Peds Exam 2

14. A preterm newborn is receiving enteral feedings. Which finding would alert the nurse to suspect that the newborn is developing NEC? A. irritability B. sunken abdomen C. clay-colored stools D. feeding intolerance

D

12. While reviewing a newborn's medical record, the nurse notes that the chest X-ray shows a ground glass pattern. The nurse interprets this as indicative of: A. respiratory distress syndrome. B. transient tachypnea of the newborn. C. asphyxia. D. persistent pulmonary hypertension.

A

14.The nurse is examining a 15-month-old child who was able to walk at the last visit and now can no longer walk. What would be the nurse's best intervention in this case? A) Schedule a full evaluation since this may indicate a neurologic disorder. B) Note the regression in the child's chart and recheck in another month. C) Document the findings as a developmental delay since this is a normal occurrence. D) Ask the parents if they have changed the child's schedule to a less active one.

A

7. A nurse is developing the plan of care for a small-for-gestational-age newborn. Which action would the nurse determine as a priority? A. Preventing hypoglycemia with early feedings B. Observing for newborn reflexes C. Promoting bonding between the parents and the newborn D. Monitoring vital signs every 2 hours

A

21. A premature, 36-week-gestation neonate is admitted to the observational nursery and placed under bili-lights with evidence of hyperbilirubinemia. Which assessment findings would the neonate demonstrate? Select all that apply. A. increased serum bilirubin levels B. clay-colored stools C. tea-colored urine D. cyanosis E. Mongolian spots

A, B, C

20. A neonate is born at 42 weeks' gestation weighing 4.4 kg (9 lb, 7 oz) with satisfactory Apgar scores. Two hours later birth the neonate's blood sugar indicates hypoglycemia. Which symptoms would the baby demonstrate? Select all that apply. A. poor sucking B. respiratory distress C. weak cry D. jitteriness E. blood glucose >40 mg/dl

A, B, C, D

20. A nurse suspects that an adolescent may have community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA). What would the nurse expect to assess? Select all that apply. A. Participation in contact sport B. Recent cut on the lower leg C. History of a recent sore throat D. Raised fluctuant lesions E. Erythematous rash over the trunk and face

A, B, D

3.The nurse is assessing the respiratory system of a newborn. Which anatomic differences place the infant at risk for respiratory compromise? Select all that apply. A) The nasal passages are narrower. B) The trachea and chest wall are less compliant. C) The bronchi and bronchioles are shorter and wider. D) The larynx is more funnel shaped. E) The tongue is smaller. F) There are significantly fewer alveoli.

A, D, F

10. After teaching the parents of a newborn with periventricular hemorrhage about the disorder and treatment, which statement by the parents indicates that the teaching was successful? A. "We'll make sure to cover both of his eyes to protect them." B. "Our newborn could develop a learning disability later on." C. "Once the bleeding ceases, there won't be any more worries." D. "We need to get family members to donate blood for transfusion."

B

10. The nurse is preparing a teaching plan for the parents of a child with a urinary tract infection (UTI). In educating the parents, the nurse would recommend that the child avoid: A. a liberal fluid intake. B. caffeine. C. cranberry juice. D. cotton underwear.

B

15. The nurse is performing a physical examination of an 11-year-old girl. What observations would be expected? A) The child has not gained weight since last year. B) The child has grown 2.5 in since last year. C) The child breathes abdominally. D) The child's third molars are about to erupt.

B

16.After teaching a class about the hemodynamic characteristics of congenital heart disease, the instructor determines that the teaching has been successful when the class identifies which defect as an example of a disorder involving increased pulmonary blood flow? A) Tetralogy of Fallot B) Atrial septal defect C) Hypoplastic left heart syndrome D) Transposition of the great vessels

B

17. A nurse is preparing a presentation for a local parent group about urinary tract infections (UTIs) in children. Which organism would the nurse incorporate into the presentation as the most common cause? A. Klebsiella B. Escherichia coli C. Staphylococcus aureus D. Pseudomonas

B

28. While hospitalized, a child develops scarlet fever. Isolation has been prescribed by the health care provider. The nurse would place this child in what type of isolation? A. Airborne B. Droplet C. Contact D. Reverse

B

8.The nurse is caring for a newborn and knows that his vision, unlike his hearing, is not fully developed. Which aspect of the child's vision would the nurse expect to be similar to his father's vision? A) Adequate color detection B) Visual acuity of 20/100 C) Nearsightedness D) Monocular vision

B

27. At the breech forceps birth of a 32 weeks' gestation neonate, the nurse notes olygohydramnios with green thick amniotic fluid. The maternal history reveals a mother of Hispanic ethnicity with marked hypertension, who admits to using cocaine daily. Which factor(s) may contribute to meconium aspiration syndrome (MAS)? Select all that apply. A. the preterm pregnancy B. the forceps breech birth C. maternal cocaine use D. maternal hypertension E. Hispanic ethnicity F. oligohydramnios present

B, C, D, F

24. A 30 weeks' gestation neonate born with low Apgar scores is in the neonatal intensive care unit with respiratory distress syndrome and underwent an exchange transfusion for anemia. Which factors place the neonate at risk for necrotizing enterocolitis? Select all that apply A. preterm birth B. respiratory distress syndrome C. low Apgar scores D. hyperthermia E. hyperglycemia F. exchange transfusion

B, C, F

19. A couple has just given birth to a baby who has low Apgar scores due to asphyxia from prolonged cord compression. The neonatologist has given a poor prognosis to the newborn, who is not expected to live. Which interventions are appropriate at this time? Select all that apply. A. Advise the parents that the hospital can make the arrangements. B. Offer to pray with the family if appropriate. C. Leave the parents to talk through their next steps. D. Initiate spiritual comfort by calling the hospital clergy, if appropriate. E. Respect variations in the family's spiritual needs and readiness.

B, D, E

17. A school-aged child with an infectious disease is placed on transmission-based precautions. If the child is not dehydrated or otherwise in distress, which nursing diagnosis would be the priority? A. Impaired skin integrity related to trauma secondary to pruritus and scratching B. Fluid volume deficit related to increased metabolic demands and insensible losses C. Social isolation related to infectivity and inability to go to the playroom D. Deficient knowledge related to how infection is transmitted

C

18.A child with a suspected cardiovascular disorder is to undergo diagnostic testing and is scheduled for an echocardiogram. When explaining this test to the child, what would the nurse most likely include? A) "This test will check the pattern of how your heart is beating." B) "They'll take a picture of your chest to look at the heart's size." C) "A special wand that picks up sound is used to check your heart." D) "Small patches are attached to your chest to check the heart rhythm."

C

13.A nurse develops a plan of care for a child that includes patching the eye. This plan of care would be most appropriate for which condition? A) Astigmatism B) Hyperopia C) Myopia D) Amblyopia

D

2. The nurse is preparing a plan of care for a 5-year-old boy with chickenpox. Which nursing intervention should be questioned? A. Administer antipyretics as ordered. B. Keep the child's fingernails short. C. Monitor fluid intake and output. D. Provide alcohol baths as needed.

D

21.The nurse is developing a plan of care for an infant with heart failure who is receiving digoxin. The nurse would hold the dose of digoxin and notify the healthcare provider if the infant's apical pulse rate was: A) 140 beats per minute B) 120 beats per minute C) 100 beats per minute D) 80 beats per minute

D

23. A nurse is preparing a presentation for a local health fair about meningitis and has developed a display that lists the following causes:Streptococcus group B Haemophilus influenzae type B Streptococcus pneumoniae Neisseria meningitidis What would the nurse highlight as the most common cause of meningitis in newborns? A. Streptococcus group B B. Haemophilus influenzae type B C. Streptococcus pneumoniae D. Neisseria meningitidis

A

5. The nurse knows that the school-age child is in Erikson's stage of industry versus inferiority. Which best exemplifies a school-ager working toward accomplishing this developmental task? A) The child signs up for after-school activities. B) The child performs his bedtime preparations autonomously. C) The child becomes aware of the opposite sex. D) The child is developing a conscience.

A

5.A 7-year-old boy has reentered the hospital for the second time in a month. Which intervention is particularly important at this time? A) Assessing his parents' coping abilities B) Seeking his parents' input about their child's needs C) Educating his family about the procedure D) Notifying the care team about his hospitalization

A

6. A nurse is caring for a 7-year-old girl scheduled for an intravenous pyelogram (IVP). Which action would be the priority before the test? A. Checking with the parents for any allergies B. Ensuring adequate hydration C. Giving the girl an enema D. Screening her for pregnancy

A

6. A preterm newborn has received large concentrations of oxygen therapy during a 3-month stay in the NICU. As the newborn is prepared to be discharged home, the nurse anticipates a referral for which specialist? A. ophthalmologist B. nephrologist C. cardiologist D. neurologist

A

23. A 33 weeks' gestation neonate is being assessed for necrotizing enterocolitis (NEC). Which nursing actions would the nurse implement? Select all that apply. A. Perform hemoccult tests on stools. B. Monitor abdominal girth. C. Measure gastric residual before feeds. D. Assess bowel sounds before each feed. E. Assess urine output.

A, B, C, D

26. The nurse in the neonatal intensive care unit is caring for a neonate she suspects is at risk for an intraventricular hemorrhage (IVH). Which nursing actions would be priorities? Select all that apply. A. Maintain fetal flexed position. B. Administer fluids slowly. C. Assess for bulging fontanel. D. Measure head circumference daily. E. Assess Moro reflex. F. Measure intake and output.

A, B, C, D

27. The nurse is caring for a hospitalized, 1-week-old infant who appears very ill. Which assessment finding(s) will the nurse report to the health care provider? Select all that apply. A. Petchiae B. Heart rate100 beats/min C. Respiratory rate 60 breaths/min D. Axillary temperature 97.6°F (36.5°C) E. Characteristic of cry

A, B, C, D, E

6. The school nurse providing school health screenings knows that the 7- to 11-year-old is in Piaget's stage of concrete operational thoughts. What should this age group accomplish when developing operations? Select all that apply. A) Ability to assimilate and coordinate information about the world from different dimensions B) Ability to see things from another person's point of view and think through an action C) Ability to use stored memories of past experiences to evaluate and interpret present situations D) Ability to think about a problem from all points of view, ranking the possible solutions while solving the problem E) Ability to think outside of the present and incorporate into thinking concepts that do exist as well as concepts that might exist F) Ability to understand the principle of conservation—that matter does not change when its form changes

A, B, C, F

12. A child is diagnosed with hemolytic-uremic syndrome (HUS). Review of the child's laboratory test results would reveal which finding? A. Decreased blood urea nitrogen (BUN) and creatinine B. Decreased platelets and leukocytosis C. Hypernatremia and hypokalemia D. Respiratory acidosis and proteinuria

B

15. A one-day-old neonate born at 32 weeks' gestation is in the neonatal intensive care unit under a radiant overhead warmer. The nurse assesses the morning axilla temperature as 95 degrees F (35 degrees C). What could explain the assessment finding? A. Conduction heat loss is a problem in the baby. B. The supply of brown adipose tissue is not developed. C. Axillary temperatures are not accurate. D. This is a normal temperature.

B

17. A nursing instructor is preparing a class on chronic lung disease. What information would the instructor include when describing this disorder? A. It is a result of cystic fibrosis. B. It is seen most commonly in premature infants. C. It typically affects females more often than males. D. It is characterized by bradypnea.

B

2. The nurse is visually inspecting a urine specimen from a 12-year-old boy. The nurse documents gross hematuria with a specimen of which color? A. Cloudy yellow B. Cola colored C. Pale to almost clear urine D. Light orange to moderately yellow colored

B

20. While presenting a panel discussion to a group of parents about urinary tract infections (UTIs) in children, one of the parents asks the nurse, "Why would my daughter be more at risk than my son?" Which response by the nurse would be most accurate? A. "Girls have a smaller bladder size than boys do." B. "A girl's urethra is closer to the rectal opening." C. "A girl's urethra is longer than a boy's urethra." D. "Her kidneys are less well protected."

B

22. The nurse is preparing an 8-year-old girl for a cystoscopy. Which instruction would be most appropriate to give to the child? A. "You need to make sure that you don't go to the bathroom before the test." B. "You might feel some burning when you go to the bathroom afterward." C. "I'm going to have to put a tube into your bladder to empty it." D. "I have to put a thick tight rubber band around your arm to get a blood specimen."

B

24.The nurse is discussing vaccination for Haemophilus influenzae type B (Hib) with the mother of a 6-month-old child. Which comment provides the most compelling reason to get the vaccination? A) "These bacteria live in every human." B) "Young children are especially susceptible to these bacteria." C) "You have a choice of two excellent vaccines." D) "Your child needs this final dose for protection."

B

26.After teaching the mother about follow-up immunizations for her daughter, who received the varicella vaccine at age 14 months, the nurse determines that the teaching was successful when the mother states that a follow-up dose should be given at which time? A) When the child is 20 to 36 months of age B) When the child is 4 to 6 years of age C) When the child is 11 to 12 years of age D) When the child is 13 to 15 years of age

B

27. The nurse is taking a health history of a child with suspected acute poststreptococcal glomerulonephritis. Which response by the client's parent will the nurse highlight for the primary health care provider as an indicator for this condition? A. "My child's has recently reported urinary frequency." B. "My child just got over a head cold with laryngitis." C. "My child's urine is pale yellow in color." D. "My child's eyes appear sunken to me."

B

30. A late preterm newborn is being prepared for discharge to home after being in the neonatal intensive care unit for 4 days. The nurse instructs the parents about the care of their newborn and emphasizes warning signs that should be reported to the pediatrician immediately. The nurse determines that additional teaching is needed based on which parental statement? A. "We will call 911 if we start to see that our newborn's lips or skin are looking bluish." B. "If our newborn's skin turns yellow, it is from the treatments and our newborn is okay." C. "If our newborn does not have a wet diaper in 12 hours, we will call our pediatrician." D. "We will let the pediatrician know if our newborn's temperature goes above 100.4°F (38°C)."

B

4.A new mother shows the nurse that her baby grasps her finger when she touches the baby's palm. How might the nurse respond to this information? A) "This is a primitive reflex known as the plantar grasp." B) "This is a primitive reflex known as the palmar grasp." C) "This is a protective reflex known as rooting." D) "This is a protective reflex known as the Moro reflex."

B

5. The nurse prepares to assess a newborn who is considered to be large-for-gestational-age (LGA). Which characteristic would the nurse correlate with this gestational age variation? A. strong, brisk motor skills B. difficulty in arousing to a quiet alert state C. birthweight of 7 lb, 14 oz (3,572 g) D. wasted appearance of extremities

B

6. A group of nursing students are reviewing the six links in the chain of infection and the nursing implications for each. The students demonstrate understanding of the information when they identify which precaution as helping to break the chain of infection to the susceptible host? A. Keeping linens dry and clean B. Maintaining skin integrity C. Washing hands frequently D. Coughing into a handkerchief

B

6. The nurse prepares to administer a gavage feeding for a newborn with transient tachypnea based on the understanding that this type of feeding is necessary because: A. lactase enzymatic activity is not adequate. B. oxygen demands need to be reduced. C. renal solute lead must be considered. D. hyperbilirubinemia is likely to develop.

B

6.When conducting a physical examination of a child with suspected Kawasaki disease, which finding would the nurse expect to assess? A) Hirsutism or striae B) Strawberry tongue C) Malar rash D) Café au lait spots

B

8. The nurse is providing care to a newborn who was born at 36 weeks' gestation. Based on the nurse's understanding of gestational age, the nurse identifies this newborn as: A. preterm. B. late preterm. C. term. D. postterm.

B

8. The nurse is talking with a chatty 7-year-old girl during her regular check-up. Which behaviors would the child also be expected to exhibit? A) Showing no interest in what the nurse sees in her ears B) Explaining what is right and what is wrong C) Demonstrating independence from her mother D) Showing no concern when the nurse hurts her own finger

B

19. A nurse identifies a nursing diagnosis of Impaired urinary elimination related to infection in the urinary tract as manifested by dysuria for a preschooler. When developing the plan of care, what would be most important for the nurse to do first? A. Develop a schedule for bladder emptying. B. Encourage fluid intake. C. Assess usual voiding patterns. D. Monitor intake and output.

C

2. A nurse is assessing a postterm newborn. Which finding would the nurse correlate with this gestational age variation? A. moist, supple, plum skin appearance B. abundant lanugo and vernix C. thin umbilical cord D. absence of sole creases

C

24.The nurse is instructing a 7-year-old child and his parents about using his prescribed corrective lenses. What would the nurse include in these instructions? A) "Make sure to take your glasses off from time to time to allow your eyes to rest." B) "Remove your glasses with both hands and lay them with the lens upright on the surface." C) "Clean the glasses every day with a mild soap and water or commercial cleaning agent." D) "Use paper towels or tissues to dry and periodically clean the lenses."

C

25. The nurse is caring for a client with hemolytic-uremic syndrome (HUS). The cilent is demonstrating oliguria. What does the nurse expect to find when reviewing the client's records? A. A pattern of below-normal blood pressure B. Higher fluid output than fluid intake C. Elevated BUN and creatinine levels D. Increased glomerular filtration rate (GFR)

C

25.During a follow-up visit, the parents of a 5-month-old infant diagnosed with congenital heart disease tell the nurse, "We're just so tired and emotionally spent. All these tests and examinations are overwhelming. We just want to have a normal life. We're so focused on the baby that it seems like our 3-year-old is lost in the shuffle." Which nursing diagnosis would the nurse identify as most appropriate? A) Risk for delayed growth and development related to necessary treatments B) Deficient knowledge related to the care of a child with congenital heart disease C) Interrupted family processes related to demands of caring for the ill child D) Fear related to infant's cardiac condition and need for ongoing care

C

26.The parents of a child with a developmental disability tell the nurse that they feel guilty because they sometimes find themselves feeling sad and wondering how their child would be without the disability. Which response by the nurse best shows empathy and encourages the parents to vent their feelings? A) "I'm sure it must be difficult to have a child developmentally delayed." B) "There are lots of parents that are experiencing the difficulty and feelings of hopelessness and grief you're having. Maybe if you talk to someone it might help you both." C) "I can only imagine how hard it is for you. You should know that it is common for parents to have these feelings when having a child with special needs." D) "It's important to focus on the positives that can come from the experience of being the parents of a child that has these issues."

C

28.After teaching a group of students about visual disorders, the instructor determines that the teaching was successful when the students identify what as the most common cause of visual difficulties in children? A) Astigmatism B) Strabismus C) Refractive errors D) Nystagmus

C

3. The nurse is developing a teaching plan for the mother of a 4-year-old girl with cold and fever. What would the nurse include in this teaching plan? A. Keeping the child covered and warm B. Calling the doctor if the child's fever lasts more than 36 hours C. Ensuring fluid intake to prevent dehydration D. Observing for changes in alertness resulting from brain damage

C

3. The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation, intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate? A. Suggest that the parents stay for just a few minutes to reduce their anxiety. B. Reassure them that their newborn is progressing well. C. Encourage the parents to touch their preterm newborn. D. Discuss the care they will be giving the newborn upon discharge.

C

7.The nurse is examining a 7-year-old boy with blepharitis. What would the nurse least likely expect to assess? A) Redness B) Scaling C) Pain D) Edema

C

9. A child is diagnosed with scarlet fever. The nurse is reviewing the child's medical record, expecting which medication to be prescribed for this child? A. Ibuprofen B. Acyclovir C. Penicillin V D. Doxycycline

C

9. The nurse is caring for an 8-year-old boy who has chronic epilepsy. What would be most important to address when teaching the child and parents about living with this condition? A. Multiple corrective surgeries to slowly remove diseased parts of his brain B. Physical, occupational, and speech therapy to maximize his potential C. Support for maintaining self-esteem because of his altered lifestyle D. Hyperventilation therapy to counteract the periods of decreased oxygenation

C

1. The nurse is teaching a group of parents who have preterm newborns about the differences between a full-term newborn and a preterm newborn. Which characteristic would the nurse describe as associated with a preterm newborn but not a term newborn? A. fewer visible blood vessels through the skin B. more subcutaneous fat in the neck and abdomen C. well-developed flexor muscles in the extremities D. greater body surface area in proportion to weight

D

10.Which would be least appropriate to include in the discharge plan for a medically fragile child? A) Assisting with referrals for financial support B) Arranging for necessary care equipment and supplies C) Assessing the family's home environment D) Encouraging passive caregiving

D

11. After teaching the parents of a child with chickenpox (varicella zoster), the nurse determines that the parents have understood the teaching when they state that their child can return to school at which time? A. After day 5 of the rash B. When the rash is completely healed C. Once the rash appears D. After the lesions have crusted

D

14. A thin newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36° C (96.8° F) and persisting oxygen saturation of <87%. The nurse interprets these findings as: A. cardiac distress. B. respiratory alkalosis. C. bronchial pneumonia. D. respiratory distress.

D

15. The nurse is preparing to obtain a blood specimen via capillary heel puncture. Which action would be most appropriate for the nurse to do? A. Apply a cool compress for several minutes before collection. B. Elevate the extremity used after puncturing it. C. Squeeze the area to facilitate specimen collection. D. Wipe away the first drop of blood with dry gauze.

D

16. The nurse is assessing the tympanic temperature of several children. The nurse documents that the child with which temperature reading has a fever? A. 98.2° F (36.8° C) B. 99.2° F (37.3° C) C. 100° F (37.8° C) D. 100.8° F (38.2° C)

D

23.The nurse is administering a hepatitis B vaccine to a child. What is the classification of this type of vaccine? A) Killed vaccines B) Toxoid vaccines C) Conjugate vaccines D) Recombinant vaccines

D

1.The nurse is developing a plan of care for a 5-year-old child with a severe hearing impairment focusing on psychosocial interventions based on assessment findings. Which behavior would the nurse have most likely assessed? A) Immature emotional behavior B) Self-stimulatory actions C) Inattention and vacant stare D) Head tilt or forward thrust

A

12. After teaching a class on the role of white blood cells in infection, the instructor determines that the teaching was successful when the class identifies which type of white blood cells as important in combating bacterial infections? A. Neutrophils B. Eosinophils C. Basophils D. Lymphocytes

A

27. The nurse working in a community clinic attempts to establish a free vaccination program to refer low-income families. What is the key strategy for success when implementing a health promotion activity? A) Partnership development B) Funding for projects C) Finding an audience D) Adequate staffing

A

29. A newborn infant has been diagnosed with persistent pulmonary hypertension of the newborn (PPHN). In providing care for this newborn what intervention should be the nurse's priority? A. Measure blood pressure B. Obtain arterial blood gases C. Monitor oxygen saturation D. Suction the newborn

A

4.The nurse is conducting a physical examination of a child with a suspected cardiovascular disorder. Which finding would the nurse most likely expect to assess if the child had transposition of the great vessels? A) Significant cyanosis without presence of a murmur B) Abrupt cessation of chest output with an increase in heart rate/filling pressure C) Soft systolic ejection D) Holosystolic murmur

A

8. The nurse determines that it is necessary to implement airborne precautions for children with which infection? A. Measles B. Streptococcus group A C. Rubella D. Scarlet fever

A

8. The nurse is caring for a 12-year-old girl with nephrotic syndrome. The girl confides that she feels like a "freak" compared to her peers because of her weight, edema, and moon face. Which response by the nurse would be most appropriate? A. "Let's put you in touch with some other girls who are also having the same body changes." B. "Luckily, this is just a temporary, unfortunate part of your condition; you need to accept it." C. "Your real friends do not care about your appearance and just want you to get well." D. "You are beautiful in your own way; what matters is what is on the inside."

A

28. A 2-hour-old neonate born via caesarean birth has begun having a respiratory rate of 110 breaths/min and is in respiratory distress. What intervention(s) is a priority for the nurse to include in this neonates's care? Select all that apply. A. Keep the head in a "sniff" position B. Administer oxygen C. Insert an orogastric tube D. Ensure thermoregulation E. Obtain an arterial blood gas

A, B, D

8.The nurse is caring for infants with failure to thrive (FTT). Which infants would be at risk for this condition? Select all that apply. A) A newborn baby with tetralogy of Fallot B) An infant with a cleft palate C) An infant born to a diabetic mother D) An infant born to an impoverished mother E) An infant with bronchopulmonary dysplasia F) An infant born to a teenage mother

A, B, D, E

21. A 15-year-old adolescent is brought to the emergency department by his parents. The adolescent is febrile with chills that started suddenly. He states, "I had a sinus infection and sore throat a couple of days ago." The nurse suspects bacterial meningitis based on which findings? Select all that apply. A. Complaints of stiff neck B. Photophobia C. Absent headache D. Negative Brudzinski sign E. Vomiting

A, B, E

23. The parents of a 7-month-old child with an infection ask the nurse about how to treat their child's fever. After providing teaching, the parents voice understanding with which statements? Select all that apply. A. "If my child's fever is under 102°F , I don't need to make an appointment with the physician." B. "Having a temperature over 38°C puts my child at risk for the infection spreading to the bloodstream." C. "I can use acetaminophen to help with the symptoms of the infection but it won't get rid of the infection." D. "Even though people get frightened, fevers are not a bad thing during an infection unless it gets too high." E. "Any fever is dangerous and can cause serious damage to brain cells if it goes on too long."

A, C, D

22.The nurse is explaining the difference between active and passive immunity to the student nurse. Which statement accurately describes a characteristic of the process of immunity? A) Active immunity is produced when the immunoglobulins of one person are transferred to another. B) Passive immunity can be obtained by injection of exogenous immunoglobulins. C) Active immunity can be transferred from mothers to infants via colostrum or the placenta. D) Passive immunity is acquired when a person's own immune system generates the immune response.

B

26. A nurse is conducting a health history for a 1-month-old with an infectious disorder. Which segment of the maternal health history would be most helpful for the nurse when determining if the infant developed the infection from the mother? A. Family history B. Past medical history C. Home treatments D. Present illness history

B

5.The nurse is assessing a child with suspected infective endocarditis. Which assessment finding would the nurse interpret as a sign of extracardiac emboli? A) Pruritus B) Roth spots C) Delayed capillary refill D) Erythema marginatum

B

14. A nurse is instructing a parent on how to obtain a stool culture for ova and parasites from a child with diarrhea. What would the nurse include in the teaching plan? A. "Give the child bismuth and then collect the next specimen." B. "Obtain the specimen from the toilet after the child has a bowel movement." C. "Keep the specimen from coming into contact with any urine." D. "Bring the specimen to the laboratory on the third day."

C

14. The nurse is reviewing the laboratory test results of a child with nephrotic syndrome. What would the nurse least likely expect to find? A. Hyperlipidemia B. Hypoalbuminemia C. Decreased blood urea nitrogen (BUN) D. Hypoproteinemia

C

15. The nurse frequently assesses the respiratory status of a preterm newborn based on the understanding that the newborn is at increased risk for respiratory distress syndrome because of: A. inability to clear fluids. B. immature respiratory control center. C. deficiency of surfactant. D. smaller respiratory passages.

C

21.The nurse is performing a vision screening for a 4-year-old child. Which screening chart would be best for determining the child's visual acuity? A) Snellen B) Ishihara C) Allen figures D) Color Vision Testing Made Easy (CVTME)

C

22. The client has a heavily draining wound for which there is an order to change the dressing every 4 hours. The nurse becomes busy and does not change the dressing as ordered. Which link in the chain of infection has the nurse allowed to flourish? A. Susceptible host B. Portal of exit C. Reservoir D. Mode of transmission

C

22.A nurse is working with an adolescent who is slightly overweight and was recently diagnosed with hypertension. They are discussing nutritional management. Which statement by the adolescent demonstrates understanding of the information? A) "I have to make sure that I don't eat a lot of salty foods." B) "I can eat any amount at a meal as long as I don't eat between meals." C) "I should eat plenty of fresh fruits and vegetables." D) "If I skip breakfast, I can eat a much bigger lunch."

C

24. The mother of a 4-year-old boy has contacted the physician's office. She reports her son was exposed to someone with chickenpox. She has inquired about when her son may show if he has gotten the disease. What information should be provided? A. The illness should be seen in a week if he has been exposed. B. Symptoms of the disease should show up within 24 to 48 hours of exposure. C. The incubation period for the disease is between 10 and 21 days. D. Younger children will have longer periods of incubation.

C

22. A jaundiced neonate must have heel sticks to assess bilirubin levels. Which assessment findings would indicate that the neonate is in pain? Select all that apply. A. There is flaccid muscle tone of the affected limb. B. Respiration rate is 52 breaths per minute. C. Heart rate is 180 beats per minutes. D. Oxygen saturation level is 88%. E. The infant has facial grimacing and quivering chin.

C, D, E

25.The mother of a 15-month-old child is questioning the nurse about the need for the hepatitis B vaccination. Which comment provides the most compelling reason for the vaccine? A) "The most common side effect is injection site soreness." B) "This is a recombinant or genetically engineered vaccine." C) "Immunizations are needed to protect the general population." D) "This protects your child from infection that can cause liver disease."

D

4. Rapid assessment of a newborn indicates the need for resuscitation. The newborn has copious secretiohs. The newborn is dried and placed under a radiant warmer. Which action would the nurse do next? A. Intubate with an appropriate-sized endotracheal tube. B. Give chest compressions at a rate of 80 times per minute. C. Administer epinephrine intravenously. D. Clear the airway with a bulb syringe.

D

6. A 16-year-old boy reports to the school nurse with headaches and a stiff neck. Which sign or symptom would alert the nurse that the child may have bacterial meningitis? A. Fixed and dilated pupils B. Frequent urination C. Sunset eyes D. Sunlight is "too bright"

D

7. A 4-year-old boy has a febrile seizure during a well-child visit. What action would be a priority? A. Hyperextending the child's head while placing him on his side B. Using a tongue blade to pry open the child's jaw C. Loosening the child's clothing to ensure a patent airway D. Protecting the child from harm during the seizure

D

9. An 8-year-old girl is scheduled for a renal ultrasound. What would the nurse include in the plan of care when preparing the child for this test? A. Withholding food and fluids after midnight B. Checking the child for allergies to shellfish C. Ensuring the child has a full bladder D. Informing the child she should feel no discomfort

D

20. A group of students are reviewing information about the various types of insulin used to treat type 1 diabetes. The students demonstrate understanding of the information when they identify which of these insulins as having the longest duration? A) Lispro B) Regular C) NPH D) Glargine

D

21. The nurse is caring for a 10-year-old in traction. While performing a skin assessment, the nurse notices that the skin over the calcaneus appears slightly red and irritated. Which action would the nurse take first? A. Reposition the child's foot on a pressure-reducing device. B. Apply lotion to his foot to maintain skin integrity. C. Make sure the skin is clean and dry. D. Gently massage his foot to promote circulation.

A

22. The nurse is caring for a 14-month-old boy with rickets who was recently adopted from overseas. His condition was likely a result of a diet very low in milk products. The nurse is providing teaching regarding treatment. Which response by the parents indicates a need for further teaching? A. "We must give him calcium and phosphorus with food every morning." B. "He must take vitamin D as prescribed and spend some time in the sunlight." C. "He must take calcium at breakfast and phosphorus at bedtime." D. "We should encourage him to have fish, dairy, and liver if he will eat it."

A

22.An infant is diagnosed with a congenital cataract. What would the nurse expect to assess? A) Absent red reflex B) Rapid irregular eye movement C) Misalignment of the eyes D) Enlarged eye appearance

A

11. A child with Duchenne muscular dystrophy is to receive prednisone as part of his treatment plan. After teaching the child's parents about this drug, which statement by the parents indicates the need for additional teaching? A. "We should give this drug before he eats anything." B. "We need to watch carefully for possible infection." C. "The drug should not be stopped suddenly." D. "He might gain some weight with this drug."

A

18. An 8-year-old girl was diagnosed with a closed fracture of the radius at approximately 2 p.m. The fracture was reduced in the emergency department and her arm placed in a cast. At 11 p.m. her mother brings her back to the emergency department due to unrelenting pain that has not been relieved by the prescribed narcotics. Which action would be the priority? A. Notifying the doctor immediately B. Applying ice C. Elevating the arm D. Giving additional pain medication as ordered

A

24. A group of students are reviewing information about head injuries in children. The students demonstrate understanding of this information when they identify what as the most common type of skull fracture in children? A. Linear B. Depressed C. Diastatic D. Basilar

A

26. A 10-month-old infant is brought to the emergency department by the parents after they found the infant face down in the bathtub. The parent states, "I just left the bathroom to answer the phone. When I came back, I found my infant." Which nursing action is priority? A. Assess the client's respiratory rate B. Start cardiopulmonary resusitative measures C. Determine how long the client was face down in the water D. Apply a heart monitor to the client

A

29.An infant is diagnosed with infantile glaucoma. When developing the plan of care for the infant, for what would the nurse expect to prepare the infant and family? A) Goniotomy B) Antibiotic therapy C) Contact lenses D) Patching of affected eye

A

3. The nurse is caring for a child hospitalized with Reye syndrome who is in the acute stage of the illness. The nurse would assess the child most carefully for what finding? A. Indications of increased intracranial pressure B. An increase in the blood glucose level C. A decrease in the liver enzymes D. A presence of protein in the urine

A

34. The nurse is caring for a child with thalassemia who is receiving chelation therapy at home using a battery-operated pump. After teaching the parents about this treatment, which statement by the mother indicates a need for additional teaching? A) "I can have the nurse administer the chelation therapy if I am uncomfortable." B) "I must be very careful to strictly adhere to the chelation regimen." C) "The deferoxamine binds to the iron so it can be removed from the body." D) "The medication can be administered while my child is sleeping."

A

36. The nurse is providing care to a child with a long-leg hip spica cast. What is the priority nursing diagnosis? A. Risk for impaired skin integrity due to cast and location B. Deficient knowledge related to cast care C. Risk for delayed development related to immobility D. Self-care deficit related to immobility

A

42. A child is brought to the clinic after tripping over a rock. The child states "I twisted my ankle" and is given a diagnosis of a sprain. What intervention is most important for the nurse to include in the discharge instructions for this child? A. For the first 24 hours apply ice for 20 minutes and remove for 60 minutes B. Bedrest with leg elevated for 36 hours C. May take an NSAID for pain as prescribed D. Use compression dressing for 72 hours

A

6. The nurse is preparing a teaching plan for the family and their 6-year-old son who has just been diagnosed with diabetes mellitus. What would the nurse identify as the initial goal for the teaching plan? A) Developing management and decision-making skills B) Educating the parents about diabetes mellitus type 1 C) Developing a nutritionally sound, 30-day meal plan D) Promoting independence with self-administration of insulin

A

6. The nurse is providing home care instructions for a 13-year-old girl recently diagnosed with systemic lupus erythematosus. Which response by the girl indicates a need for further teaching? A) "I need to wear sunscreen in the summer to prevent rashes." B) "I need to eat a healthy diet, exercise, and get plenty of sleep." C) "I need an eye examination every year." D) "I need to be careful when it is cold; I should always wear gloves."

A

41. The school nurse has performed scoliosis screening. Based on this assessment, which children require the nurse to implement a referral to the healthcare provider? Select all that apply. A. The child with asymetric shoulder elevation B. The child with a limb length discrepancy C. The child with a lateral curve of the spine D. The child with a one-sided hump upon bending over E. The child who's sibling had scoliosis surgically corrected F. The child who has uneven balance

A, B, C, D

20.A nurse is developing a plan of care for a child who is admitted to the hospital for surgery. The child is visually impaired. What would be most appropriate for the nurse to include in the child's plan of care? Select all that apply. A) Explaining instructions using simple and specific terms the child understands B) Allowing the child to explore the postoperative equipment with his hands C) Touching the child on his shoulder before letting the child know someone is there D) Using the child's body parts to refer to the area where he may have postoperative pain E) Speaking to the child in a voice that is slightly louder than the usual tone of voice

A, B, D

23.A child is diagnosed with Kawasaki disease and is in the acute phase of the disorder. What would the nurse expect the healthcare provider to prescribe? Select all that apply. A) Intravenous immunoglobulin B) Ibuprofen C) Acetaminophen D) Aspirin E) Alprostadil

A, D

16.What would the nurse include when teaching parents how to prevent otitis externa? A) Daily ear cleaning with cotton swabs B) Wearing earplugs when swimming C) Using a hair dryer on high to dry the ear canals D) Using hydrogen peroxide to dry the canal skin

B

12. A child with diabetes reports that he is feeling a little shaky. Further assessment reveals that the child is coherent but with some slight tremors and sweating. A fingerstick blood glucose level is 70 mg/dL. What would the nurse do next? A) Administer a sliding-scale dose of insulin. B) Give 10 to 15 g of a simple carbohydrate. C) Offer a complex carbohydrate snack. D) Administer glucagon intramuscularly.

B

13. The nurse is assessing a newborn who was delivered after a prolonged labor due to an abnormal presentation. The newborn sustained a cranial nerve injury. The nurse would most likely expect to assess deficits related to which cranial nerve? A. Optic B. Facial C. Acoustic D. Trigeminal

B

10.The nurse is examining a 3-year-old boy with acute otitis media who has a mild earache and a temperature of 38.5°C. Which action will be taken? A) Obtain a culture of the middle ear fluid. B) Instruct the parents to watch for worsening symptoms. C) Administer antibiotics. D) Administer antivirals.

B

17. The nurse is describing the phases of treatment to a child who was diagnosed with leukemia and his parents. How would the nurse describe the induction stage? A) Intense therapy to strengthen remission B) Rapid promotion of complete remission C) Elimination of all residual leukemic cells D) Reduction of risk for central nervous system (CNS) disease

B

17.A nurse is reviewing the medical record of a child with hearing loss and notes that the child's hearing loss is in the range 40 to 60 decibels (dB). The nurse interprets this as indicating what level of hearing loss? A) Mild loss B) Moderate loss C) Severe loss D) Profound loss

B

21. A 5-year-old child with type 1 diabetes is brought to the clinic by his mother for a follow-up visit after having his hemoglobin A1C level drawn. Which result would indicate to the nurse that the child is achieving long-term glucose control? A) 9.0% B) 8.2% C) 7.3% D) 6.9%

B

22. A child is brought to the emergency department after sustaining a concussion. The child is to be discharged home with his parents. What would the nurse include in the child's discharge instructions? A. "Expect his headache to get worse initially and then disappear." B. "Wake him every 2 hours to check his movement and responses." C. "Call your medical provider if he vomits more than five times." D. "Any watery fluid draining from his ears is normal."

B

30. The nurse is assessing a child with a possible fracture. What would the nurse identify as the most reliable indicator? A. Lack of spontaneous movement B. Point tenderness C. Bruising D. Inability to bear weight

B

5. A nurse is caring for a 14-year-old girl following myelography. What is the priority nursing action? A. Monitoring for a decrease in spasticity B. Observing for signs of meningeal irritation C. Assessing motor function D. Observing for mental confusion or hallucinations

B

7.After teaching a group of students about acute rheumatic fever, the instructor determines that the teaching was successful when the students identify which assessment finding? A) Janeway lesions B) Jerky movements of the face and upper extremities C) Black lines D) Osler nodes

B

11.A nurse is examining a 7-year-old boy with hordeolum. Which would the nurse expect to find? A) Redness B) Scaling C) Pain D) Edema

C

14. A child with spastic cerebral palsy is to receive botulin toxin. The nurse prepares the child for administration of this drug by which route? A. Oral B. Subcutaneous injection C. Intramuscular injection D. Intravenous infusion

C

19.The nurse is reviewing the medical record of a child with infective endocarditis. What would the nurse expect to find? Select all that apply. A) White blood cell count revealing leukopenia B) Microscopic hematuria with urinalysis C) Electrocardiogram with prolonged PR interval D) Lungs clear on auscultation E) Petechiae on palpebral conjunctiva

B, C, E

38. When assessing a child for slipped capital femoral epiphysis, what would the nurse identify as possible risk factors? Select all that apply. A. Age younger than 8 years B. Black race C. History of cystic fibrosis D. Excessive activity E. Obesity

B, E

15. Which exercise would the nurse suggest as most helpful to maintain mobility in a child with juvenile idiopathic arthritis? A) Jogging every other day B) Using a treadmill C) Swimming D) Playing Basketball

C

19. The nurse is caring for an active 14-year-old boy who has recently been diagnosed with scoliosis. He is dismayed that a "jock" like himself could have this condition, and is afraid it will impact his spot on the water polo team. Which response by the nurse would best address the boy's concerns? A. "If you wear your brace properly, you may not need surgery." B. "The good news is that you have very minimal curvature of your spine." C. "Let's talk to another boy with scoliosis, who is winning trophies for his swim team." D. "Let's talk to the doctor about your treatment options."

C

21.A child with persistent otitis media with effusion is to undergo insertion of pressure-equalizing tubes via a myringotomy. The child is to be discharged later that day. After teaching the parents about caring for their child after discharge, which statement indicates that the teaching was successful? A) "The tubes will stay in place for about a month and then fall out on their own." B) "His chances for ear infections now have dramatically decreased." C) "He should wear earplugs when swimming in a pool or a lake." D) "We should keep the ears protected with cotton balls for the first 24 hours."

C

23. The nurse is administering 10 units of NPH insulin to a child at 8 AM. The nurse would expect this insulin to begin acting at which time? A) By 8:15 AM B) Between 8:30 and 9 AM C) Between 9 and 11 AM D) Around 12 noon

C

23. The nurse is caring for a 14-year-old client in traction prior to surgery. The client has been in the hospital for 2 weeks and will require an additional 10 days in the hospital following surgery. The client states, "I feel isolated and I am refusing any more treatment." Which response by the nurse is most appropriate? A. "I know it is boring here, but the best place for you to remain immobile is the hospital." B. "I will see if you can have friends come spend a few nights with you." C. "Let's come up with things for you to do and see if your friends can come visit." D. "If you refuse further treatment, your condition will only get worse."

C

24. The nurse is assessing a child with pauciarticular-type juvenile idiopathic arthritis. What would the nurse expect to assess? A)Fever B)Rash C) Eye inflammation D) Splenomegaly

C

27. The nurse is developing a teaching plan for a child who is to have his cast removed. What instruction would the nurse most likely include? A. Applying petroleum jelly to the dry skin B. Rubbing the skin vigorously to remove the dead skin C. Soaking the area in warm water every day D. Washing the skin with dilute peroxide and water

C

27.The parents of a 5-year-old bring their son to the emergency department because of significant eyelid edema. The mother states, "He scratched himself near his eye a couple of days ago while playing outside in the yard." The nurse suspects periorbital cellulitis based on which finding? A) Evidence of discharge B) Reddened conjunctiva C) Purplish discoloration of eyelid D) Altered visual acuity

C

29. The school nurse is presenting a class to a group of students about common overuse disorders. Which disorder would the school nurse include? A. Dislocated radial head B. Transient synovitis of the hip C. Osgood-Schlatter disease D. Scoliosis

C

30. A teenage girl diagnosed with polycystic ovary syndrome tells the nurse, "I refuse to take oral contraceptives since I am not sexually active." What is the best response to the girl? A) "It's important for you to take the pills even if you're not sexually active in order to prevent unwanted symptoms of the disease." B) "The healthcare provider has prescribed these for you because it is an effective treatment method for the disease." C) "I know it's hard remembering to take those pills every day. Tell me more about what is making you not want to take the oral contraceptives." D) "Do your parents know that you are not taking the treatment medication your healthcare provider prescribed?"

C

31. An 8-year-old boy with a fractured forearm is to have a fiberglass cast applied. What information would the nurse include when teaching the child about the cast? A. The cast will take a day or two to dry completely. B. The edges will be covered with a soft material to prevent irritation. C. The child initially may experience a very warm feeling inside the cast. D. The child will need to keep his arm down at his side for 48 hours.

C

31. The nurse is caring for a 13-year-old girl with von Willebrand disease. After teaching the adolescent and her parents about this disorder and care, which response by the parents indicates a need for additional teaching? A)"We need to administer Stimate prior to dental work." B)"We should be aware that she may suffer from menorrhagia." C)"We should administer desmopressin as often as needed." D)"We understand that she may have frequent nosebleeds."

C

38. The nurse is reviewing the laboratory test results of a child diagnosed with disseminated intravascular coagulation (DIC). What would the nurse interpret as indicative of this disorder? A) Shortened prothrombin time B) Increased fibrinogen level C) Positive fibrin split products D) Increased platelets

C

39. An 18-month-old was brought to the emergency department by her mother, who states, "I think she broke her arm." The child is sent for a radiograph to confirm the fracture. Additional assessment of the child leads the nurse to suspect possible child abuse. Which type of fracture would the radiograph most likely reveal? A. Plastic deformity B. Buckle fracture C. Spiral fracture D. Greenstick fracture

C

4.The nurse is caring for a 6-year-old visually impaired boy and is about to begin the physical examination. Which intervention would be most appropriate to promote effective communication with the child? A) Show him the stethoscope. B) Describe the examination room. C) Use his name before touching him. D) Allow him to explore the exam room.

C

8. The nurse is assessing a 13-year-old boy with type 2 diabetes mellitus. What would the nurse correlate with disorder? A) The parents report that their child had "a cold or flu" recently. B) Blood pressure is decreased when checking vital signs. C) The parents report that their son "can't drink enough water." D) Auscultation reveals Kussmaul breathing.

C

9.The nurse is taking a health history for a 9-year-old girl. Which finding would alert the nurse to a possible risk factor specifically associated with visual impairment? A) Being born at 39 weeks' gestation B) Having several hours of homework daily C) Being of African American heritage D) Being active in sports

C

25. A nurse is preparing a presentation for a group of parents of adolescents diagnosed with type 1 diabetes. What issues would the nurse need to address? Select all that apply. A) Self-monitoring of blood glucose levels B) Feelings of being different C) Deficient decision-making skills D) Body image conflicts E) Struggle for independence

C, D, E

24. The nurse suspects that a 4 year old with type 1 diabetes is experiencing hypoglycemia based on what findings? Select all that apply. A) Blurred vision B) Dry, flushed skin C) Diaphoresis D) Slurred speech E) Fruity breath odor F) Tachycardia

C, D, F

32. The nurse is caring for a child who has been admitted for a sickle cell crisis. What would the nurse do first to provide adequate pain management? A) Administer a nonsteroidal anti-inflammatory drug (NSAID) as ordered. B) Use guided imagery and therapeutic touch. C) Administer meperidine as ordered. D) Initiate pain assessment with a standardized pain scale.

D

33. The nurse is caring for a 2-year-old boy with hemophilia. His parents are upset by the possibility that he will become infected with hepatitis or HIV from the clotting factor replacement therapy. Which response by the nurse would be most appropriate? A) "Parents commonly fear the worst; however, the factor will help your child lead a normal life." B) "There are risks with any treatment including using blood products, but these are very minor." C) "Although factor replacement is expensive, there's more financial strain from missing work if he has a bleeding episode." D) "Since dry heat treatment of the factor began in 1986, there have been no reports of virus transmission."

D

35. A group of nursing students are reviewing information about types of skin traction and skeletal traction. The students demonstrate understanding of this information when they identify which of these as a type of skeletal traction? A. Russell traction B. Bryant traction C. Buck traction D. Side arm 90-90 traction

D

6. A child is diagnosed with juvenile idiopathic arthritis and is receiving several different medications listed in the medication administration record. Which agent would the nurse identify as being used to prevent disease progression? A) Aspirin B) Prednisone C) Ibuprofen D) Methotrexate

D

6.The nurse is caring for a 3-year-old boy with amblyopia. Which intervention would be most appropriate to include in the child's plan of care? A) Rinsing the eye with cool water B) Educating the family about the disease C) Encouraging frequent hand washing D) Promoting eye safety

D

23. The nurse is assessing a 5-year-old child's genitourinary system. Which findings would the nurse document as normal? Select all that apply. A. Labial fusion B. Round abdomen C. Positive bowel sounds D. Dullness over the spleen E. Undescended testicles

B, C, D

29. A child is hospitalized with acute poststreptococcal glomerulonephritis. What assessments should the nurse include in the plan of care for this child?? Select all that apply. A. Assess level of consciousness B. Assess pain C. Monitor blood pressure D. Auscultate lung sounds E. Inspect the urine

B, C, D, E

1. The nurse is caring for a neonate who is suspected of having sepsis. Which assessment findings would the nurse interpret as most indicative of sepsis? A. Rash on face B. Edematous neck C. Hypothermia D. Coughing

C

11. A nurse is assessing a preterm newborn. Which finding would alert the nurse to suspect that a preterm newborn is in pain? A. bradycardia B. oxygen saturation level of 94% C. decreased muscle tone D. sudden high-pitched cry

D