prevent hypoglycemia, so food intake should be increased. Increased activity would not require decreased food intake, and it would not result in a decreased risk of insulin reaction. Exercise causes the insulin to be used more efficiently, so increased insulin would not be needed.

Following parental teaching, the nurse is evaluating the parents' understanding of environmental control for their child's asthma management. Which statement by the parents indicates appropriate understanding of the teaching? 1. "We will replace the carpet in our child's bedroom with tile." 2. "We're glad the dog can continue to sleep in our child's room." 3. "We'll be sure to use the fireplace often to keep the house warm in the winter." 4. "We'll keep the plants in our child's room dusted."

1. "We will replace the carpet in our child's bedroom with tile." Control of dust in the child's bedroom is an important aspect of environmental control for asthma management. When possible, pets and plants should not be kept in the home. Smoke from fireplaces should be eliminated.

Which nursing diagnosis is most appropriate for an infant with acute bronchiolitis due to respiratory syncytial virus (RSV)? 1. Activity Intolerance 2. Decreased Cardiac Output 3. Pain, Acute 4. Tissue Perfusion, Ineffective (peripheral)

1. Activity Intolerance Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory-disease process

The nurse in the newborn nursery is performing the admission assessment on a neonate. Which assessment finding indicates the neonate may have congenital hip dysplasia? 1. Asymmetry of the gluteal and thigh fat folds 2. Trendelenburg sign 3. Telescoping of the affected limb 4. Lordosis

1. Asymmetry of the gluteal and thigh fat folds A sign of congenital hip dysplasia in the infant would be asymmetry of the gluteal and thigh fat folds. Trendelenburg sign and telescoping of the affected limb are signs that present in an older child with congenital hip dysplasia. Lordosis does not occur with hip dysplasia.

A school nurse is planning care for a school-age child recently diagnosed with asthma. Which items will the school nurse include in the plan of care at the school? Select all that apply. 1. Maintain a log of quick-relief medication administration. 2. Call the parents if quick-relief medications work appropriately. 3. Assess for symptoms of exercise-induced bronchospasm. 4. Coordinate education of the child's teachers. 5. Conduct a support group for all children with asthma.

1. Maintain a log of quick-relief medication administration. 3. Assess for symptoms of exercise-induced bronchospasm. 4. Coordinate education of the child's teachers. 5. Conduct a support group for all children with asthma.

The nurse is providing care to a school-age client admitted to the emergency department following a motor vehicle crash. The client is exhibiting symptoms of hypovolemic shock. Which nursing interventions are appropriate for this client? Select all that apply. 1. Monitor hemoglobin and hematocrit. 2. Monitor liver enzymes. 3. Administer oxygen, as needed. 4. Administer a dextrose solution. 5. Monitor blood glucose.

1. Monitor hemoglobin and hematocrit. 3. Administer oxygen, as needed. 5. Monitor blood glucose.

The nurse is assessing a school-age client who experienced blunt force trauma to the chest when an airbag deployed following a motor vehicle crash. Which areas of assessment are essential for this client? Select all that apply. 1. Monitor responsiveness and behavior. 2. Monitor SpO2. 3. Auscultate the lungs for crackles, wheezes, decreased breath sounds. 4. Document input and output. 5. Note changes in voice quality or coughing.

1. Monitor responsiveness and behavior. 2. Monitor SpO2. 3. Auscultate the lungs for crackles, wheezes, decreased breath sounds. 4. Document input and output. The areas of assessment that are essential for this client include: monitoring for responsive and behavior in order to detect hypoxia and the potential for airway obstruction; monitoring SpO2 frequently to identify changes indicating deterioration in condition; auscultating the lungs for crackles, wheezes, decreased breath sound; and noting changes in voice quality or coughing. Documenting input and output is not a priority for this client.

An infant with tetralogy of Fallot is having a hypercyanotic episode ("tet" spell). Which nursing interventions are appropriate for the nurse to implement for this infant? Select all that apply. 1. Place the child in knee-chest position. 2. Draw blood for a serum hemoglobin. 3. Administer oxygen. 4. Administer morphine and propranolol intravenously as ordered. 5. Administer Benadryl as ordered.

1. Place the child in knee-chest position. 3. Administer oxygen. 4. Administer morphine and propranolol intravenously as ordered.

The family has just been informed by the healthcare provider that their newborn is diagnosed with a congenital heart defect, Tetralogy of Fallot (TOF). The family tells the nurse that the healthcare provider told them that TOF is comprised of several defects, and they ask the nurse what the defects are. What will the nurse tell the family? Select all that apply. 1. Pulmonary stenosis 2. Coarctation of the aorta 3. Right ventricular hypertrophy 4. Ventral septal defect 5. Overriding aorta

1. Pulmonary stenosis 3. Right ventricular hypertrophy 4. Ventral septal defect 5. Overriding aorta

An adolescent client must wear a brace for the correction of scoliosis. Which nursing diagnosis is most appropriate for this client? 1. Risk for Impaired Skin Integrity 2. Risk for Altered Growth and Development 3. Risk for Impaired Mobility 4. Risk for Impaired Gas Exchange

1. Risk for Impaired Skin Integrity The skin should be monitored for breakdown in any area the brace may rub. The other diagnoses would not be a priority and should be corrected by the wearing of the brace.

A child is admitted with infective endocarditis. Which nursing intervention is most appropriate for this child? 1. Start an intravenous line. 2. Place the child in contact isolation. 3. Place the child on seizure precautions. 4. Assist with a lumbar puncture.

1. Start an intravenous line. Infective endocarditis is treated with intravenous antibiotics for 2 to 8 weeks. It is not contagious, so the child is not placed in contact isolation. Seizures are not a risk of infective endocarditis. A lumbar puncture is not a diagnostic test done for infective endocarditis.

The nurse is providing care to a toddler client who is diagnosed with osteogenesis imperfecta. Which nursing intervention is appropriate for this client? 1. Support of the trunk and extremities when moving 2. Traction care 3. Cast care 4. Postop spinal surgery care

1. Support of the trunk and extremities when moving With osteogenesis imperfecta, nursing care focuses on preventing fractures. Because the bones are fragile, the entire body must be supported when the child is moved. Traction, casts, and spinal surgery are not routinely done for osteogenesis.

The nurse is providing care to a pediatric client who is diagnosed with psoriasis. Which clinical manifestations does the nurse anticipate upon assessment of this client? Select all that apply. 1. Thick, silvery, scaly erythematous plaque 2. Pruritus 3. Dry skin, likely to crack and fissure 4. Fragile skin and blisters 5. Irregular border surrounded by normal skin

1. Thick, silvery, scaly erythematous plaque 2. Pruritus 5. Irregular border surrounded by normal skin Clinical manifestations that support the diagnosis of psoriasis include thick, silvery, scaly erythematous plaque; pruritis; and irregular border surrounded by normal skin. Dry skin that is likely to crack and fissure is a clinical manifestation of atopic dermatitis. Fragile skin and blisters are clinical manifestations of epidermolysis bullosa.

A school health nurse is screening school-age students for scoliosis. Which assessment findings indicate the need for further evaluation for scoliosis? Select all that apply. 1. Uneven shoulders and hips 2. A one-sided rib hump 3. Prominent scapula 4. Lordosis 5. Pain

1. Uneven shoulders and hips 2. A one-sided rib hump 3. Prominent scapula The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula. Lordosis and pain are not present with scoliosis.

The nurse is performing an admission assessment on an infant diagnosed with hydrocephalus and a malfunctioning shunt. Which assessment findings should the nurse expect? Select all that apply. 1. Vomiting 2. Fever 3. Irritability 4. Poor appetite 5. Decreased level of consciousness

1. Vomiting 2. Fever 3. Irritability 4. Poor appetite Signs of shunt malfunction in infants are nonspecific and include irritability, vomiting, poor appetite, disordered sleep, and fever. Older children with shunt malfunction may have a headache, nausea, vomiting, and decreased level of consciousness

The nurse is teaching a group of adolescents about care for acne vulgaris. Which interventions will the nurse include in the teaching session? Select all that apply. 1. Wash skin with mild soap and water twice a day. 2. Use astringents and vigorous scrubbing. 3. Avoid picking or squeezing the lesions. 4. Apply tretinoin (Retin-A) liberally. 5. Avoid sun exposure if on tetracycline.

1. Wash skin with mild soap and water twice a day. 3. Avoid picking or squeezing the lesions. 5. Avoid sun exposure if on tetracycline. The adolescent should be taught to wash skin with mild soap and water twice a day, to avoid picking or squeezing acne lesions, and to avoid sun exposure if on tetracycline. Using astringents and scrubbing vigorously can exacerbate acne. Tretinoin (Retin-A) should be applied sparingly (pea-size doses).

1) A school-age client diagnosed with diabetes insipidus (DI) is admitted to the pediatric unit. Which laboratory value does the nurse anticipate for this client based on the diagnosis? 1. Hyperglycemia 2. Hypernatremia 3. Hypercalcemia 4. Hypoglycemia

2. Hypernatremia In all forms of diabetes insipidus, serum sodium can increase to pathologic levels, so hypernatremia can occur and should be treated. The glucose level is not affected, so hypoglycemia or hyperglycemia is not caused by the diabetes insipidus. Hypercalcemia (high calcium) does not occur with this endocrine disorder.

The nurse explains to the parents of a child with a severe burn that wearing of an elastic pressure garment (Jobst stocking) during the rehabilitative stage can help with the prevention of which complication? 1. Poor circulation 2. Hypertrophic scarring 3. Pain 4. Formation of thrombus in the burn area

2. Hypertrophic scarring During the rehabilitation stage, Jobst stockings or pressure garments are used to reduce development of hypertrophic scarring and contractures

A preschool-age child is brought to the clinic by the mother, who says the child has been lethargic and anorexic lately and complains of bone pain. On exam, the nurse notes petechiae, joint pain, and an enlarged liver. Which diagnosis does the nurse anticipate for this child? 1. Hodgkin disease 2. Leukemia 3. Rhabdomyosarcoma 4. Ewing sarcoma

2. Leukemia Hodgkin disease, rhabdomyosarcoma, and Ewing sarcoma are all childhood cancers, but they do not have the clinical manifestations listed. Leukemia is one of the most common childhood cancers, and has those clinical symptoms.

The nurse is providing care to an adolescent child who is at risk for developing adult-onset cardiovascular disease. Which teaching points will decrease the adolescent's risk? Select all that apply. 1. Encourage a decrease in smoking. 2. Limit fat intake to 20 to 35 percent of intake. 3. Encourage participation in vigorous exercise for at least 30 minutes. 4. Maintain a normal weight. 5. Include high-fat dairy products in the daily diet.

2. Limit fat intake to 20 to 35 percent of intake. 3. Encourage participation in vigorous exercise for at least 30 minutes. 4. Maintain a normal weight. Teaching points that will decrease the adolescent's risk of developing adult-onset cardiovascular disease include: limiting fat intake to 20 to 35 percent of total daily intake; encouraging the participation in vigorous exercise at least 30 minutes each day; and maintaining a normal weight. The adolescent and family members should be encouraged to stop smoking, not just to decrease smoking. The family should be educated to include low-fat dairy products in the daily diet.

A pediatric client is admitted to the hospital unconscious. The client has a history of type 1 diabetes, and according to the client's mother, has been to two birthday parties in the last few days and has resisted taking the prescribed insulin. At school the client had two more pieces of birthday cake and some ice cream at a class birthday party. What is the likely reason for this client's unconscious state? 1. Metabolic alkalosis 2. Metabolic ketoacidosis 3. Insulin shock 4. Insulin reaction

2. Metabolic ketoacidosis Metabolic acidosis or ketoacidosis could have occurred because of the excessive intake of sugar with no additional insulin. The body burns fat and protein stores for energy when no insulin is available to metabolize glucose. Altered consciousness occurs as symptoms progress. Metabolic alkalosis, insulin shock, or insulin reaction would not be happening in this case.

The charge nurse on a hospital unit is developing plans of care related to separation anxiety. The charge nurse recognizes that which hospitalized child at highest risk to experience separation anxiety when parents cannot stay? 1. 6-month-old 2. 18-month-old 3. 3-year-old 4. 4-year-old

2. 18-month-old While all of these children can experience separation anxiety, the young toddler is at highest risk. Toddlers are the group most at risk for a stressful experience when hospitalized. Separation from parents increases this risk greatly.

The parents of a critically injured child wish to stay in the room while the child is receiving emergency care. Which action by the nurse is the most appropriate? 1. Escort the parents to the waiting room and assure them that they can see their child soon. 2. Allow the parents to stay with the child. 3. Ask the physician if the parents can stay with the child. 4. Tell the parents that they do not need to stay with the child.

2. Allow the parents to stay with the child. Parents should be allowed to stay with their child if they wish to do so. This position is supported by the Emergency Nurses Association and is a key aspect of family-centered care.

The nurse is teaching the parent of a type 1 diabetic preschool-age client about management of the disease. Which teaching point is appropriate for the nurse to include in this session? 1. Allowing the client to administer all the insulin injections 2. Allowing the client to choose which finger to stick for glucose testing 3. Allowing the client to draw up the insulin dose 4. Allowing the client to test blood glucose

2. Allowing the client to choose which finger to stick for glucose testing The preschool-age client's need for autonomy and control can be met by allowing the client to pick which finger to stick for glucose testing. Administering the insulin, drawing up the dose, and testing blood glucose should not be done by the client until he or she is middle-school age or older.

A child is ready for discharge after surgery for a myelomeningocele repair. Before discharge, the nurse works with the parents to establish a catheterization schedule to prevent urinary tract infection. With what frequency should the nurse instruct the parents to catheterize the child? 1. Every 1 to 2 hours 2. Every 3 to 4 hours 3. Every 6 to 8 hours 4. Every 10 to 12 hours

2. Every 3 to 4 hours To decrease the incidence of bladder or urinary tract infections, catheterization should occur every 3 to 4 hours.

The nurse is teaching a group of mothers of infants about the benefits of immunization. Which immunization will the nurse teach to the mothers that can assist in preventing the life-threatening disease epiglottitis? 1. Measles, mumps, and rubella (MMR) 2. Haemophilus influenzae type B (HIB) 3. Hepatitis B 4. Polio

2. Haemophilus influenzae type B (HIB) The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

A nurse is conducting a daily weight on a pediatric client diagnosed with diabetes insipidus and notes the child has lost 2 pounds in 24 hours. Which action by the nurse is the most appropriate? 1. Continue to monitor the child. 2. Notify the healthcare provider regarding the weight loss. 3. Chart the weight and report the loss to the next shift. 4. Do nothing more than chart the weight, as this would be a normal finding.

2. Notify the healthcare provider regarding the weight loss. With diabetes insipidus, the child may have severe fluid-volume deficit. A weight loss of 2 pounds indicates a loss of 1 liter of fluid, so the healthcare provider should be notified and fluids replaced either orally or intravenously. This is a significant loss in a 24-hour period, so continuing to monitor, charting the weight and reporting to the next shift, and doing nothing would prolong treatment.

A nurse is assessing a child after an open reduction of a fractured femur. Which assessment findings would indicate that the child is experiencing compartment syndrome? Select all that apply. 1. Pink, warm extremity 2. Pain not relieved by pain medication 3. Dorsalis pedis pulse present 4. Prolonged capillary-refill time with paresthesia 5. Skin appears tense.

2. Pain not relieved by pain medication 4. Prolonged capillary-refill time with paresthesia 5. Skin appears tense. The major serious complication post-fracture reduction is compartment syndrome. A prolonged capillary-refill time with loss of paresthesia, pain not relieved by medication, and skin that appears tense are signs of compartment syndrome. Pink, warm extremity; pain relieved by medication; and a present dorsalis pedis pulse would all be normal findings post-fracture reduction.

A pediatric client sustains a minor burn. When teaching the family the treatment for this burn, the nurse would teach that the client's diet should be high in which substance? 1. Fats 2. Protein 3. Minerals 4. Carbohydrates

2. Protein Parents should be taught that management of a minor burn requires a high-calorie, high-protein diet. This is necessary to meet the increased nutritional requirements of healing.

The nurse is providing care for a pediatric client who has a third-degree circumferential burn of the right arm. Which nursing diagnosis is the priority for this client? 1. Risk for Infection 2. Risk for Altered Tissue Perfusion 3. Risk for Altered Nutrition: Less than Body Requirements 4. Impaired Physical Mobility

2. Risk for Altered Tissue Perfusion When the burn is circumferential, blood flow can become restricted due to edema and result in tissue hypoxia; therefore, the priority diagnosis is Risk for Altered Tissue Perfusion to the Extremity. Infection, Nutrition, and Mobility would have second priority in this case.

A toddler-age client has a tonic-clonic seizure while in a crib in the hospital. The client's jaw is clamped. Which nursing action is the priority? 1. Place a padded tongue blade between the child's jaws. 2. Stay with the child and observe the respiratory status. 3. Prepare the suction equipment. 4. Restrain the child to prevent injury.

2. Stay with the child and observe the respiratory status. During a seizure, the nurse remains with the child, watching for complications. The child's respiratory rate should be monitored. Be sure nothing is placed in the child's mouth during a seizure. Suction equipment should already be set up at the bedside before a seizure begins. The child should not be restrained during a seizure.

The nurse is teaching the parents of a group of cardiac patients. Which teaching guideline will the nurse include for any child who has undergone cardiac surgery? 1. The child should be restricted from most play activities. 2. The child should be evaluated to determine if prophylactic antibiotics for dental, oral, or upper-respiratory-tract procedures are necessary. 3. The child should not receive routine immunizations. 4. The child can be expected to have a fever for several weeks following the surgery.

2. The child should be evaluated to determine if prophylactic antibiotics for dental, oral, or upper-respiratory-tract procedures are necessary. Parents should be taught that the child may need prophylactic antibiotics for some dental procedures, according to the American Heart Association, to prevent endocarditis. The child should live a normal and active life following repair of a cardiac defect. Immunizations should be provided according to the schedule, and any unexplained fever should be reported.

A preschool child is seen in the clinic, and the nurse anticipates a diagnosis of leukemia. Which reaction does the nurse anticipate this child will exhibit upon diagnosis? 1. Acceptance, especially if able to discuss the disease with children their own age 2. Thoughts that they caused their illness and are being punished 3. Understanding of what cancer is and how it is treated 4. Unawareness of the illness and its severity

2. Thoughts that they caused their illness and are being punished Preschool-age children may think they caused their illness. Adolescents find contact with others who have gone through their experience helpful. School-age children can understand a diagnosis of cancer. Infants and toddlers are unaware of the severity of the disease.

Parents of a child admitted with respiratory distress are concerned because the child won't lie down and wants to sit in a chair leaning forward. Which response by the nurse is the most appropriate? 1. "This helps the child feel in control of his situation." 2. "The child needs to be encouraged to lie flat in bed." 3. "This position helps keep the airway open." 4. "This confirms the child has asthma."

3. "This position helps keep the airway open." Leaning forward helps keep the airway open. The child is not in control just because he is leaning forward. Lying flat in bed will increase the respiratory distress. This position does not confirm asthma.

A pediatric client is seen in the clinic with a possible diagnosis of type 2 diabetes. The mother asks what the healthcare provider uses to make the diagnosis. The nurse explains that type 2 diabetes is suspected if the child has obesity, acanthosis nigricans, and two non-fasting blood-glucose levels above which level? 1. 120 2. 80 3. 200 4. 50

3. 200 Blood-glucose levels at or above 200 mg/dL without fasting is diagnostic of type 2 diabetes.

A nurse is assessing language development in all the infants presenting at the doctor's office for well-child visits. At which age range would the nurse expect a child to verbalize the words "dada" and "mama"? 1. 3 and 5 months 2. 6 and 8 months 3. 9 and 12 months 4. 13 and 18 months

3. 9 and 12 months Children should be able to verbalize "mama" or "dada" to identify their parents by 1 year of age.

A child diagnosed with a Wilms tumor is prescribed chemotherapy. Which laboratory test will the nurse monitor prior to administering the chemotherapy to determine the child's infection-fighting capability? 1. Hemoglobin 2. RBC count 3. Absolute neutrophil count (ANC) 4. Platelets

3. Absolute neutrophil count (ANC) The absolute neutrophil count uses both the segmented (mature) and bands (immature) neutrophils as a measure of the body's infection-fighting capability. RBC count, hemoglobin, and platelets cannot determine infection-fighting capabilities.

The nurse is teaching family members how to care for their infant in a Pavlik harness to treat congenital developmental dysplasia of the hip. Which statement will the nurse include in the teaching session? 1. "Apply lotion or powder to minimize skin irritation." 2. "Put clothing over the harness for maximum effectiveness of the device." 3. "Check at least 2 or 3 times a day for red areas under the straps." 4. "Place a diaper over the harness, preferably using a thin, superabsorbent, disposable diaper."

3. "Check at least 2 or 3 times a day for red areas under the straps." The brace should be checked 2 or 3 times for red areas under the straps. Lotion or powder can contribute to skin breakdown. A light layer of clothing should be under the brace, not over. The diaper should also be under the brace.

Which statement by the nurse is most appropriate prior to giving an intramuscular injection to a 2-1/2-year-old child? 1. "We will give you your shot when your mommy comes back." 2. "This is medicine that will make you better. First we will hold your leg, then I will wipe it off with this magic cloth that kills the germs on your leg right here, then I will hold the needle like this and say 'one, two, three . . . go' and give you your shot. Are you ready?" 3. "It is all right to cry, I know that this hurts. After we are done you can go to the box and pick out your favorite sticker." 4. "This is a magic sword that will give you your medicine and make you all better."

3. "It is all right to cry, I know that this hurts. After we are done you can go to the box and pick out your favorite sticker." The most appropriate response would be to acknowledge the child's feelings and give her something to look forward to (picking out a sticker). Waiting for the mother to come back would be inappropriate because toddlers do not have an understanding of time. Giving elaborate descriptions and using colorful language are inappropriate. The instructions should not end with a "are you ready" statement because the toddler will say no. You also don't want to frighten and/or confuse the child by using statements such as use of a magic sword.

The nurse is caring for a client in the pediatric intensive-care unit (PICU). The parents have expressed anger over the nursing care their child is receiving. Which nursing intervention is most appropriate based on the situation? 1. Ask the physician to talk with the family. 2. Explain to the parents that their anger is affecting their child so they will not be allowed to visit the child until they calm down. 3. Acknowledge the parents' concerns and collaborate with them regarding the care of their child. 4. Call the chaplain to sit with the family.

3. Acknowledge the parents' concerns and collaborate with them regarding the care of their child. Hospitalization of the child in a pediatric intensive-care unit is a great stressor for parents. If the parents feel that they are not informed or involved in the care of their child, they may become angry and upset. Calling the physician or chaplain may be appropriate at some point, but the nurse must assume the role of supporter in this situation to promote a sense of trust. Telling the parents that they cannot visit their child will only increase their anger.

The nurse is providing care to a school-age client who is admitted to the hospital after a motor vehicle accident. Which interventions are appropriate to prepare this client and family for their hospital stay? Select all that apply. 1. A hospital tour 2. A health fair brochure 3. An orientation to the unit 4. An age-appropriate explanation of procedures 5. A child life program consultation

3. An orientation to the unit 4. An age-appropriate explanation of procedures 5. A child life program consultation Interventions that are appropriate for this client and family are those that occur as the result of an unplanned hospital admission. The nurse would orient the client and family to the unit and provide age-appropriate explanation for all procedures. It is also appropriate for the nurse to consult with the child life program. A hospital tour and a health fair brochure are appropriate interventions for a planned hospitalization.

During the recovery-management phase of burn treatment, which is the most common complication seen in children? 1. Shock 2. Metabolic acidosis 3. Burn-wound infection 4. Asphyxia

3. Burn-wound infection Infection of the burned area is a frequent complication in the recovery—management phase. A goal of burn-wound care is protection from infection.

The nurse is caring for a pediatric client who sustained a severe burn. Determine the order of what would be done for this child when the medical team arrives on the scene: Response 1. Start intravenous fluids. Response 2. Provide for relief of pain. Response 3. Establish an airway. Response 4. Place a Foley catheter.

3. Establish an airway. 1. Start intravenous fluids. 2. Provide for relief of pain. 4. Place a Foley catheter. The first step in burn care is to ensure that the child has an airway, is breathing, and has a pulse. Due to the severity of the burn, establishing IV access and starting resuscitation fluids would be next, followed by addressing the area of pain and inserting a Foley catheter

The nurse is providing teaching to a community group regarding preventative strategies to reduce the risk of burn injury. Which topics will the nurse include in the teaching session? Select all that apply. 1. Avoid contact with unknown animals and wild animals. 2. Layer children's clothing for warmth. 3. Keep infants and toddlers off the lap when drinking hot beverages or eating soup. 4. Lower the temperature settings for hot water heaters. 5. Wear light-colored clothes and avoid eating sweetened foods and beverages when outside.

3. Keep infants and toddlers off the lap when drinking hot beverages or eating soup. 4. Lower the temperature settings for hot water heaters. In order to decrease the risk of burn injury, the nurse would tell the group to keep infants and toddlers off the lap while drinking hot beverages or eating soup and to lower the temperature settings for the hot water heaters. Avoiding contact with unknown animals and wild animals along with wearing light-colored clothes and avoiding eating sweetened foods and beverages when outside are strategies to prevent bites and stings. Layering children's clothing for warmth is a strategy to prevent hypothermia.

Which nursing intervention is most appropriate when caring for an infant with a myelomeningocele in the preoperative stage? 1. Placing infant supine to decrease pressure on the sac 2. Appling a heat lamp to facilitate drying and toughening of the sac 3. Measuring head circumference every shift to identify developing hydrocephalus 4. Appling a diaper to prevent contamination of the sac

3. Measuring head circumference every shift to identify developing hydrocephalus The infant should be monitored for developing hydrocephalus, so the head circumference should be monitored daily. The infant will be placed prone, not supine, and the defect will be protected from trauma or infection. Therefore, applying heat and a diaper around the defect would not be recommended. A sterile saline dressing may be used to cover the sac to maintain integrity.

A nurse notes blue sclera during a newborn assessment. Which item will the newborn require further assessment for based on this finding? 1. Marfan syndrome 2. Achondroplasia 3. Osteogenesis imperfecta 4. Muscular dystrophy

3. Osteogenesis imperfecta Clinical manifestations of osteogenesis imperfecta include blue sclera. This is not present in Marfan syndrome, achondroplasia, or muscular dystrophy.

A child is being discharged from the hospital after a 3-week stay following a motor vehicle accident. The mother expresses concern about caring for the child's wounds at home. She has demonstrated appropriate technique with medication administration and wound care. Which nursing diagnosis is the priority in this situation? 1. Knowledge Deficit of Home Care 2. Altered Family Processes Related to Hospitalization 3. Parental Anxiety Related to Care of the Child at Home 4. Risk for Infection Related to Presence of Healing Wounds

3. Parental Anxiety Related to Care of the Child at Home While all of the diagnoses might have been appropriate at some point, the current focus is the mother's anxiety about caring for the child at home. The priority of the nurse is relieving this anxiety.

The nurse is planning care for a 3-month-old infant diagnosed with eczema. Which should be the focus of the nurse's care for this infant? 1. Maintaining adequate nutrition 2. Keeping the baby content 3. Preventing infection of lesions 4. Applying antibiotics to lesions

3. Preventing infection of lesions Nursing care should focus on preventing infection of lesions. Due to impaired skin-barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infections by organisms. Maintaining adequate nutrition and keeping the infant content are not as high a priority. Antibiotics are not routinely applied to the lesions.

A child with myelomeningocele, corrected at birth, is now 5 years old. Which is the priority nursing diagnosis for a child with corrected spina bifida at this age? 1. Risk for Altered Nutrition 2. Risk for Impaired Tissue Perfusion-Cranial 3. Risk for Altered Urinary Elimination 4. Risk for Altered Comfort

3. Risk for Altered Urinary Elimination A child with spina bifida will continue to have a risk for altered urinary elimination because the bowel and bladder sphincter controls are affected. Urinary retention is a problem, so bladder interventions are initiated early to prevent kidney damage. Risk for Altered Nutrition, Impaired Tissue Perfusion, and Altered Comfort are not problems once surgery has been performed to close the defect.

A pediatric client is diagnosed with type 1 diabetes. The nurse teaches the client the difference between insulin shock and diabetic hyperglycemia. The nurse evaluates that the client understands the teaching when the client states which characteristics of diabetic hyperglycemia? 1. Tremors and lethargy 2. Hunger and hypertension 3. Thirst and flushed skin 4. Shakiness and pallor

3. Thirst and flushed skin Thirst and flushed skin are characteristic of diabetic hyperglycemia. Tremors, lethargy, hunger, shakiness, and pallor are characteristic of hypoglycemia. Hypertension is not a sign associated with hyperglycemia or hypoglycemia.

A nurse is conducting a postoperative assessment on an infant who has just had a ventriculoperitoneal shunt placed for hydrocephalus. Which assessment finding would indicate a malfunction in the shunt? 1. Incisional pain 2. Movement of all extremities 3. Negative Brudzinski sign 4. Bulging fontanel

4. Bulging fontanel A bulging fontanel would be an abnormal finding and could indicate that the shunt is malfunctioning. Incisional pain, movement of all extremities, and negative Brudzinski sign are all normal findings after a ventriculoperitoneal shunt has been placed.

A school-age client is admitted to the hospital with osteomyelitis. Which statement regarding the treatment of osteomyelitis is most appropriate for the nurse to share with the parents? 1. "Cultures should be done immediately after the first dose of antibiotic infuses." 2. "Antibiotics are ineffective against this virus." 3. "Methicillin is the antibiotic of choice." 4. "Antibiotic therapy should continue for 3 to 6 weeks."

4. "Antibiotic therapy should continue for 3 to 6 weeks." Medical management of osteomyelitis begins with intravenous administration of a broad-spectrum antibiotic. Antibiotic therapy should continue for 3 to 6 weeks. Cultures are always done before an antibiotic is started. Methicillin is not the drug of choice.

The nurse must perform a procedure on a toddler. Which technique is the most appropriate when performing the procedure? 1. Ask the mother to restrain the child during the procedure. 2. Ask the child if it is okay to start the procedure. 3. Perform the procedure in the child's hospital bed. 4. Allow the child to cry or scream.

4. Allow the child to cry or scream. While the toddler will need to be restrained, the parent should not be the one to do this. The nurse should avoid giving the child a choice if there is no choice. The treatment room should be utilized for the procedure so that the hospital bed remains a safe place. The child should be allowed to cry or scream during the procedure.

The nurse is administering a dose of rapid-acting insulin at 0800 to an insulin-dependent pediatric client. Based on when the insulin peaks, when will the client be at greatest risk for a hypoglycemic episode? 1. At about noon 2. Between bedtime and breakfast the next morning 3. Between lunch and dinner 4. Around 0930

4. Around 0930 Rapid-acting insulin peaks 30-90 minutes after administration. An injection given at 0800 would peak around 0930.

The nurse finds that an infant has stronger pulses in the upper extremities than in the lower extremities, and higher blood pressure readings in the arms than in the legs. Which assessment will the nurse perform next on this infant? 1. Pedal pulses 2. Pulse oximetry level 3. Hemoglobin and hematocrit values 4. Blood pressure of the four extremities

4. Blood pressure of the four extremities Coarctation of the aorta can present with stronger pulses in the upper extremities than in the lower extremities and higher blood pressure readings in the arms than in the legs because of obstruction of circulation to the lower extremities. Blood pressure values of the four limbs should be the next assessment data collected. Pedal pulses, pulse oximetry, and labs themselves will not provide the data needed.

The charge nurse is concerned with reducing the stressors of hospitalization. Which nursing intervention is most helpful in decreasing the stressors for the toddler-age client? 1. Assign the same nurse to the toddler as much as possible. 2. Let the child listen to an audiotape of the mother's voice. 3. Place a picture of the family at the bedside. 4. Encourage a parent to stay with the child.

4. Encourage a parent to stay with the child. While all of the interventions are appropriate for the hospitalized toddler, presence of a parent is most important. Separation from parents is the major stressor for the hospitalized toddler.

A child returns from spinal-fusion surgery. Which item is the priority assessment for this child? 1. Increased intracranial pressure 2. Seizure activity 3. Impaired pupillary response during neurological checks 4. Impaired color, sensitivity, and movement to lower extremities

4. Impaired color, sensitivity, and movement to lower extremities When the spinal column is manipulated, there is a risk for impaired color, sensitivity, and movement to lower extremities. The other signs are neurological impairment and are not high risk with spinal surgery.

A group of children on one hospital unit are all suffering separation anxiety. Which child is experiencing the despair stage of separation anxiety? 1. Does not cry if parents return and leave again 2. Screams and cries when parents leave 3. Appears to be happy and content with staff 4. Lies quietly in bed

4. Lies quietly in bed Children in the despair stage appear sad, depressed, or withdrawn. A child who is lying in bed might be exhibiting any of these. Screaming and crying are components of the protest stage. The young child who appears to be happy and content with everyone is in the denial stage, as is the child who does not cry if parents return and leave again.

The nurse is planning care for a pediatric client diagnosed with adrenal hyperplasia. Which nursing diagnosis is most appropriate for this client? 1. Impaired Social Interaction Related to Unnatural Facial Features 2. Nutrition: Less than Body Requirements due to Nausea and Vomiting 3. Depression Related to Inability to Take in Oral Fluids 4. Risk for Deficient Fluid Volume Related to Failure of Regulatory Mechanisms

4. Risk for Deficient Fluid Volume Related to Failure of Regulatory Mechanisms Adrenal hyperplasia alters the regulatory mechanisms, creating a fluid volume deficit. There is no major nutritional deficit, social interaction, or depression related directly to the diagnosis of adrenal hyperplasia.

A school-age client is transported to the emergency department by ambulance from the scene of a car accident. The client is alert and oriented × 3; pulse, respirations, and blood pressure are stable; and the neck and back are immobilized on a backboard. The nurse sees no obvious bleeding. The client states, "I can't feel or move my legs." Which injury does the nurse suspect? 1. Traumatic brain injury 2. Ruptured spleen 3. Traumatic shock 4. Spinal cord injury

4. Spinal cord injury Spinal cord injury results in paralysis and anesthesia of the affected body parts below the level of the lesion. Altered levels of consciousness may indicate traumatic brain injury. The child may have a ruptured spleen, but it is not evident from the data given. Traumatic shock results in initially increasing then decreasing pulse and respirations, and falling blood pressure.

The school nurse is conducting pediculosis capitis (head lice) checks. Which findings would indicate a "positive" head check? 1. White, flaky particles throughout the entire scalp region 2. Maculopapular lesions behind the ears 3. Lesions in the scalp that extend to the hairline or neck 4. White sacs attached to the hair shafts in the occipital area

4. White sacs attached to the hair shafts in the occipital area Evidence of pediculosis capitis includes white sacs (nits) that are attached to the hair shafts, frequently in the occiput area. Lesions may be present from itching, but the positive sign is evidence of nits. Lice and nits must be distinguished from dandruff, which appears as white, flaky particles.

1. A young school-age child is in the pediatric intensive-care unit (PICU) with a fractured femur and head trauma. The child was not wearing a helmet while riding his new bicycle on the highway and collided with a car. Which nursing diagnoses may be appropriate for this family? Select all that apply. a. Guilt Related to Lack of Child Supervision and Safety Precautions b. Family Coping: Compromised, Related to the Critical Injury of the Child c. Parental Role Conflict Related to Child's Injuries and PICU Policies d. Knowledge Deficit Related to Home Care of Fractured Femur e. Anger Related to Feelings of Helplessness

a. Guilt Related to Lack of Child Supervision and Safety Precautions b. Family Coping: Compromised, Related to the Critical Injury of the Child e. Anger Related to Feelings of Helplessness

The nurse in the long-term-care clinic is reviewing the charts of a group of children with chronic physical, psychological, functional, and/or social limitations. Which conditions are most likely to lead to chronic limitations? Select all that apply. a. Near drowning b. Congenital heart defect c. Sinusitis d. Fetal insult when the mother contracted rubella in the first trimester of pregnancy e. Sepsis contracted as a neonate

a. Near drowning b. Congenital heart defect d. Fetal insult when the mother contracted rubella in the first trimester of pregnancy e. Sepsis contracted as a neonate

The emergency-room nurse receives a preschool-age child who was hit by a car. Which nursing interventions are a priority for this child? Select all that apply. a. Performing a rapid head-to-toe assessment b. Recording the parents' insurance information c. Assessing airway, breathing, and circulation d. Asking the parents about organ donation e. Asking the parents if anyone witnessed the accident

a. Performing a rapid head-to-toe assessment c. Assessing airway, breathing, and circulation

The nurse is providing care to a toddler client who is diagnosed with osteogenesis imperfect. Which nursing intervention is appropriate for this client? a. Support of the trunk and extremities when moving b. Traction care c. Cast care d. Postop spinal surgery care

a. Support of the trunk and extremities when moving

The nurse completes parent education related to treatment for a pediatric client with congenital clubfoot. Which statement by the parents indicates the need for further education? a. "We're happy this is the only cast our baby will need." b. "We'll watch for any swelling of the feet while the casts are on." c. "We'll keep the casts dry." d. "We're getting a special car seat to accommodate the casts."

a. "We're happy this is the only cast our baby will need."

Parents of a child in the pediatric intensive care unit (PICU) have been experiencing shock and disbelief regarding their situation. Which statement by the parents indicates they are moving forward into the next stage of coping? a. "Why not me instead of my child?" b. "It is hard for me to have others take care of my child." c. "I feel like life is suspended in time." d. "I am glad I can help with his care."

a. "Why not me instead of my child?"

The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis) immunization for a 6-month-old infant. To administer this injection safely, the nurse chooses which needle, size and length, injection type, and injection site? a. 25-gauge, 5/8-inch needle; IM (intramuscular); anterolateral thigh. b. 22-gauge, 1/2-inch needle; IM (intramuscular); ventrogluteal. c. 25-gauge, 5/8-inch needle; ID (intradermal); deltoid. d. 25-gauge, 3/4-inch needle; SQ (subcutaneous); anterolateral thigh.

a. 25-gauge, 5/8-inch needle; IM (intramuscular); anterolateral thigh.

The nurse in the newborn nursery is performing the admission assessment on a neonate. Which assessment finding indicates the neonate may have congenital hip dysplasia? a. Asymmetry of the gluteal and thigh fat folds b. Trendelenburg sign c. Telescoping of the affected limb d. Lordosis

a. Asymmetry of the gluteal and thigh fat folds

The nurse is teaching a group of students about wound healing. Which items will the nurse include as occurring during the hemostasis and inflammation stage of wound healing? Select all that apply. a. Clot formation to seal the wound b. Production of collagen and granulation tissue c. Scar formation and strengthening d. Swelling as a result of increased capillary permeability e. Release of inflammatory mediators by platelets

a. Clot formation to seal the wound b. Production of collagen and granulation tissue d. Swelling as a result of increased capillary permeability

The school nurse completes an assessment of a school-age client to determine the services this child will need in the classroom. The client is a newly diagnosed with type I diabetes mellitus. Based on this information, which special healthcare need category is the most appropriate? a. Dependent on medication or special diet b. Dependent on medical technology c. Increase use of healthcare services d. Functional limitations

a. Dependent on medication or special diet

The hospital has just provided its nurses with information about biologic threats and terrorism. After completing the course, a group of nurses is discussing its responsibility in relation to bioterrorism. Which statement by the nurse indicates a correct understanding of the concepts presented? a. "It is important to separate clients according to age and illness to prevent the spread of disease." b. "I will notify the Centers for Disease Control (CDC) if a large number of persons with the same life-threatening infection present to the emergency room." c. "It is important to dispose blood-contaminated needles in the lead-lined container." d. "I will initiate isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA)."

b. "I will notify the Centers for Disease Control (CDC) if a large number of persons with the same life-threatening infection present to the emergency room."

The nurse must prepare parents to see their adolescent daughter in the pediatric intensive-care unit (PICU). The child arrived by life flight after experiencing multiple traumas in a car accident involving a suspected drunk driver. At this time, which statement by the nurse to the family is the most appropriate? a. "Don't worry; everything will be okay. We will take excellent care of your child." b. "Your child's condition is very critical; her face is swollen, and she may not look like herself." c. "You should press charges against the drunk driver." d. "Your child's leg was crushed and may have to be amputated."

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

When infants are seen for fractures, which nursing intervention is a priority? a. No intervention is necessary. It is not uncommon for infants to fracture bones. b. Assess for child abuse. Fractures in infants are often nonaccidental. c. Assess the family's safety practices. Fractures in infants usually result from falls. d. Assess for genetic factors.

b. Assess for child abuse. Fractures in infants are often nonaccidental.

The nurse is teaching a prenatal class about infant care. Under which circumstances should the nurse emphasize that parents should call their healthcare provider immediately? Select all that apply. a. Child 4 months old, received a DTaP immunization yesterday, and has a temperature of 38.0 degrees C (100.4 degrees F) b. Child under 3 months old and has a temperature over 40.1 degrees C (104.2 degrees F) c. Child difficult to awaken and has a pulsing fontanel d. Child has purple spots on the skin and is lethargic. e. Child has a stiff neck and has been irritable for three days

b. Child under 3 months old and has a temperature over 40.1 degrees C (104.2 degrees F) c. Child difficult to awaken and has a pulsing fontanel d. Child has purple spots on the skin and is lethargic. e. Child has a stiff neck and has been irritable for three days

A parent reports that her school-age child, who has had all recommended immunizations, had a mild fever one week ago and now has bright red cheeks and a lacy red maculopapular rash on the trunk and arms. Which disease process does the nurse suspect based on the parent's description? a. Chicken pox (varicella) b. Fifth disease (erythema infectiosum) c. German measles (rubella) d. Roseola (exanthem subitum

b. Fifth disease (erythema infectiosum)

A school-age client diagnosed with diabetes insipidus (DI) is admitted to the pediatric unit. Which laboratory value does the nurse anticipate for this client based on the diagnosis? a. Hyperglycemia b. Hypernatremia c. Hypercalcemia d. Hypoglycemia

b. Hypernatremia

The nurse explains to the parents of a child with a severe burn that wearing of an elastic pressure garment (Jobst stocking) during the rehabilitative stage can help with the prevention of which complication? a. Poor circulation b. Hypertrophic scarring c. Pain d. Formation of thrombus in the burn area

b. Hypertrophic scarring

During a well-child visit, the nurse identifies that an 18-month-old infant is bow legged. The nurse is aware that this assessment is: a. common in children between the ages of 2 and 7 years. b. a common variation until 1 year after walking begins. c. a serious condition needing further evaluation. d. an indication of neurological impairment.

b. a common variation until 1 year after walking begins.

A child who has fractured his forearm is unable to extend his fingers. The nurse knows that this: a. is normal following this type of injury. b. may indicate compartmental syndrome. c. may indicate fat embolism. d. may indicate damage to the epiphyseal plate.

b. may indicate compartmental syndrome.

The nurse is teaching family members how to care for their infant in a Pavlik harness to treat congenital developmental dysplasia of the hip. Which statement will the nurse include in the teaching session? a. "Apply lotion or powder to minimize skin irritation." b. "Put clothing over the harness for maximum effectiveness of the device." c. "Check at least two or three times a day for red areas under the straps." d. "Place a diaper over the harness, preferably using a thin, superabsorbent, disposable diaper."

c. "Check at least two or three times a day for red areas under the straps."

The nurse is working in an adolescent medical clinic. What can the nurse anticipate when comparing adolescents in the clinic with chronic conditions to their peers? a. A high level self-esteem b. A concern for their parents c. An altered body image d. A decreased concern about their appearance

c. An altered body image

The antiemetic drug ondansetron (Zofran) is administered to a child receiving chemotherapy. When should the nurse administer this medication? a. Only if the child experiences nausea b. After the chemotherapy has been administered c. Before chemotherapy administration as a prophylactic measure d. Never; this antiemetic is not effective for controlling nausea and vomiting associated with chemotherapy.

c. Before chemotherapy administration as a prophylactic measure

A school bus carrying children in grades K-12 crashed into a ravine. The critically injured children were transported by ambulance and admitted to the pediatric intensive-care unit (PICU). The nurse is concerned about calming the frightened children. Which nursing intervention is most appropriate to achieve the goal of calming the frightened children? a. Tell the children that the physicians are competent. b. Assure the children that the nurses are caring. c. Call the children's parents to come into the PICU. d. Explain that the PICU equipment is state of the art.

c. Call the children's parents to come into the PICU.

The nurse is planning care for a 3-month-old infant diagnosed with eczema. Which should be the focus of the nurse's care for this infant? a. Maintaining adequate nutrition b. Keeping the baby content c. Preventing infection of lesions d. Applying antibiotics to lesions

c. Preventing infection of lesions

The nurse can instruct parents to expect children in which age group to begin to assume more independent responsibility for their own management of a chronic condition, such as blood-glucose monitoring, insulin administration, intermittent self-catheterization, and appropriate inhaler use? a. Toddlers b. Preschoolers c. School-age d. Adolescents

c. School-age

When providing education for the parents of a child with Duchenne muscular dystrophy, the nurse plans to include: a. testing all female children for the disease. b. testing the father for the presence of the trait on the Y chromosome. c. genetic counseling for all female relatives. d. testing the parents to determine the carrier.

c. genetic counseling for all female relatives.

The nurse is working with a group of parents who have children with chronic conditions. Which statement by a parent would indicate a risk for a caregiver burden that could become overwhelming? a. "My mother moved in and helped us take our quadruplets home." b. "Our health insurance sent us a rejection letter for my child's brand-name medication, and we must fill out forms to get the generic." c. "I chose to quit my job to be home with my child, and my husband helps in the evening when he can." d. "I have to care for my child day and night, which leaves little time for me."

d. "I have to care for my child day and night, which leaves little time for me."

the nurse is examining a 12-month-old who is brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with bright red scaly plaques and small papules. Satellite lesions are also present. What is the most likely cause of this client's diaper rash? a. Impetigo (staph) b. Urine and feces c. Infrequent diapering d. Candida albicans (yeast)

d. Candida albicans (yeast)

A mother refuses to have her child be immunized with 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 response by the nurse is most appropriate? a. Honor her request because she is the parent. b. Explain that antibodies can fight many diseases. c. Tell her that not immunizing her infant may protect pregnant women. d. Explain that if her child contracts measles, mumps, or rubella, there could be very serious and permanent complications from these diseases.

d. Explain that if her child contracts measles, mumps, or rubella, there could be very serious and permanent complications from these diseases.

A child returns from spinal-fusion surgery. Which item is the priority assessment for this child? a. Increased intracranial pressure b. Seizure activity c. Impaired pupillary response during neurological checks d. Impaired color, sensitivity, and movement to lower extremities

d. Impaired color, sensitivity, and movement to lower extremities

The school nurse is conducting pediculosis capitis (head lice) checks. Which findings would indicate a "positive" head check? a. White, flaky particles throughout the entire scalp region b. Maculopapular lesions behind the ears c. Lesions in the scalp that extend to the hairline or neck d. White sacs attached to the hair shafts in the occipital area

d. White sacs attached to the hair shafts in the occipital area

When teaching the parents of a child with osteogenesis imperfecta about nutrition, the nurse should emphasize a diet that is: a. high in protein. b. high in calories. c. low in fiber. d. high in calcium

d. high in calcium