PEDS FINAL

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

Answer: 1 Explanation: 1. 0.9% normal saline (NS) is an isotonic fluid and maintains Na and chloride at present levels. 2. D5 0.2% (¼) normal saline would not be used initially but later, as maintenance fluids. 3. D5W can lower sodium levels, and so it would not be used to replace fluids in severe isotonic dehydration. 4. Albumin is used to restore plasma proteins.

1) Which pediatric client will the community health nurse assess first? 1. A 6-year-old who is wheezing and short of breath. 2. A 2-year-old who has been pulling at his ear. 3. A 2-month-old with a 2-day history of diarrhea. 4. A 10-year-old with a sore throat and low-grade fever.

Answer: 1 Explanation: 1. A child who has symptoms of respiratory distress should be seen right away. 2. While the 2-year-old is exhibiting symptoms of an ear infection and needs to be seen, however, this is not the priority client for assessment. 3. While the 2-month-old with a 2-day history of diarrhea needs to be seen, this is not the priority client for assessment. 4. While a 10-year-old with a sore throat and low-grade fever need to be seen, this is not the priority client for assessment.

7) A nurse is planning care for a child with hyponatremia. The nurse, delegating care of this child to a licensed vocational nurse (LVN), cautions the LVN to immediately report which clinical manifestation? 1. Seizures 2. Respiratory distress 3. Hyperthermia 4. Bradycardia

Answer: 1 Explanation: 1. A child with hyponatremia is at risk for seizures. 2. Respiratory distress is not a risk of hyponatremia. 3. Hyperthermia is not a risk of hyponatremia. 4. Bradycardia is not a risk of hyponatremia.

14) Which athletic activity should the nurse recommend for a school-age child who is diagnosed with pulmonary artery hypertension? 1. Golf 2. Basketball 3. Cross-country running 4. Soccer

Answer: 1 Explanation: 1. A child with pulmonary artery hypertension should have exercise tailored to avoid dyspnea, such as golf. 2. Soccer, basketball, and cross-country running are all aerobic activities requiring heavy exertion. 3. Soccer, basketball, and cross-country running are all aerobic activities requiring heavy exertion. 4. Soccer, basketball, and cross-country running are all aerobic activities requiring heavy exertion.

5) In the morning, a nurse receives change-of-shift report on four pediatric clients, each of whom has some form of fluid-volume excess. Which of the children should the nurse see first? 1. The child with tachypnea and pulmonary congestion 2. The child with hepatomegaly and normal respiratory rate 3. The child with dependent and sacral edema and regular pulse 4. The child with periorbital edema and normal respiratory rate

Answer: 1 Explanation: 1. A child with respiratory distress should be the first client the nurse checks after receiving a report. 2. The child with hepatomegaly and normal respiratory rate is more stable than the child with tachypnea and pulmonary congestion. 3. The child with dependent and sacral edema and regular pulse is more stable than the child with tachypnea and pulmonary congestion. 4. The child with periorbital edema and normal respiratory rate is more stable than the child with tachypnea and pulmonary congestion.

9) A child diagnosed with hemophilia presents to the emergency department (ED) with multiple injuries following a motor vehicle crash. Which injury is the priority when conducting the nursing assessment? 1. Occipital hematoma 2. Radial fracture 3. Dislocated shoulder 4. Abdominal abrasions

Answer: 1 Explanation: 1. A potential intracranial bleed would receive highest priority because of the danger of increased intracranial pressure and potential neurologic damage. 2. Although at risk for bleeding, this would not take priority over a head injury. 3. A dislocation is not at high risk for bleeding or tissue ischemia. 4. Although at risk for bleeding, this would not take priority over a head injury.

1) The nurse is providing care to a pediatric client who is experiencing separation anxiety. Which data would support the documentation of the "despair" phase? 1. Lies quietly in bed. 2. Does not cry if his parents return and leave again. 3. Appears to be happy and content with staff. 4. Screams and cries when his parents leave.

Answer: 1 Explanation: 1. Children in the "despair" stage appear sad, depressed, or withdrawn. A child who is lying in bed might be exhibiting any of these. 2. 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 his parents return and leave again. 3. 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 his parents return and leave again. 4. Screaming and crying are components of the "protest" stage.

12) A child is admitted to the hospital for hypercalcemia and is placed on diuretic therapy. Which diuretic would the nurse expect to give? 1. Furosemide (Lasix) 2. Hydrochlorothiazide (Aquazide) 3. Spironolactone (Aldactone) 4. Mannitol (Osmitrol)

Answer: 1 Explanation: 1. Furosemide (Lasix) is the diuretic used to aid in excretion of calcium. 2. Thiazide diuretics (like hydrochlorothiazide) decrease calcium excretion and should not be given to the hypercalcemic client. 3. Spironolactone (Aldactone) is a potassium-sparing diuretic. While there is a net increase in calcium in the urine, it is not as effective an option as furosemide. 4. Mannitol (Osmitrol) is a diuretic used to decrease cerebral edema and is not routinely used to aid in excretion of calcium.

8) A child is prescribed oral corticosteroid for a rash caused by graft-versus-host disease. Which should the nurse monitor the child for after administering the drug? 1. Hyperglycemia 2. Hepatic toxicity 3. Seizures 4. Renal toxicity

Answer: 1 Explanation: 1. Hyperglycemia is a side effect of steroid therapy. 2. Hepatic toxicity is not a side effect associated with steroid therapy. 3. Seizures are not a side effect associated with steroid therapy. 4. Renal toxicity is not a side effect associated with steroid therapy.

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

Answer: 1 Explanation: 1. If a child with hemophilia experiences a bleeding episode, superficial bleeding should be controlled by applying pressure to the wound. 2. Heat would increase the bleeding by dilating the superficial blood vessels. A cool compress should be applied. 3. The extremity should be immobilized to prevent further bleeding; passive range-of-motion could cause further bleeding at the site. 4. The extremity should be elevated, if possible, to prevent swelling at the site.

16) Which is the priority nursing action when preparing a neonate born with a gastroschisis defect for transport to a pediatric hospital for corrective surgery? 1. Covering the exposed intestines with sterile moist gauze 2. Wrapping the newborn warmly in two or three blankets 3. Providing a sterile water feeding to maintain hydration during transport 4. Allowing the parents of the newborn to see their child prior to transport

Answer: 1 Explanation: 1. It is important to keep the intestine from drying during transport. 2. Placement in a transport isolette would be preferred to wrapping due to the nature of the birth defect. 3. The newborn should be NPO. 4. While it is important for the parents to see their child before transport, this is not the priority nursing intervention.

1) The nurse prepares to administer a vitamin K injection during the admission assessment for a newborn. The father asks, "Why does my baby need a shot?" Which rationale for administering this injection should the nurse include in the response? 1. Activates clotting factors 2. Dissolves blood clots 3. Promotes gas exchange 4. Promotes the production of hemoglobin

Answer: 1 Explanation: 1. Levels of clotting factors are lower in infants, so vitamin K is given prophylactically to activate essential clotting factors. 2. Vitamin K promotes clotting; it is not administered to dissolve blood clots. 3. Vitamin K does not promote gas exchange. 4. Vitamin K has no effect on the production of hemoglobin.

4) A preschool-age child is admitted to the hospital with acute postinfectious glomerulonephritis (APIGN) and is admitted to the hospital. Which is the priority nursing diagnosis for this child? 1. Risk for Injury related to hypertension. 2. Altered Growth and Development related to a chronic disease. 3. Risk for Infection related to hypertension. 4. Fluid Volume Excess related to decreased plasma filtration

Answer: 1 Explanation: 1. The child with APIGN has marked hypertension, which can lead to cardiac failure and cerebral injuries. 2. Growth and development are not normally affected because this is an acute process, not a chronic one. 3. While a risk for infection might be present, it is not related to the hypertension. 4. Although fluid retention occurs, this is not the priority diagnosis.

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

Answer: 1 Explanation: 1. The child with acute postoperative pain takes shallow breaths and suppresses coughing to avoid more pain. These self-protective actions increase the potential for respiratory complications. 2. Uncontrolled pain does not usually lead to urinary complications. 3. Uncontrolled pain does not lead to cardiac complications. 4. Uncontrolled pain does not frequently lead to bowel complications.

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

Answer: 1 Explanation: 1. The child with sickle-cell disease is at risk for infection, and dehydration can precipitate crisis. 2. High altitudes with lower oxygen concentrations pose a risk; mid-altitude is not a risk factor. 3. Weight loss is acceptable as long as hydration is maintained. 4. Hydration should be encouraged; risk of overhydration is minimal.

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

Answer: 1 Explanation: 1. The first sign of retinoblastoma is a white pupil. The red reflex is absent. This is known as leukocoria, or "cat's eye" reflex. 2. Blue-tinged sclerae are a sign of osteogenesis imperfecta, not retinoblastoma. 3. Red reflex is absent in retinoblastoma. 4. Yellow sclerae are a sign of jaundice, not retinoblastoma.

6) The nurse is caring for a child on bed rest who has severe edema in a left lower extremity due to blocked lymphatic drainage. Which nursing diagnosis would take priority? 1. Risk for Impaired Skin Integrity 2. Risk for Altered Body Image 3. Risk for Imbalanced Nutrition: Less Than Body Requirements 4. Risk for Activity Intolerance

Answer: 1 Explanation: 1. The highest priority problem is skin integrity. 2. Body image would not take priority over the integrity of the skin for this scenario. 3. Nutrition would not take priority over the integrity of the skin for this scenario. 4. Activity intolerance would not take priority over the integrity of the skin for this scenario.

19) Which parental statement indicates correct understanding for the reason a cardiac catheterization is needed for a child who is diagnosed with a congenital heart defect? 1. "This procedure will keep the ductus arteriosus open and oxygenated and unoxygenated blood mixed." 2. "This procedure is used to close the ductus arteriosus to prevent mixing of arterial and venous blood." 3. "This procedure will redirect the blood so that blood bypasses the right ventricle." 4. "This procedure connects the ventricle to the atrium."

Answer: 1 Explanation: 1. This statement is accurate. 2. A stent maintains an opening; it does not close an opening. 3. A stent maintains the ductus as patent. It does not bypass the ventricle. 4. This is not the purpose of the stent.

12) The nurse is unsuccessful in inserting a nasogastric tube for a newborn client. The nurse suspects the newborn has esophageal atresia/tracheoesophageal (EA/TE) fistula. Which nursing action is appropriate while waiting for the healthcare provider to further assess the neonate? 1. Position the newborn in semi-Fowler position. 2. Allow the newborn to be taken to the mother's room for bonding. 3. Offer the newborn formula feeding instead of breastfeeding. 4. Wrap the newborn in blankets and place in a crib by the viewing window.

Answer: 1 Explanation: 1. This will reduce stomach juices from being aspirated into the lungs. 2. Because an anomaly is suspected, the newborn should remain under visualization until the diagnosis is confirmed and medical orders determined. 3. If an EA/TE fistula is suspected, the feeding should be withheld until the diagnosis is confirmed or cleared. 4. A newborn wrapped in blankets cannot be observed clearly. The child should be placed in an over-bed warmer.

3) A toddler-age client presents to the emergency department with a sore throat and difficulty swallowing. The nurse suspects acute epiglottitis. Which nursing action is avoided based on the current assessment data? 1. Throat culture 2. Medical history 3. Vital signs 4. Auscultation of breath sounds

Answer: 1 Explanation: 1. Throat cultures should never be done when a diagnosis of epiglottis is suspected. Manipulation of the throat can stimulate the gag reflex in an already inflamed airway and can cause complete occlusion of the airway. 2. Medical history should be obtained, which assists in diagnosis. 3. Vital signs should always be taken when assessment is done. 4. Assessment of breath sounds is essential for diagnosis.

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

Answer: 1 Explanation: 1. Toxoids are chemicals normally associated with a disease that stimulate the production of immunity. A tetanus immunization is an example of a toxoid vaccine. 2. A live virus vaccine contains a microorganism that is live but attenuated, or in a weakened form. A varicella immunization is an example of a live virus vaccine. 3. A killed virus vaccine contains a microorganism that has been killed but is still capable of causing the human body to produce antibodies. This term is used to describe an inactivated poliovirus vaccine. 4. A recombinant vaccine used a genetically altered organism. A hepatitis B immunization is an example of this type vaccine.

7) A high school student calls to ask the nurse for advice on how to care for a new navel piercing. Which response by the nurse is appropriate? 1. "Avoid contact with another person's bodily fluids until the area is well healed." 2. "Do not move or turn the jewelry for the first 3 days." 3. "Apply lotion to the area, rubbing gently, to prevent skin from becoming dry and irritated." 4. "Apply warm soaks to the area for the first 2 days to minimize swelling."

Answer: 1 Explanation: 1. Until the piercing has healed, it is a nonintact area of skin that has potential for infection, especially from contact with bodily fluids from someone else. 2. The jewelry needs to be gently rotated several times per day to aid with healing. 3. Lotion can provide a medium for bacteria, and rubbing at the site can cause irritation to the area. 4. Ice, not warm soaks, should be applied to the area for the first two days to minimize the swelling

12) Which should the nurse use when reconstituting vaccines? 1. The diluents provided 2. Normal saline 3. Any solution available 4. Sterile water

Answer: 1 Explanation: 1. When reconstituting vaccines, it is important to use the solution provided and follow the manufacturer's directions. 2. Not all medications are compatible with normal saline. 3. Only use what is suggested by the manufacturer. 4. Unless otherwise suggested, use what is suggested by the manufacturer. Page Ref: 1056-1059

7) Which nursing intervention is contraindicated for a pediatric client who is experiencing thrombocytopenia secondary to chemotherapy treatments? 1. Administering intramuscular injections 2. Monitoring intake and output 3. Palpating during the assessment 4. Providing oral hygiene

Answer: 1 Explanation: 1. When the child is thrombocytopenic (decreased platelets) from chemotherapy, the nurse should not administer intramuscular injections because of the risk of bleeding. 2. Monitoring intake and output is not contraindicated for a pediatric client who is experiencing thrombocytopenia as a result of chemotherapy treatments. 3. Palpation during the assessment is not contraindicated due to thrombocytopenia. This action is contraindicated for a child who is diagnosed with Wilms tumor. 4. Providing oral hygiene is not contraindicated for a pediatric client who is experiencing thrombocytopenia as a result of chemotherapy treatments.

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

Answer: 1 Explanation: 1. Many hospitals now allow parents to be present with their child during and after procedures. Parents often want to support their child, and their presence offers reassurance and comfort to the child. 2. When parents ask to be present for a procedure, they are doing so to be available to comfort the child, not to control the procedural outcome. 3. Parents might be in the medical field, but their primary concern is to comfort their child during the procedure. 4. The parents' first concern is to comfort their child, not supervising the nursing staff.

2) The nurse is providing care to several hospitalized pediatric clients. Which child has the greatest risk for a developmental disability? 1. An 18-month-old admitted with a diagnosis of near drowning 2. A school-age child newly diagnosed with type 1 diabetes mellitus 3. An toddler with sepsis 4. A 2-year-old child with a fractured femur

Answer: 1 Explanation: 1. Near drowning indicates a period of time when the child was underwater and not breathing; near drowning can leave a child with a permanent chronic condition. 2. Diabetes is a chronic disease but does not lead to developmental disabilities. 3. Sepsis is treatable and will not result in a developmental disability. 4. A fractured femur is limiting to a child but will not leave the child with a chronic, limiting condition.

1) Which clinical manifestations should the nurse anticipate when assessing a child who has been admitted to the hospital unit with a diagnosis of minimal change nephrotic syndrome (MCNS)? 1. Massive proteinuria, hypoalbuminemia, and edema 2. Hematuria, bacteriuria, and weight gain 3. Urine specific gravity decreased and urinary output increased 4. Gross hematuria, albuminuria, and fever

Answer: 1 Explanation: 1. Nephrotic syndrome is an alteration in kidney function secondary to increased glomerular basement membrane permeability to plasma protein. It is characterized by massive proteinuria, hypoalbuminemia, and edema. 2. Bacteriuria and fever are associated with a urinary tract infection. Because of the edema, a weight gain, not a weight loss, would be seen. 3. In MCNS, the urine output decreases and the specific gravity of urine increases. 4. Gross hematuria and hypertension are associated with glomerulonephritis.

1) A parent of a newborn asks the nurse why young children seem to become ill so often when compared with older children and adults. Which is the best response by the nurse? 1. "Newborns have lower numbers of natural killer cells." 2. "Newborns have high levels of IgA in their systems." 3. "Newborns are lacking lymphoid tissue." 4. "Newborns have an immature thymus gland."

Answer: 1 Explanation: 1. Newborns have lower numbers of natural killer cells than do older children and adults, decreasing their ability to respond to certain antigens. 2. IgA is not present at birth. Development of IgA begins at 2 weeks of age but does not reach adult levels until the age of 6. 3. Lymphoid tissue, such as the spleen and tonsils, is present at birth. 4. The thymus is large at birth and grows during childhood, decreasing by adulthood.

6) A newborn diagnosed with an omphalocele defect is admitted to the intensive care nursery. Which nursing action is appropriate based on the current data? 1. Placing the newborn on a radiant warmer 2. Placing the newborn in an open crib 3. Preparing the newborn for phototherapy 4. Preparing the newborn for a bottlefeeding

Answer: 1 Explanation: 1. Omphalocele is a congenital malformation in which intra-abdominal contents herniate through the umbilical cord. The newborn loses heat through the viscera; a warmer is indicated to prevent hypothermia. 2. The crib would not provide adequate maintenance of temperature control. 3. Phototherapy is used to treat hyperbilirubinemia, not an omphalocele defect. 4. The newborn will require surgical correction of the defect prior to initiating bottle or breast feeding.

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

Answer: 1 Explanation: 1. PCA is most appropriate in children 5 years old and older. Children must be able to press the button and understand that they will receive pain medicine by pushing the button. 2. Children who have suffered head trauma would not be candidates for PCA. 3. PCA generally is prescribed for clients who will be hospitalized for at least 48 hours. 4. Children who are developmentally delayed would not be candidates for PCA

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

Answer: 1 Explanation: 1. Physical complaints, suicidal thoughts, and other problems can result from bullying. 2. Sexual abuse should be suspected if the child is experiencing vaginal discharge or excessive sexual curiosity for age. 3. Lead poisoning can lead to physical symptoms, including neurologic deficits, but would not include the signs of emotional distress that the child is exhibiting. 4. Drug abuse is more likely to occur in an adolescent than a child of this age.

11) A 6-year-old child is hypokalemic. Which menu choice should the nurse encourage for this child? 1. Pizza with a fruit plate 2. Chicken strips with chips 3. Fajita with rice 4. A hamburger with French fries

Answer: 1 Explanation: 1. Pizza with a fruit plate should be encouraged because fruits (bananas, apricots, cantaloupe, cherries, peaches, and strawberries) have high amounts of potassium, and a child is likely to eat this combination. 2. Chicken strips and chips are not good sources of potassium. 3. The nurse is looking for potassium-rich foods that are attractive to children. This choice does not meet the requirement. 4. A hamburger and French fries do not provide potassium.

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

Answer: 1 Explanation: 1. Preschoolers engage in magical thinking, and might believe they wished or caused the death of their parents. 2. Preschoolers do not have a concept of death as permanent; therefore, they might expect their parents to return home. 3. Preschoolers engage in magical thinking, and might believe they wished or caused the death of their parents. 4. Preschoolers do not have a concept of death as permanent; therefore, they might expect their parents to return home.

23) A school-age client is diagnosed with rheumatic fever. Which parental statement indicates the need for further education by the nurse? 1. "I understand rheumatic fever is a strep infection of the heart." 2. "My child will be on bed rest for several weeks." 3. "My child will be treated with aspirin and/or corticosteroids." 4. "Once my child has recovered, she will still need to be monitored for sequelae to the disease."

Answer: 1 Explanation: 1. Rheumatic fever is not a strep infection of the heart but an autoimmune connective tissue disease in response to a previous strep infection. This statement requires clarification. 2. This statement is correct. No further clarification is needed. 3. This statement is correct and needs no clarification. 4. Children who have had one episode of rheumatic fever are at greater risk for future episodes. In addition, long-term valve damage may occur. This statement needs no further clarification.

18) The school nurse recognizes that many adolescents who are currently pregnant are hiding their pregnancies from adults, both at school and at home. Which should the nurse educate the adolescents about based on the current data? 1. Safe haven laws 2. Birth control available to all teenagers 3. Domestic abuse protection 4. The father's financial responsibility for the infant

Answer: 1 Explanation: 1. Safe haven laws provide for unwanted babies to be left in certain locations without legal repercussions to the mother. 2. A pregnant teenager does not need to know about birth control at this time. 3. This is not the primary information that needs to be given to pregnant teenagers. 4. Most teenagers are aware that the fathers are financially responsible. This is not information that is needed now.

19) Which nursing action is most appropriate to decrease the risk of transmitting viral infections by clients and family members at a local clinic? 1. Sanitizing toys, telephones, and doorknobs to kill pathogens 2. Teaching parents safe food preparation and storage 3. Withholding immunizations for children with compromised immune systems 4. Allowing all children to congregate in the same waiting room

Answer: 1 Explanation: 1. Sanitizing toys and all contact surfaces, separating children with infections, and teaching children to wash their hands all control the growth and spread of microorganisms. 2. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms, but it is not related to the flu virus. 3. Immunizations should not be withheld from immunocompromised children, and this is not an infection-control strategy. 4. Children should be separated in different waiting rooms when seeking care at a pediatric clinic.

9) A 10-year-old child is transported to the emergency department (ED) by ambulance from the scene of a motor vehicle crash. The child is alert and oriented ×3; pulse, respirations, and blood pressure are stable; neck and back are immobilized on a backboard. The nurse sees no obvious bleeding. The child states," I can't move or feel my legs." Which injury does the nurse suspect based on the current data? 1. Spinal cord injury 2. Traumatic shock 3. Traumatic brain injury 4. Ruptured spleen

Answer: 1 Explanation: 1. Spinal cord injury results in paralysis and anesthesia of the affected body parts below the level of the lesion. 2. Traumatic shock results in initially increasing then decreasing pulse and respirations and falling blood pressure. 3. Altered levels of consciousness could indicate traumatic brain injury. 4. The child might have a ruptured spleen, but it is not evident from the data given in this scenario.

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

Answer: 1 Explanation: 1. Tachycardia is a sign of congestive heart failure because the heart attempts to improve cardiac output by beating faster. 2. The weight, instead of decreasing, increases, because of retention of fluids. 3. Blood pressure does not increase in CHF. 4. Bradycardia is a serious sign and can indicate impending cardiac arrest.

22) A child is admitted to the pediatric medical unit with a diagnosis of Kawasaki disease. Which provider prescription should the nurse question? 1. Contact isolation 2. Oral aspirin every 8 hours 3. Echocardiogram 4. Vital signs every 4 hours

Answer: 1 Explanation: 1. The child is not contagious so contact isolation is not appropriate. 2. Aspirin is used as an anti-inflammatory and is prescribed around the clock. This is appropriate. 3. This examination will be used as a baseline to compare against as the child recovers to assist in monitoring for cardiac lesions. 4. The child will need close monitoring during the early period of the disease.

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

Answer: 1 Explanation: 1. The child should be allowed to cry or scream during the procedure. 2. The treatment room should be utilized for the procedure so that the hospital bed remains a safe place. 3. The nurse should avoid giving the child a choice if there is no choice. 4. While the toddler will need to be restrained, the parent should not be the one to do this.

10) A child returns from exploratory surgery following a gunshot wound to the abdomen. Which nursing intervention should be excluded for the plan of care? 1. Immediate initiation of oral feedings 2. Assessment of the surgical site 3. Administration of opioid narcotics for pain management 4. Visitation at the bedside

Answer: 1 Explanation: 1. The child will be NPO after an exploratory abdominal surgery. The nurse should exclude this from the child's plan of care. 2. The surgical site must be visualized frequently for bleeding. 3. Pain management is essential and opioid analgesics are often necessary after exploratory surgery. 4. This describes family-centered care; parents should be involved as much as possible and should be present before the child wakes up.

19) Which nursing actions are appropriate when providing care to a pediatric client who has sustained a smoke-inhalation injury? Select all that apply. 1. Assessing for respiratory distress 2. Auscultating the lungs for wheezing 3. Prescribing oxygen for low saturations 4. Administering prescribed prophylactic antibiotic therapy 5. Providing support to the family

Answer: 1, 2, 5 Explanation: 1. A pediatric client who sustained a smoke-inhalation injury is at risk for respiratory distress; therefore, it is appropriate for the nurse to assess this patient for clinical manifestations associated with the phenomenon. 2. Crackles and wheezing are both complications associated with a smoke-inhalation injury. This nursing action is appropriate. 3. It is outside the scope of nursing practice to prescribe oxygen therapy for a pediatric client. The nurse would, however, administer prescribed oxygen for this client. 4. Prophylactic antibiotic therapy is not included in the treatment plan for a pediatric client who sustained a smoke-inhalation injury. 5. The nurse should provide support to the family of a pediatric client who sustained a smoke-inhalation injury.

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

Answer: 1, 2, 5 Explanation: 1. A toxoid is not an organism but a chemical produced by the organism. The toxoid has been treated to weaken its toxic effect. 2. The immunization contains organisms that are dead and incapable of reproducing. 3. This immunization contains live but weakened organisms. These organisms can mutate and reproduce and may cause disease in a weakened immune system. 4. An attenuated vaccine is the same as a live virus vaccine. 5. Immunoglobulins are the antibodies produced by others against a disease. They do not contain the live or killed virus.

19) Which pediatric client diagnoses necessitate close monitoring for respiratory acidosis? Select all that apply. 1. Aspiration 2. Epiglottitis 3. Sepsis 4. Meningitis 5. Cystic fibrosis

Answer: 1, 2, 5 Explanation: 1. Aspiration places the pediatric client at risk for respiratory acidosis. 2. Epiglottitis places the pediatric client at risk for respiratory acidosis. 3. Sepsis places the pediatric client at risk for respiratory alkalosis. 4. Meningitis places the pediatric client at risk for respiratory alkalosis. 5. Cystic fibrosis places the pediatric client at risk for respiratory acidosis.

15) The mother of a child admitted after a motor vehicle accident expresses concern about caring for the child's wounds at home. The mother has demonstrated appropriate technique with medication administration and wound care. Which is the priority nursing diagnosis? 1. Parental Anxiety related to care of the child at home 2. Altered Family Processes related to hospitalization 3. Risk for Infection for related to presence of healing wounds 4. Knowledge Deficit related to home care

Answer: 1 Explanation: 1. 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. 2. The child is being discharged, so this is not the priority diagnosis. 3. The mother has shown appropriate care of the wounds, decreasing the likelihood of infection, so this diagnosis is not the priority. 4. The mother has exhibited correct technique, so this is not the priority diagnosis.

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

Answer: 1 Explanation: 1. Planning a time to visit when the child is most comfortable will be best for the client and the siblings. 2. Unless hospital policy prevents visitation by younger children, they should be allowed to visit. 3. Children should be prepared for a visit, but visits should be allowed. Children who cannot visit often imagine the situation is worse than it is. 4. All children may carry germs. Children should be assessed for signs of infection, but if they are free of symptoms, they should be allowed to visit.

26) Which functions of red blood cells (RBCs) should the nurse include in a teaching session for the family of a pediatric client who is diagnosed with anemia? Select all that apply. 1. Carry oxygen from the lungs to the tissues 2. Return carbon dioxide from the tissues to the lungs 3. Assist the body to fight infection 4. Assist the body to fight allergens 5. Form hemostatic plugs to stop bleeding

Answer: 1, 2 Explanation: 1. A function of RBCs is to carry oxygen from the lungs to the tissues. 2. A function of RBCs is to return carbon dioxide from the tissues to the lungs. 3. A function of the white blood cells, not the RBCs, is to fight infection. 4. A function of the white blood cells, not the RBCs, is to fight allergens. 5. A function of platelets, not RBCs, is to form hemostatic plugs to stop bleeding.

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

Answer: 1, 2 Explanation: 1. Compassionate Friends is a support group the nurse should include in a bereavement package for a family who suddenly lost a child in a motor vehicle crash. 2. First Candle is a support group the nurse should include in a bereavement package for a family who suddenly lost a child in a motor vehicle crash. 3. Al Anon is a support group appropriate for the family of an alcoholic client. 4. Infant Loss Support is an appropriate support group to provide to a family who has suffered the loss of a newborn or infant. 5. Rachel's Vineyard is a support group that assists those grieving due to loss via abortion.

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

Answer: 1, 2 Explanation: 1. Hypnosis is a complementary intervention that is appropriate for the nurse to include in the plan of care for a pediatric client who is experiencing chronic pain. 2. Guided imagery is a complementary intervention that is appropriate for the nurse to include in the plan of care for a pediatric client who is experiencing chronic pain. 3. PCA is not a complementary pain management therapy. 4. Fentanyl patch is not a complementary pain management therapy. 5. EMLA cream is not a complementary pain management therapy.

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

Answer: 1, 2 Explanation: 1. In order to report pain, the child needs adequate verbalization skills to communicate to the nurse. 2. The child who understands more or less can be given a three-option pain scale. The child who cannot understand more or less may need a behavioral pain scale. 3. The assessment does not require the child to sit still. 4. Children perceive pain. The issue is if the nurse can recognize the child's pain. 5. Children do not need to understand pain in order to feel pain.

30) Which injury prevention topics should the nurse include in the plan of care for a pediatric client who has received hematopoietic stem cell transplantation (HSCT)? Select all that apply. 1. Medication storage strategies 2. Needle and syringe disposal 3. Immunization schedule 4. Yearly influenza vaccination 5. Routine dental appointments

Answer: 1, 2 Explanation: 1. Medication storage strategies is a topic the nurse should include in the plan of care related to injury prevention strategies. 2. Needle and syringe disposal is an area the nurse should include in the plan of care related to injury prevention strategies. 3. An altered immunization schedule is a topic related to infection, not injury, prevention. 4. Yearly influenza vaccination is a topic related to infection, not injury, prevention. 5. Routine dental appointments are an important topic to include regarding oral health, not injury prevention.

25) The nurse is providing care to a pediatric client who is homeless. Which nursing actions will decrease the risk for the child developing an infectious disease? Select all that apply. 1. Teaching hygienic methods 2. Arranging for medications, as needed 3. Evaluating the family for food security 4. Performing a nutritional assessment 5. Teaching oral hygiene

Answer: 1, 2 Explanation: 1. Teaching hygienic measures is an appropriate nursing action to decrease the child's risk for developing an infectious disease. 2. Arranging for medications, as needed, is an appropriate nursing action to decrease the child's risk for developing an infectious disease. 3. Evaluating the family for food security is an appropriate nursing action to assess nutritional deficits. 4. Performing a nutritional assessment is an appropriate nursing action to assess nutritional deficits. 5. Teaching oral hygiene is an appropriate nursing action to address dental care problems.

26) The nurse provides care to pediatric clients with chronic disease process. Which diagnoses does the nurse categorize as dependent on medications or special diets? Select all that apply. 1. Diabetes mellitus 2. Epilepsy 3. Celiac disease 4. Down syndrome 5. Traumatic brain injury

Answer: 1, 2, 3 Explanation: 1. A child who is diagnosed with diabetes mellitus is categorized as dependent on medications or special diets. 2. A child who is diagnosed with epilepsy is categorized as dependent on medications or special diets. 3. A child who is diagnosed with celiac disease is categorized as dependent on medications or special diets. 4. A child who is diagnosed with Down syndrome is categorized as having functional limitations. 5. A child who is diagnosed with a traumatic brain injury is categorized as having functional limitations.

22) Which clinical manifestations should the nurse anticipate when providing care to a pediatric client who huffing glue? Select all that apply. 1. Impaired coordination 2. Elevated liver enzymes 3. Delirium 4. Dementia 5. Giddiness

Answer: 1, 2, 3 Explanation: 1. Impaired coordination is a clinical manifestation that the nurse anticipates for a client who abuses volatile inhalants, such as glue. 2. Elevated liver enzymes are a clinical manifestation that the nurse anticipates for a client who abuses volatile inhalants, such as glue. 3. Delirium is a clinical manifestation that the nurse anticipates for a client who abuses volatile inhalants, such as glue. 4. Dementia is not a clinical manifestation that the nurse anticipates for a client who abuses volatile inhalants, such as glue. 5. Giddiness is not a clinical manifestation that the nurse anticipates for a client who abuses volatile inhalants, such as glue.

27) The nurse provides care to pediatric clients with chronic disease process. Which diagnoses does the nurse categorize as needing increased use of healthcare services? Select all that apply. 1. Cancer 2. Sickle cell disease 3. Renal failure 4. Cystic fibrosis 5. Autism spectrum disorder

Answer: 1, 2, 4 Explanation: 1. A child who is diagnosed with cancer is categorized as needing increased use of healthcare services. 2. A child who is diagnosed with sickle cell disease is categorized as needing increased use of healthcare services. 3. A child who is diagnosed with renal failure is categorized as being dependent on medical technology. 4. A child who is diagnosed with cystic fibrosis is categorized as needing increased use of healthcare services. 5. A child who is diagnosed with autism spectrum disorder is categorized as having functional limitations.

20) Which feeding techniques should the nurse include in the teaching session for the parents of an infant who is being discharged in order to gain weight for the corrective surgery needed for a congenital heart defect? Select all that apply. 1. Breastfeed if possible. 2. Complete each feeding within 30 minutes. 3. Position the infant flat to promote swallowing. 4. Dilute the formula with extra water to ensure adequate fluid intake. 5. Burp the infant frequently

Answer: 1, 2, 5 Explanation: 1. Breastfeeding is recommended because it provides antibodies to help protect the infant from infection. 2. Allowing the infant to nurse for more than 30 minutes will burn more calories than calories are gained. 3. The infant should be positioned at a 45-degree angle to reduce the workload of the heart. 4. The formula should not be diluted beyond the label recommendations, as it would lower the caloric count. 5. This is appropriate for the infant with a congenital heart defect as well as the normal infant.

28) Which communicable diseases, preventable through childhood immunization, should the nurse include in a presentation to families at a local community center wellness fair? (Select all that apply.) 1. Measles 2. Chickenpox 3. Fifth disease 4. Mononucleosis 5. Whooping cough

Answer: 1, 2, 5 Explanation: 1. Measles is a communicable disease that can be prevented through childhood immunization. 2. Chickenpox is a communicable disease that can be prevented through childhood immunization. 3. Fifth disease, while a communicable disease, is not preventable through childhood immunization. 4. Mononucleosis, while a communicable disease, is not preventable through childhood immunization. 5. Whooping cough, or pertussis, is a communicable disease that can be prevented through childhood immunization.

23) The healthcare provider has prescribed the toddler an oral medication. The toddler has fought medication administration in the past. Which strategies may be helpful when administering the medication to this toddler? Select all that apply. 1. Request the medication in liquid form and draw the medication in an oral syringe. 2. Put the medication in a favorite drink in the child's sippy cup. 3. Allow the mother to administer the medication to the child. 4. Notify the healthcare provider to change the route to intravenous. 5. Hold the child down and squirt the medication in the corner of his mouth.

Answer: 1, 3 Explanation: 1. These activities will make the administration easier. 2. This would not be appropriate as it increases the volume that must be administered and may unfavorably change the taste of the drink. 3. The child is more willing to take the medication from the mother. 4. This would not be appropriate. 5. This could cause the child to choke on the medication and is inappropriate.

22) Which nursing actions will decrease the risk of extravasation when administering chemotherapy to a pediatric client through a peripheral line? Select all that apply. 1. Ensuring that the intravenous line is a free flowing line 2. Administering the medication by infusion pump 3. Checking for blood return before and during chemotherapy administration 4. Diluting the medication with normal saline 5. Administering the vesicant drug last

Answer: 1, 3 Explanation: 1. This is critical, as extravasation is leaking into the tissues. 2. An infusion pump does not ensure that the line is free flowing; this is inappropriate. 3. This checks for intravenous administration and is appropriate. 4. Not all medications can be mixed with normal saline, and this does not protect against extravasation. 5. The vesicant drug should be administered first.

15) Which statements should the nurse include in the discharge medication teaching for a child diagnosed with asthma who is prescribed cromolyn sodium (a mast cell stabilizer)? Select all that apply. 1. "The medication works to prevent exacerbations." 2. "The medication should be administered at the first symptom of an asthmatic attack." 3. "The medication should be taken on a daily basis." 4. "The medication should not be administered if the child has a cold." 5. "The medication desensitizes the child against specific allergens."

Answer: 1, 3 Explanation: 1. This statement is true. Cromolyn sodium is used to inhibit an asthmatic response to allergens. 2. This is incorrect. This medication does not improve the child's condition during an asthmatic attack. 3. This is a preventative medication so doses should not be missed. 4. The medication should be taken daily. 5. This medication does not desensitize the child against allergens.

14) The pediatric public health nurse visits a facility for the homeless. Which types of medical issues will the nurse assess these children for based on the current data? Select all that apply. 1. Dental caries 2. Infections secondary to tattoos 3. Lack of immunizations 4. Nutritional deficits 5. Munchausen syndrome by proxy

Answer: 1, 3, 4 Explanation: 1. Children who are homeless do not have the facilities or the supplies to care for their teeth and do not see a dentist on a regular basis. 2. This is not a specific problem related to homelessness, and many states prohibit tattooing of children. 3. Homelessness often leads to lack of medical care, and some of the children may not be current on their immunizations. 4. The family that is homeless often has difficulty with maintaining adequate nutrition. 5. This is not a common problem for the homeless child.

16) Which assessment data would cause the nurse to suspect that a pediatric client is experiencing hypovolemic shock? Select all that apply. 1. Dyspnea 2. Bradycardia 3. Tachycardia 4. Capillary refill time greater than 3 seconds. 5. Blood pressure 72/42 mmHg

Answer: 1, 3, 4 Explanation: 1. Increased work of breathing is an early sign of shock, indicating compensation for decreased cardiac output and volume. 2. Bradycardia is a late and ominous sign of shock indicating that the child is no longer able to compensate. 3. Tachycardia is an early compensatory mechanism for hypovolemia in a child. 4. Decreased capillary refill time would be an early indicator of decreased fluid volume and compensation. 5. Decreased blood pressure is a later finding and would not occur until other compensatory mechanisms were exhausted.

21) Which interventions should the nurse include in the plan of care for a hospitalized child who is diagnosed with rheumatoid arthritis (RA)? Select all that apply. 1. Performing passive range-of-motion (ROM) exercises with the child 2. Discouraging the child from completing activities of daily living (ADLs) 3. Encouraging periods of rest for the child 4. Placing cool compresses on the child's joints 5. Performing daily weights

Answer: 1, 3, 5 Explanation: 1. Active and passive ROM is encouraged as this decreases joint stiffness and inflammation. 2. The child should be encouraged, not discouraged, to be as independent as possible with ADLs. 3. Exacerbations of RA often cause fatigue; therefore, it is appropriate for the nurse to encourage rest periods. 4. Warm, not cool, compresses should be placed on the joints. 5. Daily weights are needed, as it is not uncommon for the child with RA to experience reduced activity and metabolic needs yet maintain the same diet, which places the child at risk for overweight and obesity.

22) The nurse is providing education to a family whose child experiences anaphylaxis when exposed to any amount of latex. Which items, often found in the home or school environment, should the nurse include in the teaching session? Select all that apply. 1. Art supplies 2. Toothpaste 3. Balloons 4. Perfumes 5. Chewing gum

Answer: 1, 3, 5 Explanation: 1. Art supplies often contain latex; therefore, the nurse should include this item in the teaching session. 2. Toothbrushes, not tooth paste, are known to contain latex. The nurse should not include this item in the teaching session. 3. Balloons often contain latex; therefore, the nurse should include this item in the teaching session. 4. Perfumes are not known to contain latex. The nurse should not include this item in the teaching session. 5. Chewing gum often contains latex; therefore, the nurse should include this item in the teaching session.

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

Answer: 1, 3, 5 Explanation: 1. Education is a resource that enables families to develop and adapt to stressors. 2. While effective communication does enable families to develop and adapt to stressors, it is not considered a resource. 3. Prior experiences are a resource that enables families to develop and adapt to stressors. 4. While problem solving does enable families to develop and adapt to stressors, it is not considered a resource. 5. Adequate finances are a resource that enables families to develop and adapt to stressors

27) The nurse is providing care to a pediatric client who will require radiation as a portion of the treatment regimen. Which topics should the nurse include in the teaching session related to long- term ramifications associated with this treatment option? 1. Scoliosis 2. Adhesions 3. Hypothyroidism 4. Visual impairment 5. Cardiotoxicity

Answer: 1, 3, 5 Explanation: 1. Scoliosis is a long-term ramification associated with radiation treatment for cancer. 2. Adhesions are a long-term ramification associated with surgical intervention, not radiation treatment, for cancer. 3. Hypothyroidism is a long-term ramification associated with radiation treatment for cancer. 4. Visual impairment is a long-term ramification associated with surgical intervention, not radiation treatment, for cancer. 5. Cardiotoxicity is a long-term ramification associated with radiation treatment for cancer.

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

Answer: 2 Explanation: 1. Administering the prn dose of the antiemetic drug only if the child is nausea is not the best use of this medication. 2. The antiemetic should be administered before chemotherapy and every 4 hours during the administration of chemotherapy, as a prophylactic measure. 3. Administering the prn dose of the antiemetic drug after the next dose of chemotherapy may not provide adequate coverage for nausea. 4. Antiemetic drugs are not administered to treat diarrhea. They are administered to treat nausea and vomiting.

17) Which is the priority nursing action when providing care to a pediatric client who is diagnosed with hypovolemic shock? 1. Assessing the cause of bleeding 2. Establishing an open airway and administering oxygen 3. Administering analgesics for pain control 4. Providing replacement of volume

Answer: 2 Explanation: 1. Airway patency and replacement of volume are priorities before assessing the cause of the bleeding. 2. Airway patency and oxygen delivery (breathing) are always first in the treatment for a client with health concerns. 3. Pain would be a consideration but would not be attended to as a first priority. 4. Replacement of volume is vital but would follow establishing airway and breathing.

21) The nurse is preparing to administer a blood transfusion to a child with a severe anemia. Which type of transfusion reaction can be avoided by the nurse's assessment? 1. Allergic 2. Hemolytic 3. Febrile 4. Septic

Answer: 2 Explanation: 1. Allergic reactions are due to a protein in the donated blood to which the child reacts. The nurse cannot prevent this type of reaction. 2. A hemolytic reaction results from mismatched blood, a preventable error. This error is most likely to occur at the bedside if the nurse does not carefully identify the unit of blood and the patient. 3. A febrile reaction is related to contamination of blood. The nurse has no control over this type of reaction. 4. Septic is another name for a febrile reaction and is not preventable by the nurse.

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

Answer: 2 Explanation: 1. Asking parents to wait is uncaring and insensitive. 2. The best nursing intervention is to give the parents an appropriate environment before they are told the news, so that they can begin grieving privately. 3. Nurses as well as other healthcare providers are capable of breaking bad news to families with caring and empathy. 4. Telling the parents the news in public is uncaring and insensitive.

5) A preschool-age boy presents to the outpatient clinic for a sore throat. In the child's mind, which is the most likely causative agent of the sore throat? 1. Being exposed to a classmate with strep throat 2. Yelling at sibling for being annoying 3. Not eating the right foods 4. Not taking daily vitamins

Answer: 2 Explanation: 1. At this age, the child does not yet understand that he can become sick from exposure to someone else who is sick. 2. Preschoolers understand some aspects of being sick, but not the cause of illness. They are likely to think that they are sick as a result of something that they have done. They frequently will view illness as punishment. 3. Not eating the right foods can be a factor in some illnesses, but this thinking is beyond the level of a 4-year-old boy. 4. While not taking his vitamins can be a factor in some illnesses, this thinking is beyond the capabilities of a 4-year-old boy.

11) Which assessment finding would necessitate action by the nurse for a 10-month-old child who is 4 hours postoperative for the placement of a urethral stent? 1. Bloody urine 2. One void since returning from surgery 3. Bladder spasms responding to pharmacologic intervention 4. Double diapering from the previous shift

Answer: 2 Explanation: 1. Bloody urine is expected in the immediate postoperative period. 2. A 10-month-old child will void more often than 1 time in 4 hours. This could indicate the stent is occluded. The surgeon should be notified. 3. This is a normal finding. 4. This is a desired finding and does not need to be reported to the surgeon.

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

Answer: 2 Explanation: 1. Bradycardia is not a sign of dehydration. 2. Tachycardia is a sign that indicates moderate dehydration. 3. In dehydration, the blood pressure is hypotensive. 4. Fontanels would be sunken in moderate dehydration.

15) The nurse is developing an ecomap for a pediatric client and family. Which explanation should the nurse provide prior to beginning this task? 1. "It provides information about your family structure including family life events, health, and illness." 2. "It illustrates your family relationships and interactions with community activities including school, parental jobs, and children's activities." 3. "It is a short questionnaire of five questions that measures your family's growth, affection, and resolve." 4. "It is an assessment that consists of three categories of information about your family's strengths and problems."

Answer: 2 Explanation: 1. Information of this type is called a genogram. 2. This is the description of the ecomap. 3. The five-item questionnaire measuring family growth, affection, resolve, adaptability, and partnership is a Family Apgar. 4. This describes a Calgary Family Assessment Model

6) An infant who is diagnosed with a mild heart defect will not have surgical correction for at least 2 years. Which information should the nurse include in the discharge teaching regarding management in the home environment? 1. "Your child will have a low-grade fever until the defect is repaired." 2. "It is important for your child to maintain normal activity." 3. "Your child is not at risk for congestive heart failure." 4. "It is important to avoid antipyretics for the treatment of fever."

Answer: 2 Explanation: 1. Low-grade fever is not a normal finding in a child with a mild cyanotic heart defect and could be a sign of infective endocarditis. 2. A child with a mild cyanotic heart defect should be treated as normally as possible without activity adjustment. 3. Any child with a heart defect could develop congestive heart failure. 4. Fevers are treated with antipyretics so that dehydration is avoided.

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

Answer: 2 Explanation: 1. Massage and holding the infant are more appropriate following the procedure, or as an adjunct to pain medication for ongoing pain or distress. 2. Sucrose provides short-term, natural pain relief, and is most appropriate for use in neonates to decrease pain associated with a quick procedure. 3. Massage and holding the infant are more appropriate following the procedure, or as an adjunct to pain medication for ongoing pain or distress. 4. Swaddling for a neonate undergoing a quick painful procedure will not decrease the pain.

4) Which common mode of infectious disease should the nurse include in a teaching session with parents within the community? 1. Playing with the same toy 2. Coughing without covering the mouth 3. Sitting together eating meals 4. Playing board games

Answer: 2 Explanation: 1. Microorganisms might be left on toys that children share, but this is not the most common mode of transmission of infectious diseases. 2. The fecal-oral and respiratory routes are the most common sources of transmission in children. 3. Eating together will not transmit infectious disease. 4. Playing with board games will not transmit infectious disease.

3) An adolescent client reports recurrent abdominal pain with diarrhea and bloody stools. Which type of inflammatory bowel disease does the nurse suspect based on these data? 1. Necrotizing enterocolitis (NEC) 2. Ulcerative colitis (UC) 3. Crohn disease 4. Appendicitis

Answer: 2 Explanation: 1. NEC is usually seen in premature infants and generally not in an adolescent client. 2. Diarrhea and bloody stools are typical symptoms of UC. 3. The teen with Crohn disease might have abdominal pain and diarrhea, but stools usually do not have blood in them. 4. Appendicitis is not associated with bloody stools and usually not with diarrhea.

17) The hospital has instructed its nurses that they must participate in disease surveillance associated with infectious agents. Which disease(s) are likely to be the weapons of terrorists? 1. Rocky Mountain spotted fever and Lyme disease 2. Plague, anthrax, and smallpox 3. Rubella, mumps, and chickenpox 4. Severe acute respiratory syndrome (SARS)

Answer: 2 Explanation: 1. Rocky Mountain spotted fever and Lyme disease are caused by ticks endemic to wooded areas. 2. Plague, anthrax, and smallpox are choices of terrorists because they are highly contagious, lethal diseases that can kill large numbers of people in a relatively short time. 3. Rubella, mumps, and chickenpox are childhood communicable diseases that are not usually fatal. 4. SARS is a rare infectious disease.

3) A 16-year-old has a stiff neck, headache, fever of 103°F, and the nurse notes purpuric lesions on the child's legs. Although the adolescent's physical needs take priority at the present time, the nurse can expect which psychologic stressor to be the most significant for this adolescent? 1. Fear of getting behind in schoolwork 2. Separation from friends and permanent changes in appearance 3. Separation from parents and home 4. Fear of painful procedures and bodily mutilation

Answer: 2 Explanation: 1. School-age children are developing a sense of industry, and fear getting behind in schoolwork. 2. Adolescents are developing their identity, and rely most on their friends. They are concerned about their appearance and how they look compared with their peers. 3. Separation from parents and home is the main psychological stressor for infants and toddlers. 4. Preschoolers fear pain and bodily mutilation.

2) Which is the appropriate nursing intervention when providing care to a child, diagnosed with nephrotic syndrome, who is edematous and on bed rest? 1. Monitor blood pressure every 30 minutes. 2. Reposition every 2 hours. 3. Limit visitors. 4. Encourage fluids.

Answer: 2 Explanation: 1. Vital signs are taken every 4 hours. 2. A child with severe edema, on bed rest, is at risk for altered skin integrity. To prevent skin breakdown, the child should be repositioned every 2 hours. 3. The child needs social interaction, so visitors should not be limited. 4. Fluids need to be monitored; they should not be encouraged.

13) A nasogastric tube to suction is ordered for a neonate diagnosed with a diaphragmatic hernia. Which complication related to gastric drainage is the priority when planning care for this neonate? 1. Weight loss 2. Metabolic alkalosis 3. Dehydration 4. Hyperbilirubinemia

Answer: 2 Explanation: 1. Weight loss and inadequate nutrition are not the priority for this client. 2. When large quantities of gastric juice is removed, acid is lost and metabolic alkalosis follows. 3. The volume would not be sufficient to cause dehydration. 4. Hyperbilirubinemia is unrelated to gastric suction.

16) A child is admitted to the hospital with a diagnosis of lead poisoning. Which should be included in the home assessment to determine the probable source of the lead poisoning? SATA 1. The home's foundation for a possible radon leak 2. The home's water pipes 3. The dirt surrounding the house 4. The presence of imported toys or antique baby furniture 5. Gas stored in cans in the garage.

Answer: 2, 3, 4 Explanation: 1. Radon is not a source of lead. 2. Older water pipes were made from lead, which leaches out into the water. 3. Children who eat dirt may acquire lead poisoning due to contamination with fumes from lead gas. 4. Toys imported from other countries and old furniture may have lead paint. The child can be exposed if the child puts these objects in the mouth. 5. Most gas is now not lead based. If the child were to drink the gas from the cans, the problem would be the hydrocarbons, not the lead.

21) Which nursing assessment data would indicate that a pediatric client sustained a large pulmonary contusion in a motor vehicle crash? Select all that apply. 1. Eupnea 2. Dyspnea 3. Hemoptysis 4. Fever 5. Crackles

Answer: 2, 3, 4, 5 Explanation: 1. Eupnea, or a normal respiratory rate, is not assessment data the nurse expects for a pediatric client who sustained a large pulmonary contusion in a motor vehicle crash. 2. Dyspnea is a clinical manifestation associated with respiratory distress, which can occur for the pediatric client who sustained a large pulmonary contusion in a motor vehicle crash. 3. Hemoptysis is a clinical manifestation associated with a large pulmonary contusion. 4. Fever is a clinical manifestation associated with a large pulmonary contusion. 5. Crackles are a clinical manifestation associated with a large pulmonary contusion.

20) Which interventions should the nurse include in the plan of care to address nutrition for a child who is diagnosed with acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1. Encourage three large meals each day. 2. Eliminate unpleasant odors from the environment during meals. 3. Weigh the child each day, using the same scale. 4. Assess skin turgor every 4 hours. 5. Include favorite foods in the meal plan.

Answer: 2, 3, 5 Explanation: 1. Children diagnosed with AIDS who are experiencing impaired nutrition should be offered small frequent meals to meet nutritional needs. 2. Unpleasant stimuli and odors often decrease the desire for food. 3. Taking daily weights, using the same scale, is an appropriate intervention to monitor the child's nutritional status. 4. Skin turgor should be assessed each shift, not every 4 hours, in order to monitor hydration status. 5. Allowing children to eat their favorite foods encourages intake.

10) Which complications should the nurse monitor for when providing care to a child who is having hemodialysis for the treatment of kidney failure? Select all that apply. 1. Migraines 2. Hypotension 3. Infections 4. Fluid overload 5. Shock

Answer: 2, 3, 5 Explanation: 1. Migraines are not a clinical manifestation associated with hemodialysis. 2. Rapid changes in fluid and electrolyte balance during hemodialysis can lead to hypotension. 3. Infection is another complication that may occur during hemodialysis. 4. Fluid overload is not a clinical manifestation associated with hemodialysis. 5. Rapid changes in fluid and electrolyte balance during hemodialysis can lead to shock.

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

Answer: 3 Explanation: 1. A delay in giving pain medication will not decrease the chance of withdrawal symptoms if the medication is stopped without weaning. 2. Delaying the pain medication will not decrease the chance of addiction. 3. Analgesics may be given on a scheduled basis. Delays in giving analgesics increase the chance of breakthrough pain and the subsequent anticipation of pain. 4. Delaying the pain medication will not increase the child's pain tolerance.

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

Answer: 3 Explanation: 1. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients. 2. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients. 3. Pancreatic enzymes are administered with meals and large snacks. 4. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

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

Answer: 3 Explanation: 1. A vaccine allergy contradicts the administration of the vaccine for life. This factor does not warrant a delay. The child should not receive the vaccine at the next well-child visit or at any other time. 2. A mild upper respiratory infection would not be a contraindication for vaccine administration. 3. The antibodies in the immune globulin will prevent the child from developing immunity to the vaccination. By the next well-child visit, the immune globulins will not prevent immunity from developing. 4. Antibiotic administration will not prevent the development of active immunity.

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

Answer: 3 Explanation: 1. Actual loss is a real loss objectively confirmed by others. 2. A perceived loss is subjectively experienced by a person, but cannot be confirmed by others. 3. Anticipatory loss is experienced before the loss actually transpires. 4. Loss is a general term for something of value being changed, no longer available, or no longer able to be experienced by an individual.

7) A child diagnosed with aplastic anemia is admitted to the hospital. The parents ask the nurse what aplastic anemia is. Which response by the nurse is accurate? 1. "Aplastic anemia causes a proliferation of white blood cells." 2. "Aplastic anemia is characterized by abnormally shaped red blood cells." 3. "Aplastic anemia is caused the bone marrow producing inadequate cells." 4. "Aplastic anemia is a disorder that occurs after a viral illness."

Answer: 3 Explanation: 1. All blood cells, not just white blood cells, are affected by aplastic anemia. 2. Aplastic anemia does not cause abnormally shaped red blood cells; this is a description of sickle-cell disease. 3. In aplastic anemia, the bone marrow does not produce sufficient numbers of circulating blood cells. 4. There is no known association between aplastic anemia and viral illness.

6) Which does the nurse include in the plan of care for an adolescent with a chronic condition? 1. Being more concerned for parents 2. Exhibiting less concern about appearance 3. Having an altered body image 4. Portraying a higher self-esteem

Answer: 3 Explanation: 1. As adolescents develop a sense of identity, they are focused on themselves and the present. 2. Adolescents with chronic conditions will have a heightened concern about their appearance. 3. Adolescents with chronic conditions might have inaccurate assessments of their body image. 4. Adolescents with chronic conditions have low self-esteem when comparing their bodies with those of their peers.

4) An adolescent female client is diagnosed with systemic lupus erythematosus (SLE). Which action by the client indicates acceptance of the body changes that occur because of SLE? 1. Attends school but does not stay for after-school activities 2. Discusses the body changes with healthcare providers only 3. Discusses the body changes with her best friend 4. Only attends small parties at friends' homes

Answer: 3 Explanation: 1. Avoiding social activities does not show acceptance of body changes. 2. Discussing changes only with healthcare providers does not indicate the teen has adjusted to the body image changes. 3. Peer interaction is important to the teen. Being able to discuss the changes to her body with a peer indicates acceptance of the changes in her body image. 4. Avoiding social activities other than those involving immediate friends indicates the teen is still concerned with body image.

15) Which is the priority nursing intervention when caring for a neonate who is born with bladder exstrophy? 1. Measuring intake and output 2. Inserting a Foley catheter 3. Covering the defect with sterile plastic wrap 4. Palpating the bladder mass to ensure urine is expelled

Answer: 3 Explanation: 1. Because the bladder constantly drains onto the skin of the abdomen, measuring output is not possible. 2. The bladder is open to the abdomen. A Foley catheter cannot be inserted. 3. This reduces the contamination of the bladder, which should be sterile. 4. The bladder is very sensitive and palpation would cause unnecessary pain.

10) Which parental statement regarding the use of cyclosporin A after a heart transplant indicate correct understanding of the information presented by the nurse? 1. "This medication is used to treat hypertension." 2. "This medication is used to reduce serum cholesterol level." 3. "This medication is used to prevent rejection." 4. "This medication is used to treat infections."

Answer: 3 Explanation: 1. Calcium channel blockers may be used to treat hypertension. 2. Lovastatin is given to reduce serum cholesterol level. 3. Cyclosporin A is given to prevent rejection. 4. An antibiotic may be given to treat an infection.

4) A school bus carrying children in grades K-12 crashed into a ravine. The critically injured children are transported by ambulance and admitted to the pediatric intensive care unit (PICU). Which is the most effective nursing intervention to calm the frightened children? 1. Explain that the equipment being used is state-of-the-art. 2. Tell the children that the providers are competent. 3. Call the children's parents to come to the unit. 4. Assure the children that the nurses are caring.

Answer: 3 Explanation: 1. Children often cannot recognize or care about state-of-the-art equipment. 2. Healthcare providers, no matter how competent or caring, cannot substitute for parents. 3. A sense of physical and psychologic security is best achieved by the presence of parents. Children at all developmental levels look first to their parents or whoever acts as their parents for safety and security. 4. Healthcare providers, no matter how competent or caring, cannot substitute for parents.

2) Which assessment data would cause the nurse to suspect that a 3-year-old child has Hirschsprung disease? 1. Clay-colored stools and dark urine 2. History of early passage of meconium in the newborn period 3. History of chronic, progressive constipation and failure to gain weight 4. Continual bouts of foul-smelling diarrhea

Answer: 3 Explanation: 1. Clay-colored stools and dark urine are not associated with Hirschsprung disease. 2. The infant with Hirschsprung disease often has delayed meconium stools. 3. These are symptoms of Hirschsprung disease in an older infant or child. 4. Diarrhea is not typical; obstruction is more likely.

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

Answer: 3 Explanation: 1. Furosemide (Lasix) produces rapid diuresis and blocks reabsorption of sodium and water in renal tubules. 2. Furosemide (Lasix) produces rapid diuresis and blocks reabsorption of sodium and water in renal tubules. 3. Spironolactone (Aldactone) is a maintenance diuretic that is potassium-sparing. Hypokalemia would increase the risk of Lanoxin toxicity. 4. Angiotensin-converting enzyme (ACE) inhibitors promote vascular relaxation.

6) Which clinical manifestations should the nurse anticipate upon assessment for a preschool-age child with a urinary tract infection (UTI)? 1. Headache, hematuria, and vertigo 2. Foul-smelling urine, elevated blood pressure (BP), and hematuria 3. Urgency, dysuria, and fever 4. Severe flank pain, nausea, and headache

Answer: 3 Explanation: 1. Hematuria might be present, but there will be no complaints of headache or vertigo. 2. While foul-smelling urine and hematuria can be present, there is no elevated BP, headache, or vertigo. 3. Clinical manifestations of UTI in a preschool-age child include fever, urgency, and dysuria. 4. There could be flank pain, although the preschooler might be unable to describe it. There will be no complaints of headache.

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

Answer: 3 Explanation: 1. Hypernatremia is a condition where the body fluids are too concentrated and there is an excess of sodium. 2. Metabolic acidosis refers to a condition where the pH of the blood is acidic. 3. This occurs when fluid loss is characterized by a proportionately greater loss of sodium than water. Serum sodium is below normal levels. Hemoglobin and hematocrit will be high due to the loss of serum water. 4. This occurs when fluid loss is not balanced by intake, and the losses of water and sodium are in proportion.

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

Answer: 3 Explanation: 1. Pathologic Grieving results when persons do not move through the stages of grief to resolution. 2. Compassion Fatigue is experienced by caregivers as their ability to feel compassion is exhausted. 3. Parents experience chronic sorrow as they grieve when their child does not meet developmental milestones or participate in activities of "normal" children. The time between periods of grieving might be times of parental denial, which allows the family to function. 4. Dysfunctional Parenting involves inadequately meeting the needs of children.

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

Answer: 3 Explanation: 1. Periodically distancing themselves from their parents and preferring involvement with their peers are normal adolescent behaviors. 2. Mood swings are normal adolescent behaviors. 3. Even though most teens do prefer staying up late, they are not usually so tired that they fall asleep during the day, especially while engaged in classroom activities. This behavior is abnormal and could indicate involvement with substance abuse or an underlying pathology. 4. Experimentation with different clothes and hair is a normal adolescent behavior

8) Which parental statement at the end of a teaching session by the nurse indicates correct understanding of colostomy stoma care for the infant client? 1. "We will change the colostomy bag with each wet diaper." 2. "We will expect a moderate amount of bleeding after cleansing the area around the stoma." 3. "We will watch for skin irritation around the stoma." 4. "We will use adhesive enhancers when we change the bag."

Answer: 3 Explanation: 1. Physical or chemical skin irritation can occur if the appliance is changed too frequently, or with each wet diaper. 2. Bleeding is usually attributable to excessive cleaning. 3. Skin irritation around the stoma should be assessed; it could indicate leakage. 4. Adhesive enhancers should be avoided on the skin of infants. Their skin layers are thin, and removal of the appliance can strip off the skin.

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

Answer: 3 Explanation: 1. Preschool-age children do not have a fear of being bad and the sibling's subsequently being punished. 2. Fighting is normal, and preschool-age children do not have those thoughts. 3. Preschool-age children might fear that they caused their brother or sister to be injured or become ill, or they may worry that bad thoughts on their part brought on the illness. 4. Preschool-age children are more likely to believe that they somehow were the cause of their sibling's death, not their parents.

18) Which parental action indicates accurate understanding of information presented by the nurse to treat a fever related to otitis media? 1. Putting the child in a tub of cold water to reduce the fever 2. Alternating acetaminophen with ibuprofen every 2 hours 3. Offering generous amounts of fluids frequently 4. Using aspirin every 4 hours to reduce the fever

Answer: 3 Explanation: 1. Putting the child in a tub of cold water will chill the child and cause shivering, a response that will increase body temperature. 2. Alternating acetaminophen with ibuprofen every 2 hours could result in an overdose. 3. The body's need for fluids increases during a febrile illness. 4. Aspirin has been associated with Reye syndrome and should not be given to children with a febrile illness unless prescribed by the healthcare provider.

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

Answer: 3 Explanation: 1. Rapid weaning is not necessary; reduction of pain medication should proceed at a rate dictated by the child's pain. 2. A high-protein diet is not necessary; a well-balanced diet should be promoted. 3. Adequate hydration will help prevent further sequestration and crisis. 4. Normal activities are not restricted.

7) A 2-month-old infant with a congenital heart defect is admitted to the pediatric intensive care unit with congestive heart failure. Which intervention should the nurse include in the infant's plan of care? 1. Monitor respirations during active periods. 2. Give larger feedings less often to conserve energy. 3. Organize activities to allow for uninterrupted sleep. 4. Force fluids appropriate for age.

Answer: 3 Explanation: 1. Respirations are difficult to monitor during active periods, making this an unrealistic goal. 2. Feedings should be small-volume, high-calorie. 3. It is important to allow for uninterrupted sleep to decrease metabolic demands on the heart. 4. Fluids should be restricted to high-calorie and low-volume in order to avoid overloading the lungs with fluid.

15) Which parental action, observed during a home care visit for an infant diagnosed with gastroesophageal reflux, requires intervention by the nurse? 1. The infant's formula has rice cereal added. 2. The mother holds the infant in a high Fowler position while feeding. 3. After feeding, the infant is placed in a car seat. 4. The mother draws up the ranitidine (Zantac) in a syringe for oral administration.

Answer: 3 Explanation: 1. Rice cereal thickens the formula and helps prevent regurgitation. This is appropriate. 2. This position will help prevent regurgitation and is appropriate. 3. Infant seats are not recommended, as they put pressure on the abdomen and may contribute to regurgitation. 4. Since dosing is small, it is appropriate to use a syringe for accurate measurement.

19) A school-age child, diagnosed with rhabdomyosarcoma, is experiencing nausea and vomiting related to the prescribed chemotherapy in spite of the use of antiemetics. The mother is pushing the child to eat the food. Which statement by the nurse is appropriate to address this situation? 1. "Since your child is receiving IV fluids, it is not important to push oral intake of food." 2. "A food aversion may occur if you continue to force your child to eat." 3. "Emesis that is caused by your child being force-fed can damage the stomach." 4. "A psychologic conflict could occur between you and your child if you continue to push eating."

Answer: 2 Explanation: 1. Intravenous fluids do not replace normal food intake. 2. If the child is forced to eat and then vomits, the child can develop a food aversion in which the child associates that food with vomiting. 3. Vomiting is unpleasant but does not usually lead to stomach damage. 4. This is not a correct statement. Parents and children often disagree, but the child will still relate to the parent.

6) The nurse is teaching parents how to prevent the spread of infectious disease. Which is the priority health promotion strategy the nurse should recommend for all age groups of children? 1. Decreasing environmental exposure to pathogens 2. Performing hand hygiene 3. Ensuring all toys are clean and free from germs 4. Keeping child away from sick adults

Answer: 2 Explanation: 1. It is not possible to keep children free from colds. 2. Proper hand hygiene is one of the most important health promotion strategies for all age groups of children as well as child care providers. 3. Keeping all toys clean and free from germs is not possible. 4. It is not always possible to keep children away from sick adults.

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

Answer: 2 Explanation: 1. Listerine is a commercial mouth rinse that can have an alcohol base and cause drying of the membranes. 2. The mouth care should be with a nonalcohol base. Normal saline can keep the child's lips and mouth moist. 3. Viscous lidocaine causes numbing, and could depress the gag reflex in a younger child. 4. Scope is a commercial mouth rinse that can have an alcohol base and cause drying of the membranes.

13) A child with rhabdomyosarcoma is prescribed radiation therapy after surgical removal of the tumor. Which intervention should the nurse include in the child's plan of care? 1. Apply lotion to the area before radiation therapy. 2. Apply sunscreen to the area when the child is exposed to sunlight. 3. Remove any markings left after each radiation treatment. 4. Vigorously scrub the area when bathing the child.

Answer: 2 Explanation: 1. Lotion can increase the chance of a radiation burn when applied before the treatment. 2. Radiation therapy causes the skin in that area to be sensitive. Sunscreen should be applied so that sunburns are avoided. 3. Radiation markings are to guide the radiologist and should not be removed. 4. Vigorous scrubbing is not recommended.

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

Answer: 4 Explanation: 1. A specific gravity higher than 1.010 can mean fluid intake is not high enough. 2. A pH of less than 7 means acidosis. 3. A specific gravity higher than 1.010 can mean fluid intake is not high enough, and a pH of less than 7 means acidosis. 4. Because the breakdown of malignant cells releases intracellular components into the blood and electrolyte imbalance causes metabolic acidosis, the patient should remain well hydrated, with the urine specific gravity at less than 1.010 and the pH at 7.0 to 7.5.

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

Answer: 4 Explanation: 1. Although equipment is important and is used routinely during sedation, it does not replace the need for visual assessment. 2. Parents may be allowed to stay with the child, but assessment of breathing effort must take priority. 3. Although equipment is important and is used routinely during sedation, it does not replace the need for visual assessment. 4. When the child is sedated for a procedure, it is very important for the nurse to actually visualize the child and the child's effort of breathing.

13) Which is the priority nursing diagnosis for the child diagnosed with idiopathic thrombocytopenic purpura (ITP)? 1. Ineffective Breathing Pattern 2. Nausea 3. Fluid Volume Deficit 4. Risk for Injury

Answer: 4 Explanation: 1. Although in an advanced state thrombocytopenic purpura can impact breathing, it does not usually cause ineffective breathing patterns. 2. Nausea is not a symptom of ITP. 3. Fluid-volume deficits are not likely to occur with ITP. 4. ITP is the most common bleeding disorder in children, so risk for injury and subsequent bleeding is the priority nursing diagnosis.

17) Which rationale will the seasoned nurse share with the novice nurse regarding why the specific gravity for infants is lower than for older children? 1. The infant has a greater body surface area. 2. The infant has a higher basal metabolic rate. 3. The infant has a greater percentage of body weight that is water. 4. The infant's kidneys are less able to concentrate urine.

Answer: 4 Explanation: 1. Although this is true, it does not explain the lower specific gravity. 2. This statement is true but does not explain the specific gravity differences. 3. Although the statement is true, it does not explain the specific gravity differences. 4. This statement is accurate and explains why the specific gravity of the infant's urine is closer to water than an older child's urine specific gravity.

13) Which laboratory test does the nurse anticipate for a child who is admitted to the hospital with suspected rheumatic fever? 1. Erythrocyte sedimentation rate 2. Throat culture 3. C-reactive protein 4. Antistreptolysin-O (ASO) titer

Answer: 4 Explanation: 1. An erythrocyte sedimentation rate and a C-reactive protein can indicate inflammation. 2. A culture can indicate a current streptococcal infection. 3. An erythrocyte sedimentation rate and a C-reactive protein can indicate inflammation. 4. The laboratory test for antistreptococcal antibodies is an antistreptolysin-O (ASO) titer.

9) Which is the priority nursing action when working with a parent who is suspected of Munchausen syndrome by proxy? 1. Try to keep the parent separated from the child as much as possible. 2. Explain to the child that the parent is causing the illness and that the healthcare team will prevent the child from being harmed. 3. Carefully document parent-child interactions. 4. Confront the parent with concerns of possible abuse.

Answer: 3 Explanation: 1. Separating the parent from the child might alienate the parent and cause her to leave with the child. 2. Talking to the child about the healthcare team's suspicions could be confusing and frightening for the child. 3. Munchausen syndrome by proxy is very difficult to prove, and evidence provided by the careful documentation of the nursing staff can be very influential. Care must be taken not to make the parent suspicious and to keep the child in the hospital until enough evidence is collected. 4. Confronting the parent might alienate the parent and cause her to leave with the child.

16) A child is being discharged from the hospital requiring complex, long-term care with medication administration through a central line and maintenance of oxygen administration by nasal cannula. A home health nurse will be visiting each day. What should the nurse teach the family members prior to hospital discharge? 1. How to insert an IV line 2. Nothing, the family is familiar with the care 3. Instruction on oxygen administration 4. How to remove a central line

Answer: 3 Explanation: 1. Starting an IV line is not within the family's responsibilities for home care. 2. The nurse can never assume the family members are familiar with the care required, even if they have been participating during the hospital stay. 3. Prior to discharge, the parents will need to learn about oxygen administration. 4. Removing a central line is not within the realm of what family members need to do at home.

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

Answer: 3 Explanation: 1. The nurse should not use medical terms to discuss the child's procedure. 2. In most circumstances, it is not only permitted but desired to have the parents present during a procedure. 3. Parents often want to support their child before and after procedures, and their presence offers reassurance and comfort to the child. Prepare family members for what to anticipate and what is expected of them. 4. The nurse can speak to the family to prepare them and does not need to wait for the healthcare provider.

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

Answer: 3 Explanation: 1. The parents should be allowed to stay with their child on the unit. 2. The parents should be aware of the rules about rooming in, but they should know first that they can stay. 3. The practice of rooming-in involves a parent's staying in the child's hospital room during the course of the child's hospitalization. Some hospitals provide cots, while others have special built-in beds on pediatric units. 4. The parents should be allowed to stay with their child

2) Which initial laboratory data does the nurse anticipate for a child who is admitted to the hospital with a cyanotic heart defect? 1. A low platelet count 2. A high white blood cell count 3. A high hemoglobin 4. A low hematocrit

Answer: 3 Explanation: 1. The platelets would be normal. 2. The white blood cell count would not be high unless an infection was present. 3. The child's bone marrow responds to chronic hypoxemia by producing more red blood cells to increase the amount of hemoglobin available to carry oxygen to the tissues. This occurs in cases of cyanotic heart defects. 4. The hematocrit would not be low.

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

Answer: 3 Explanation: 1. The scenario indicates that the child has been through this before, so Knowledge Deficit is not the most appropriate diagnosis. 2. The child's fear is related not to the unfamiliar environment but to the anticipated pain of the IV stick. 3. This child is not old enough to understand the need for an IV infusion. The scenario indicates that the child has been through this painful procedure before, and the child's reaction to entering the treatment room is based on anticipation of repeat discomfort. 4. The child's behavior is appropriate for coping in this age child.

24) Which changes can a nurse manager implement to reduce the stress experienced by hospitalized pediatric clients? 1. Having only female nurses on the unit 2. Assigning nurses one-on-one with clients 3. Allowing the nurses to wear colored scrubs in place of white uniforms 4. Having the nurses avoid entering the client's room unless a procedure is to be performed

Answer: 3 Explanation: 1. The sex of the nurse has not been shown to be a source of stress. 2. Staffing patterns will not allow a one-to-one nurse to client ratio on the regular pediatric unit. 3. This change has been shown to reduce stress in children. 4. Nurses should visit when not performing procedures to allow the children to become familiar and comfortable with the nurses.

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

Answer: 3 Explanation: 1. There is no reason to withhold any of the vaccinations due at this time. 2. The flu vaccination would not routinely be given to a 4-month-old infant. 3. Giving the vaccine as scheduled will keep the infant properly immunized. 4. Recent exposure to an infectious disease is not a reason to defer a vaccine.

4) Which heart defect should the nurse suspect for an infant whose upper extremities have stronger pulses than the lower extremities and blood pressure is higher in the arms than in the legs? 1. Transposition of the great vessels 2. Patent ductus arteriosus 3. Coarctation of the aorta 4. Atrial septal defect

Answer: 3 Explanation: 1. These defects are not associated with blood pressures that are different in upper and lower extremities. 2. These defects are not associated with blood pressures that are different in upper and lower extremities. 3. 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. 4. These defects are not associated with blood pressures that are different in upper and lower extremities.

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

Answer: 3 Explanation: 1. This action would be appropriate only in nonemergency situations. 2. This action would be appropriate only in nonemergency situations. 3. The nurse should immediately recognize the symptoms of severe upper respiratory distress and advise the parent to call 911. 4. This action would be appropriate only in nonemergency situations.

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

Answer: 3 Explanation: 1. This is a mild allergic reaction and does not require calling 911. 2. A slight temperature does not require calling 911. 3. This could be the onset of anaphylaxis, and immediate response is essential to the survival of the child. The mother should call 911. 4. This is a common reaction to immunizations and does not indicate anaphylaxis. Page Ref: 1058

17) A toddler is admitted to the surgical unit for a planned closure of a temporary colostomy. Which medical prescription should the nurse question? 1. Clear liquids today. NPO tomorrow 2. Type and cross-match for 1 unit of packed red blood cells. 3. Rectal temperatures every 4 hours 4. Start an intravenous line with D5NS at 20 mL per hour.

Answer: 3 Explanation: 1. This is appropriate in anticipation of surgery. 2. Although not always required during surgery, this would not be inappropriate planning for the surgical procedure. 3. Rectal temperatures are avoided due to the fragile state of the rectum. 4. An IV is appropriate for surgical access.

3) Which is a therapeutic nursing response when the mother of a pediatric client diagnosed with cancer states, "I regret not seeking medical attention earlier for my child."? 1. "You may feel guilty, but you should not blame yourself." 2. "Most cancers can be treated easily." 3. "Many types of cancer are difficult to diagnose and might not show early symptoms." 4. "Early diagnosis is not significant in the diagnosis and management of cancer."

Answer: 3 Explanation: 1. This is not a therapeutic response. It is not appropriate for the nurse to tell the family how they should feel. 2. This answer is not accurate, as cancer is generally prolonged and difficult for both the child and family. 3. Many cancers do not present significant findings until late and can progress rapidly. Giving such information is a communication tool. 4. Outcomes for many cancers are improved with early diagnosis.

27) Which functions of white blood cells (WBCs) should the nurse include in a teaching session for the family of a pediatric client who is diagnosed with human immunodeficiency virus (HIV)? Select all that apply. 1. Carry oxygen from the lungs to the tissues 2. Return carbon dioxide from the tissues to the lungs 3. Assist the body to fight infection 4. Assist the body to fight allergens 5. Form hemostatic plugs to stop bleeding

Answer: 3, 4 Explanation: 1. A function of red blood cells, not WBCs, is to carry oxygen from the lungs to the tissues. 2. A function of red blood cells, not WBCs, is to return carbon dioxide from the tissues to the lungs. 3. A function of the WBCs is to fight infection. 4. A function of the WBCs is to fight allergens. 5. A function of platelets, not WBCs, is to form hemostatic plugs to stop bleeding.

20) Which pediatric client diagnoses necessitate close monitoring for respiratory alkalosis? Select all that apply. 1. Aspiration 2. Epiglottitis 3. Sepsis 4. Meningitis 5. Cystic fibrosis

Answer: 3, 4 Explanation: 1. Aspiration places the pediatric client at risk for respiratory acidosis. 2. Epiglottitis places the pediatric client at risk for respiratory acidosis. 3. Sepsis places the pediatric client at risk for respiratory alkalosis. 4. Meningitis places the pediatric client at risk for respiratory alkalosis. 5. Cystic fibrosis places the pediatric client at risk for respiratory acidosis.

29) Which clinical manifestations does the nurse anticipate for a pediatric client who is diagnosed with the subacute stage of Kawasaki disease? Select all that apply. 1. High fever 2. Diarrhea 3. Thrombocytosis 4. Joint pain 5. Beau lines

Answer: 3, 4 Explanation: 1. High fever is a clinical manifestation anticipated for a pediatric client diagnosed with the acute stage of Kawasaki disease. 2. Diarrhea is a clinical manifestation anticipated for a pediatric client diagnosed with the acute stage of Kawasaki disease. 3. Thrombocytosis is a clinical manifestation anticipated for a pediatric client diagnosed with the subacute stage of Kawasaki disease. 4. Joint pain is a clinical manifestation anticipated for a pediatric client diagnosed with the subacute stage of Kawasaki disease. 5. Beau lines are a clinical manifestation anticipated for a pediatric client diagnosed with the convalescent stage of Kawasaki disease.

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

Answer: 3, 4 Explanation: 1. Poliovirus is an example of a killed virus vaccine that is used to decrease the risk of communicable diseases. 2. Tetanus is an example of a toxoid vaccine that is used to decrease the risk of communicable diseases. 3. Measles is an example of a live virus vaccine that is used to decrease the risk of communicable diseases. 4. Varicella is an example of a live virus vaccine that is used to decrease the risk of communicable diseases. 5. Hepatitis B is an example of a recombinant vaccine that is used to decrease the risk of communicable diseases.

21) Which interventions should the nurse include in the plan of care for a pediatric client who is receiving peritoneal dialysis in the treatment of chronic renal failure to prevent infection? Select all that apply. 1. Provide small, frequent meals. 2. Avoid battles over nutritional intake. 3. Administer supplements by tube feedings, if needed. 4. Implement hand hygiene frequently. 5. Perform daily catheter site care.

Answer: 3, 4 Explanation: 1. This intervention is appropriate to meet the child's nutritional needs; however, this will not prevent infection. 2. This intervention is appropriate to meet the child's nutritional needs; however, this will not prevent infection. 3. This intervention is appropriate to meet the child's nutritional needs; however, this will not prevent infection. 4. Aseptic technique reduces chance of introducing bacteria into the abdomen. 5. Skin around the catheter site will have fewer organisms that could potentially cause infection.

7) The nurse is planning care for a school-age client who is postoperative for the surgical removal of the appendix. In addition to pharmacologic pain management, which should the nurse include in the plan of care to address pain? 1. Applying a warm, moist pack every 4 hours 2. Applying EMLA cream to the incision site prior to ambulation 3. Applying a cold, moist pack every 2 hours 4. Applying a pillow against the abdomen to splint the incision site when coughing

Answer: 4 Explanation: 1. Heat and moisture are not used on the incision area, as they can impair the healing process of the wound. 2. EMLA cream is a medication that requires a prescription. 3. Heat and ice are not used on the incision area, as they can impair the healing process of the wound. 4. A splint pillow placed on the abdomen is a nonpharmacologic strategy to decrease discomfort after an appendectomy.

1) The nurse is providing care for a pediatric client who is diagnosed with a Wilms tumor. Which laboratory test result should the nurse monitor prior to administering the prescribed chemotherapy dose? 1. Hemoglobin 2. Red blood cell count 3. Platelets 4. Absolute neutrophil count (ANC)

Answer: 4 Explanation: 1. Hemoglobin indicates oxygen-carrying capacity, not immune response. 2. Red blood cell count has no correlation with immune function. 3. Platelets are associated with clotting, not immune function. 4. The absolute neutrophil count uses both the segmented (mature) and bands (immature) neutrophils as a measure of the body's infection-fighting capability.

5) Which immunization should the nurse include in a teaching session for parents of a toddler-age client to decrease the risk for epiglottitis? 1. Hepatitis B 2. Polio 3. Measles, mumps, and rubella (MMR) 4. Haemophilus influenzae type B (HIB)

Answer: 4 Explanation: 1. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis. 2. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis. 3. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis. 4. The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis.

5) The nurse is providing care to homeless adolescents at an outreach clinic. Which concept is important for the nurse to consider when providing care to this population? 1. Teens who are homeless will get a job and somewhere to live. 2. Teens who are homeless will seek help when needed. 3. Teens who are homeless will not be fearful of authority figures. 4. Teens who are homeless are most likely to have unprotected sex.

Answer: 4 Explanation: 1. Homeless teens are less likely to obtain employment and a place to live, as often these teens do not have the skills to be able to accomplish such tasks. 2. Homeless teens are less likely to seek help when needed, frequently because of mistrust of others. 3. Homeless teens are generally fearful and distrustful of authority figures. 4. Teens who are homeless are more likely to engage in risky behaviors, such as unprotected sex with multiple partners and substance abuse. They are more likely to need emergency care, to be depressed, and to become pregnant than are other teens.

14) Which is the priority nursing action for a premature neonate who is experiencing apnea? 1. Administering oxygen 2. Performing back blows and chest thrusts 3. Calling a code blue 4. Providing stimulation by stroking the back

Answer: 4 Explanation: 1. If the infant is not breathing, oxygen will not help. 2. This is intervention for choking, not apnea. 3. A code is not the initial response. If the nurse is unable to restart breathing, then a code should be initiated. 4. Tactile stimulation is often sufficient to restart the infant's respirations. Apnea of prematurity is due to immaturity of the respiratory center.

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

Answer: 4 Explanation: 1. IgM is the first antibody produced with primary immune response. It does not cross the placenta. 2. IgA does not cross the placenta. 3. Although the function of IgD is not fully understood, it is not thought to cross the placenta. 4. IgG crosses the placenta and provides the newborn with passive immunity.

9) Which teaching point should the nurse include in the discharge instructions for a pediatric client who has undergone cardiac surgery? 1. Should not receive routine immunizations. 2. Should be restricted from most play activities. 3. Fever is expected for several weeks following the surgery. 4. Prophylactic antibiotics are required for any dental, oral, or upper respiratory tract procedures.

Answer: 4 Explanation: 1. Immunizations should be provided according to the schedule. 2. The child should live a normal and active life following repair of a cardiac defect. 3. Fever is not expected for a prolonged period after surgery, and any unexplained fever should be reported. 4. Parents should be taught that the child should receive prophylactic antibiotics to prevent endocarditis.

15) A preschool-age child is being seen in the oncology clinic. Which reaction should the nurse anticipate based on the child's stage of development? 1. Unawareness of the illness and its severity 2. Acceptance, especially if able to discuss the disease with children their own age 3. Understanding of what cancer is and how it is treated 4. Thoughts that they caused their illness and are being punished

Answer: 4 Explanation: 1. Infants and toddlers are unaware of the severity of the disease. 2. Immediate acceptance will not occur with children of any age. Adolescents find contact with others who have gone through their experience helpful. 3. School-age children can understand a diagnosis of cancer. 4. Preschool-age children are egocentric and have magical thinking, and thus they might believe they caused their own illness.

1) The nurse is providing care to a pediatric client, diagnosed with inflammatory bowel disease, who is prescribed daily prednisone. Which parental statement regarding administration of this drug indicates correct understanding of the teaching provided by the nurse? 1. "I will administer this medication between meals." 2. "I will administer this medication at bedtime." 3. "I will administer this medication one hour before meals." 4. "I will administer this medication with meals."

Answer: 4 Explanation: 1. Prednisone can cause gastric irritation and should not be given on an empty stomach. 2. Prednisone can cause gastric irritation and should not be given before bedtime on an empty stomach. 3. Prednisone can cause gastric irritation and should not be given on an empty stomach one hour before meals. 4. Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals to reduce the gastric irritation.

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

Answer: 4 Explanation: 1. Providing the parents information of a chronic health problem of their newborn should not be done over the phone. 2. This information should be provided to the parents in person. 3. This information should be shared on a one-to-one basis. 4. The appropriate environment allows for privacy and freedom from interruptions. The parents should be allowed other support people to be present as they request.

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

Answer: 4 Explanation: 1. Recovery or acceptance is the stage when the person starts to reach out to others. This mother is not there. 2. In this stage of grief behavior, the mother would be making statements such as, "If only..." or "what if ...." 3. The mother is not expressing any hostile feelings. 4. Disorganization or despair is a period of sadness and lethargy. Daily activities seem pointless during this stage.

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

Answer: 4 Explanation: 1. Rectal prolapse is a complication of the large, bulky fatty stools. 2. Constipation is not a symptom of cystic fibrosis. 3. Steatorrhea and rectal prolapse might be signs of cystic fibrosis seen in an older infant or child. 4. Newborns with cystic fibrosis might present in the first 48 hours with meconium ileus.

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

Answer: 4 Explanation: 1. Restraints are used only as a last resort and are not appropriate for an IV start. 2. Moderate sedation has its own side effects and possible complications and should not be used for quick procedures. 3. Drugs may not be used for quick procedures, such as a dressing change or an unexpected intravenous insertion, injection, or venipuncture. 4. Complementary therapies—especially guided imagery, relaxation techniques, and distraction—can reduce the anxiety associated with the anticipation of the procedure.

10) The sibling of a pediatric client diagnosed with leukemia expresses feelings of anger and guilt to the nurse. Which explanation should the nurse provide to the client's parents regarding the reaction of the sibling? 1. Abnormal; the sibling should be referred to a psychologist. 2. Unexpected; the cancer is easily treated. 3. Unusual; the illness does not affect the sibling. 4. Normal; the sibling is affected, too, and anger and guilt are expected feelings.

Answer: 4 Explanation: 1. Siblings are generally affected to some degree, but this a normal reaction. 2. Cancer is not easily treated and will affect the entire family. 3. A diagnosis of cancer affects the entire family; siblings will be affected to some degree. 4. A diagnosis of cancer affects the whole family, and initial feelings experienced by the sibling might be anger and guilt.

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

Answer: 4 Explanation: 1. Some vaccines are stored in the freezer. 2. This is appropriate to maintain potency. 3. The vaccine is still effective until the expiration day. 4. The door will not maintain the temperature of the vaccine. Vaccines should be stored in the middle of the refrigerator.

18) Which nursing action is appropriate when preparing the family of a school-age child with a chronic illness to provide care in the home setting? 1. Teaching the family about appropriate sensory stimuli, such as a mobile 2. Educating the family to allow the child choices, such as which food to eat first 3. Preparing the family for the transition of care into adulthood 4. Encouraging interaction between the child and others with the same diagnosis

Answer: 4 Explanation: 1. Teaching age-appropriate interventions is important; however, a mobile is an age appropriate toy for the infant, not the school-age child. 2. Providing choices is important for the preschool-age child, not the school-age child. 3. Preparing the family for the transition of care into adulthood is important for the adolescent, not school-age, patient. 4. School-age children should be encourages to interact with other child who have the same diagnosis.

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

Answer: 4 Explanation: 1. The 6-week break will not decrease the side effects of nausea and vomiting. 2. Necessary treatment should never be delayed for the convenience of the medical personnel. 3. The 6-week break is not to decrease the incidence of heart failure, as this is not an adverse effect to chemotherapy. 4. Cancer cells have lost the ability to repair themselves, so medications allow the normal cells to repair while the cancer cells die.

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

Answer: 4 Explanation: 1. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales and can usually be used with children 3 years and older. 2. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales and can usually be used with children 3 years and older. 3. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales and can usually be used with children 3 years and older. 4. The FLACC scale is an appropriate tool for infants and young children who cannot report pain.

1) Which is the most appropriate nursing diagnosis for the adolescent diagnosed with cystic fibrosis who is intubated with an endotracheal tube? 1. Anxiety related to leaving chores undone at home 2. Fear of future pain related to medical procedures 3. Risk for Overweight related to inactivity 4. Powerlessness (moderate) related to inability to speak or communicate with friends

Answer: 4 Explanation: 1. The adolescent is oriented to the present, not future, and is unlikely to worry about household chores. 2. The adolescent is oriented to the present, not future, and is unlikely to worry about future unknown procedures. 3. The adolescent with cystic fibrosis is likely to be underweight, and is unlikely to take in more calories than needed while intubated. 4. The adolescent values communication with peers, and might feel frustrated that she cannot speak to them while intubated.

25) Which topic should the nurse include in the discharge instructions for the family of a child who has undergone hematopoietic stem cell transplantation (HSCT)? 1. Avoiding influenza vaccination 2. Returning to school within 6 weeks 3. Maintaining a low-calcium diet 4. Practicing diligent hand hygiene

Answer: 4 Explanation: 1. The child and the family should be encouraged to get yearly influenza vaccinations. 2. The child cannot return to school for 6 to 12 months after an HSCT. In-hospital or in-home schooling is required. 3. The child should be placed on calcium supplements to reduce the risk of osteopenia. 4. Handwashing is essential to prevent the spread of infection.

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

Answer: 4 Explanation: 1. The child has adequate platelets, and administration of platelets will not promote clotting. 2. Whole blood will increase the blood volume without promoting clotting. 3. A unit of packed cells will provide red blood cells (RBCs) but not the factor needed to clot. 4. Factors are located in the plasma. Fresh or fresh frozen plasma will provide the best source of factor available.

4) The nurse is assessing abdominal girth for a pediatric client who presents with abdominal distension. Which nursing action is appropriate? 1. Measuring the girth just below the umbilicus 2. Measuring the girth just below the sternum 3. Measuring the girth just above the pubic bone 4. Measuring the girth around the portion of the stomach

Answer: 4 Explanation: 1. The circumference below the umbilicus would not be an accurate abdominal girth. 2. The circumference just below the sternum would not be an accurate abdominal girth. 3. The circumference just above the pubic bone would not be an accurate abdominal girth. 4. An abdominal girth should be taken around the largest circumference of the abdomen, just above the umbilicus.

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

Answer: 4 Explanation: 1. The glucose value is a laboratory test for checking diabetes. A nucleoside transcriptase inhibitor does not affect glucose values. 2. Sodium is an electrolyte. A nucleoside transcriptase inhibitor does not affect sodium values. 3. Potassium is an electrolyte. A nucleoside transcriptase inhibitor does not affect potassium values. 4. A nucleoside transcriptase inhibitor causes bone marrow suppression with resulting anemia. Red blood cell counts are monitored at least monthly for changes.

3) Which must the nurse realize prior to accepting any assignment as a home health nurse? 1. All decisions will be made by the healthcare provider. 2. Independent decisions regarding emergency care of the child will be made by the nurse. 3. The family will adapt their lifestyle to the needs of the nurse. 4. The family is in charge.

Answer: 4 Explanation: 1. The home health nurse must realize that the family is in charge. 2. The family must provide informed consent for emergency care. 3. The nurse must be flexible and adaptable to the lifestyle of the family. 4. The home health nurse must realize that the family is in charge.

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

Answer: 4 Explanation: 1. The infant is unable to concentrate urine and will continue to void dilute urine. Therefore, this is not the priority nursing assessment for an infant at risk for dehydration. 2. The infant's kidney is immature and unable to concentrate urine. Therefore, this is not the priority nursing assessment for an infant at risk for dehydration. 3. Pulse will elevate and blood pressure may drop, but the other vital sign findings will remain unchanged. However, this is not the best assessment of dehydration. 4. Daily weights on an infant provide the most accurate assessment of fluid balance.

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

Answer: a. "There has to be a cure; are you sure of the diagnosis?" Feedback: The universal reaction to a child's life-threatening condition is shock and disbelief. Anger and guilt surface as parents become more aware of their child's illness or injury (blaming the wife for drinking wine). As the parents move to the stages of deprivation and loss they become ambivalent and release their responsibility ("We weren't ready, what do we do now?"). Mourning is the last stage and occurs when the child remains seriously ill or unresponsive, when the outcome remains uncertain for an extended period, or when long-term care is required ("What are we going to do without her?").

A mother of a child diagnosed with a potentially life-threatening form of cancer says to the nurse, "I don't understand how this could happen to us. We have been so careful to make sure our child is healthy." Which response by the nurse is most appropriate? a. "This must be a difficult time for you and your family. Would you like to talk about how you are feeling?" b. "Why do you say that? Do you think that you could have prevented this?" c. "Many children are diagnosed with cancer. It is not always life-threatening." d. "You shouldn't feel that you could have prevented the cancer. It is not your fault."

Answer: a. "This must be a difficult time for you and your family. Would you like to talk about how you are feeling?" Feedback: Parents of children diagnosed with cancer require major emotional support and should be allowed to express their feelings.

The nurse is teaching a prenatal class about respiratory infections. Which statement by a parent indicates that further teaching is necessary? a. "When my newborn has a stuffy nose, he will be okay because newborns are obligatory mouth breathers." b. "Children's narrower airways cause them to breathe harder when they are congested." c. "The only time a newborn breathes through the mouth is when he's crying." d. "I should keep my newborn's nose clean so he can breathe and eat without difficulty."

Answer: a. "When my newborn has a stuffy nose, he will be okay because newborns are obligatory mouth breathers." Feedback: Newborns are obligatory nose breathers. The only time newborns breathe through the mouth is when they are crying. The other statements by the parent are correct.

Following a motor vehicle accident and successful cardiopulmonary resuscitation, arterial blood gases are drawn from a 13-year-old client. What will the nurse identify as the result of this test? a. Acid-base balance b. Prognosis c. Capillary metabolic exchange d. Carbonic acid level

Answer: a. Acid-base balance Feedback: The test provides information about immediate status of the client's acid-base balance. It will not provide data that can predict future outcomes. Capillary blood gases are done on newborns and infants to decrease the amount of blood used, but that is not the test referred to in this question. Carbonic acid contributes to the acid-base balance, but is not measured specifically in this test as a percentage.

Assessment of a 2-year-old by a nurse in the emergency department reveals the following: edema, hematuria, hypertension, and oliguria. What would the nurse assess as the most likely cause of these symptoms? a. Acute renal failure b. Urinary tract infection c. Vesicoureteral reflux d. Bladder exstrophy

Answer: a. Acute renal failure Feedback: There are several things that can cause acute renal failure, including hemolytic uremic syndrome, nephritic syndrome, and severe dehydration. Most children with acute renal failure are admitted to a pediatric intensive care unit. A urinary tract infection would not cause any of the listed symptoms. Bladder exstrophy is a congenital defect discovered at birth. Vesicoureteral reflux is a backflow of urine from the bladder to the kidneys.

A school nurse is planning on speaking with parents at the 8th-grade PTA meeting. Which topic is important? a. An increase in physical education requirements for all students b. Required equipment for managing pediatric emergencies c. Clinical procedures and linking with community resources d. How to assess for changes in airway and circulation

Answer: a. An increase in physical education requirements for all students Feedback: School nurses advocate for the children as policies are developed for the school community, such as nutritious school breakfasts and lunches, recess, and physical education classes for all students. Nurses based in a healthcare center, clinic, or hospital will provide topics on required emergency equipment for managing pediatric emergencies, and information about clinical procedures and community resources.

A 3-year-old diagnosed with a brain tumor is discharged from the hospital following brain surgery. Which response by the parents indicates discharge teaching was successful? a. "My child can begin radiation treatments now that he's discharged." b. "We have to make sure to watch for a decrease in urine." c. "Children with brain tumors have an increased rate of development." d. "The American Medical Association (AMA) is a resource for assistance."

Answer: a. "My child can begin radiation treatments now that he's discharged." Feedback: The child diagnosed with a brain tumor does not begin chemotherapy or radiation until after discharge from the hospital. Signs and symptoms of diabetes insipidus may occur following brain surgery, so the parents need to watch for an increase in urine production. Children with brain tumors may have slowed development, incoordination, learning disabilities, or other effects. The American Cancer Society is a potential resource for assistance, not the AMA.

The nurse is caring for a school-age child who has chronic fluid overload with edema, and teaches the parents about skin care for their child. Which statement by the parents indicates the need to review the material further? a. "Pajamas sound ideal for clothes." b. "Places where the skin rubs together are risk areas for breakdown." c. "It is best to buy clothes that are loose-fitting, so they do not rub the skin." d. "We should check the skin daily to look for any red areas."

Answer: a. "Pajamas sound ideal for clothes." Feedback: The statement "Pajamas sound ideal for clothes" indicates further review is necessary. Dressing the child in pajamas promotes the sick role, singles the child out, and does not promote self-esteem. Body image is a concern with edema. The remaining statements are appropriate.

A parent questions the nurse regarding why her child requires assessment with the Denver Developmental Screening Test prior to surgery for a brain tumor. What would be the most appropriate response by the nurse? a. "The results will provide a baseline to compare with after surgery." b. "The Denver Developmental Screening Test assesses cognitive development." c. "The Denver Developmental Screening Test assesses the growth of the child." d. "A Denver Developmental Screening Test is conducted on every child."

Answer: a. "The results will provide a baseline to compare with after surgery." Feedback: Having a baseline assessment is important so that deficits postsurgery can be monitored. The Denver Developmental Screening Test is not an assessment of growth or cognitive abilities. Also, not every child is given the Denver Developmental Screening Test.

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

Answer: 4 Explanation: 1. Antibiotic therapy does not cause incontinence. 2. Urinary incontinence is not a symptom of cystic fibrosis. 3. There are no symptoms of a urinary tract infection (UTI). 4. Regression is a common response to hospitalization.

27) Which medication should the nurse include in a pamphlet to educate parents about methods to reduce the risk of children developing Reye syndrome? 1. Antibiotics 2. Acetaminophen 3. Ibuprofen 4. Aspirin

Answer: 4 Explanation: 1. Antibiotics are not associated with Reye syndrome. 2. Acetaminophen is not associated with Reye syndrome. 3. Ibuprofen use is not associated with Reye syndrome. 4. Administering aspirin to a child with a viral illness has been found to be associated with Reye syndrome.

25) Which is an appropriate statement for the nurse to include in the discharge instructions to the parents of a child who is recovering from cardiac surgery? 1. "The child will have a fever for several weeks following the surgery." 2. "The child will be restricted from most play activities." 3. "The child will not receive routine immunizations." 4. "The child will receive prophylactic antibiotics prior to any dental procedures."

Answer: 4 Explanation: 1. Any unexplained fever should be reported. 2. The child should live a normal and active life following repair of a cardiac defect. 3. Immunizations should be provided according to the schedule. 4. Parents should be taught that the child should receive prophylactic antibiotics to prevent endocarditis, according to the American Heart Association.

5) A school-age client diagnosed with rheumatoid arthritis (RA) wants to participate in the school sports programs. The client asks the nurse to recommend a sporting activity that is appropriate. Which activity would be the most appropriate for the nurse to recommend? 1. Baseball 2. Basketball 3. Football 4. Swimming

Answer: 4 Explanation: 1. Baseball places stress on the knee joints. 2. Basketball involves running, which will stress the joints. 3. All positions in football will cause stress to the joints. 4. Swimming helps to exercise all the extremities without putting undue stress on joints

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

Answer: a. Anger related to the crisis of child's condition Feedback: The nurse recognizes that parents might express a range of strong emotions during a crisis involving severe injury to their child. Parents often will lash out at the closest target, the staff. No data suggest lack of trust in the nurse or incompetence of the staff. Although the father's anger might stem from a feeling of guilt over the accident, this is not the most accurate nursing diagnosis, because it does not address the father's principal behavior of anger.

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

Answer: a. Anticipatory Grieving related to child's deteriorating health status Feedback: The parent is preparing for the worst outcome and expresses an intuition. There is no behavioral evidence of problems with family coping, deficient knowledge, or impaired parenting.

In addition to an impaired gas exchange, which other diagnosis will a child in the early stages often have as well? a. Anxiety related to hypoxia b. Fatigue related to air trapping c. Injury related to fatigue and dehydration d. Delayed Development related to hypoxia

Answer: a. Anxiety related to hypoxia Feedback: Air trapping is not present in all cases of impaired gas exchange. Delayed development does not occur unless the condition is chronic or acutely damaging. The early phase of impaired gas exchange does not cause injury or dehydration, although fatigue can occur.

An 8-year-old client is brought into the emergency department with profound anemia and pallor. The mother states, "He was so sick last month with fifth disease and now this." Which complication does the nurse suspect? a. Aplastic sickle cell crisis b. Vaso-occlusive crisis c. Spherocytosis d. Hemophilia

Answer: a. Aplastic sickle cell crisis Feedback: Aplastic crisis is triggered by infection with parvovirus B19 (fifth disease) or a depletion of folic acid. Vaso-occlusive crisis is caused by blood stasis brought on by dehydration, temperature extremes, infection, hypoxemia, or physical or emotional stress. Spherocytosis is a type of of hereditary anemia and hemophilia is a blood disorder; they are not complications of disease.

Two children believe they hurt their brother, who is hospitalized with renal failure. Which is the most important nursing intervention for the siblings? a. Ask the siblings what makes them think they hurt their brother. b. Explain why the ill child has an IV and a urinary catheter. c. Ask the children if the hospital is frightening to them. d. Refer the siblings for counseling.

Answer: a. Ask the siblings what makes them think they hurt their brother. Feedback: The nurse must dispel the siblings' irrational fears and guilt. Referral for counseling is necessary if the siblings had some involvement or responsibility in a health crisis. Explanations of the IV, the catheter, renal dialysis, and the hospital are appropriate nursing interventions, but not the most important ones at this time.

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

Answer: a. Assess the family's understanding of leukemia. Feedback: A child with leukemia has a life-threatening chronic condition that requires ongoing nursing and medical care. The nurse first must assess whether the family understands the gravity of the child's condition and required treatment. Demonstrating respect for the family's wishes does not protect the child's life.

A 3-year-old was diagnosed with acquired aplastic anemia. The nurse is reviewing her medical history and medication list. Which treatment or condition does the nurse suspect is the reason for this diagnosis? a. Vitamin B12 deficiency b. Hemophilia c. Ingestion of vitamin C d. Sickle cell anemia

Answer: a. Vitamin B12 deficiency Feedback: Acquired aplastic anemia in children can be related to nutritional deficiencies in vitamin B12 or folic acid. Hemophilia is a blood disorder not associated with aplastic anemia. The ingestion of vitamin C or sickle cell anemia does not cause acquired aplastic anemia.

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

Answer: b. Administer the pain medication as ordered. Feedback: Postoperatively, the nurse should provide comfort and pain relief. Nonpharmalogical methods help to decrease anxiety and thus pain perception. The child is not exhibiting signs of anxiety and says the pain is an 8 on a scale of 1 to 10. The child is 6-years old and postop surgery; she is capable of verbally expressing the need for pain medication.

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

Answer: b. Documenting mucous membrane moisture every shift; d. Recording intake and output accurately; e. Evaluating level of consciousness continuously Feedback: All of the choices represent assessment measures that evaluate the effectiveness of therapy except abdominal girth, which does not provide information regarding hydration status, and daily weights on a rotating schedule. Daily weights should be done, but they must be completed on the same scale at the same time each day while the infant is wearing no clothing.

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

Answer: b. Explain the procedure in simple terms. Feedback: Preschoolers have the cognitive ability to understand simple terms. Use of the favorite doll is contraindicated because it is part of that child, and the child might perceive that the doll is experiencing pain.

A school nurse teaches a coaching staff about heat-related illnesses. Which action by a coach indicates to the nurse that teaching was effective? a. Sleep 2-3 hours in the middle of the day during all-day practice. b. Have cell phones or other mechanisms to call for emergency assistance. c. During activity, stop for fluids every 30 minutes. d. Allow 1-2 hours' rest during the middle of the day, with fluids and food provided.

Answer: b. Have cell phones or other mechanisms to call for emergency assistance. Feedback: Rest 2-3 hours during the day of all-day practice, but sleep is not required. Stop for fluids every 15-20 minutes. It is essential to have a means of communication in case of emergency.

Which issue is important to discuss when educating a family about nocturnal enuresis? a. Limit daytime fluids. b. Have the child double-void before going to bed. c. Administer laxatives daily. d. Refer the child to counseling immediately.

Answer: b. Have the child double-void before going to bed. Feedback: Counseling is not always indicated. Promoting regular stools and having the child double-void before bed are appropriate interventions. Limiting daytime fluids has not been shown to be effective.

A child with cancer has the following lab result: WBC 10,000 mcg/L, RBC 5 mcg/L, and platelets 20,000 mcg/L. Which risk should the nurse consider most significant, when planning this child's care? a. Pain b. Hemorrhage c. Infection d. Anemia

Answer: b. Hemorrhage Feedback: The lab values presented are within normal range, except for the platelet count. Decrease in platelet count places the child at greatest risk for hemorrhage.

Following an accident, a 6-year-old child requires IV therapy. Before IV insertion, the nurse plans to: a. Tell the child not to move his left arm. b. Immobilize the arm with a molded, padded splint. c. Ask the parents to restrain the child. d. Provide the child with a diversional activity.

Answer: b. Immobilize the arm with a molded, padded splint. Feedback: The nurse must maintain the child's comfort and safety. A child is not always able to hold still during a painful procedure. Parents should be asked to provide comfort and support, not to restrain their child. A diversional activity may be provided after a procedure.

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

Answer: b. Impaired Gas Exchange Feedback: Although all these diagnoses are important, impaired gas exchange alters oxygenation and decreases the cellular exchange of O2 and CO2, making it the priority.

The nurse is preparing a pediatric client for a barium enema. Which diagnosis would support the need for this diagnostic test? a. Gastroschisis b. Intussusception c. Appendicitis d. Pyloric stenosis

Answer: b. Intussusception Feedback: Intussusception occurs when the intestine invaginates into another, causing pain with vomiting and passage of brown stool. The stools eventually can resemble currant jelly. Pyloric stenosis is a stenosis between the stomach and duodenum. Gastroschisis is a congenital defect where there is herniation of abdominal contents outside the abdominal wall. Appendicitis is an inflammatory process of the appendix

The school nurse sees a 14-year-old child who presents with fatigue and a nagging cough of 3 weeks' duration that has become productive with thick mucus and is much worse at night. The school nurse suspects pertussis (whooping cough), because vaccine protection wanes in 5-10 years. What is the school nurse's first nursing action? a. Provide emotional support to the parents. b. Isolate the child and contact the parents. c. Encourage fluids to prevent dehydration. d. Report the case to the Centers for Disease Control and Prevention (CDC).

Answer: b. Isolate the child and contact the parents. Feedback: Isolation is necessary to prevent the disease from spreading to classmates by aerosolized droplet infection. The case is not reportable until a positive culture is returned. The remaining interventions are important but are not the first nursing action, because the entire school population might be at risk.

Which condition in males would the nurse assess as a medical emergency? a. Cryptorchidism b. Testicular torsion c. Phimosis d. Inguinal hernia

Answer: b. Testicular torsion Feedback: Testicular torsion is a medical emergency and should be surgically repaired within 4-6 hours of onset. The testis rotates on its spermatic cord, obstructing blood supply. Inguinal hernia is when a portion of abdominal cavity protrudes into the groin. It is usually repaired after 3 months of age and is not considered emergent unless the hernia is incarcerated. Cryptorchidism is when a testicle is not descended. It is present at birth, and if the testicle does not descend by 1-2 years of age, it is repaired. Phimosis is when the skin around the glans of the penis is not retractable by young childhood.

Which behavior indicates that a 10-year-old girl with diabetes has achieved an expected outcome for the nursing diagnosis of Knowledge Deficit (child) related to learning self-care skills? a. The child participates in a diabetes support group. b. The child demonstrates correct technique of withdrawing insulin from the vial. c. The child verbalizes fear in giving injections to herself. d. The child asks her parents to check her blood sugar.

Answer: b. The child demonstrates correct technique of withdrawing insulin from the vial. Feedback: Correct technique of insulin withdrawal is an observable behavior that shows that the child has learned a self-care skill for her diabetes. The other answers are behaviors but are not related to a knowledge deficit of self-care skills.

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

Answer: b. The child reports experiencing reduced pain and improved comfort. Feedback: A goal is a statement of what will happen in the future as a result of nursing interventions. Therefore, the goal is "The child will experience reduced pain and improved comfort." Receiving analgesic medication and being allowed to rest between painful procedures are nursing interventions. An outcome documents that a goal is met in the present. Therefore, the statement "The child experiences an improvement in comfort level" is an outcome. A child being easily distracted still might experience pain.

A nurse is evaluating a parent performing a clean intermittent catheterization on a pediatric client. What would be an indication that the parent needs additional teaching? a. The parent uses a size 4 catheter for the procedure. b. The parent states that the child should be awakened once during the night to be catheterized. c. The parent uses a water-soluble lubricant to coat the end of the catheter. d. The parent uses gentle pressure to advance the catheter if resistance is met.

Answer: b. The parent states that the child should be awakened once during the night to be catheterized. Feedback: It is necessary to perform intermittent catheterization every 3-4 hours but not while the child is sleeping at night. A size 4 or 5 catheter is used for the procedure. A water-soluble lubricant, not Vaseline, is used. In males, the sphincter muscle located at the entrance to the bladder will cause resistance to the catheter, but with gentle pressure, the catheter will advance into the bladder.

The nurse serving as a consultant in the child care setting observes a teacher changing a child's diaper. Which observation would indicate a need for further training related to diaper changing? a. The teacher washes the child's hands after completing the diaper change. b. The teacher uses a washcloth to clean the diapered area. c. The teacher places soiled clothing in a plastic bag. d. The teacher removes her gloves and places them in the diaper pail.

Answer: b. The teacher uses a washcloth to clean the diapered area. Feedback: All of the behaviors are correct diaper-changing procedures except for using a washcloth to clean the child's bottom. In the child care setting, disposable wipes should be used.

A child is diagnosed with lupus and is experiencing a skin exacerbation. What should the nurse encourage the parents to do when providing care in order to decrease the risk factors associated with exacerbation in skin? a. Provide oral rehydration products. b. Use sunscreen products of 30 SPF. c. Use antimicrobial soap. d. Provide a high-protein diet.

Answer: b. Use sunscreen products of 30 SPF. Feedback: Exposure to sunlight can increase the risk of exacerbation in lupus. Maintaining good hydration, hygiene, and nutrition would not prevent the exacerbation of lupus.

The nurse notes several changes in the past 24 hours in a child with heart failure. Which finding is the most significant in assessing the child for fluid volume overload? a. Presence of lung crackles b. Weight gain of .4 kg c. Bounding pulse d. Jugular venous distention

Answer: b. Weight gain of .4 kg Feedback: All are signs of fluid volume overload. However, an increase of weight is always the best indicator of an increase in fluid. The other options indicate heart failure as a result of the increase in fluid.

The nurse in the primary care setting has assessed each of the following children briefly. Which child should be seen first by the primary healthcare provider? a. A 6-month-old with fever and congestion b. A 5-day-old scheduled for a weight check c. A 3-year-old who is lethargic and vomiting d. A 10-year-old with a knee injury

Answer: c. A 3-year-old who is lethargic and vomiting Feedback: While it is important for all of the children to be seen, it is most important that the child who is lethargic and vomiting be seen first. These symptoms might be indicative of serious infection, such as meningitis. When all children can wait to be seen, the child who arrives first or has a scheduled appointment would take priority. When a child presents in distress, or with serious symptoms, the nurse must prioritize and make sure this child is seen first.

Which client would the nurse suspect to have pyloric stenosis? a. A 7-month-old with choking episodes b. An 11-year-old with an olive-shaped abdominal mass c. A 5-week-old infant with projectile vomiting d. A 2-year-old with a harsh cough

Answer: c. A 5-week-old infant with projectile vomiting Feedback: The most likely incidence of pyloric stenosis is in a 2- to 8-week-old infant. The common symptoms are nonbilious projectile vomiting, irritability, and failure to gain weight.

Which nursing intervention is directed to the school-age child's independent management of asthma symptoms? a. Assess the child and family's level of understanding of asthma. b. Discuss with the child how to tell friends about asthma. c. Encourage the child to use his flowmeter and record the results every day. d. Teach the parents the proper use of inhalers.

Answer: c. Encourage the child to use his flowmeter and record the results every day. Feedback: Among the answer choices, only encouraging the child to use his flowmeter and recording results every day is directed toward independent self-care. The other nursing interventions are all important, but they do not address the child's independent management of symptoms.

An adolescent experiencing status asthmaticus was rushed to the emergency department by ambulance and was pronounced dead on arrival. The parents arrive and ask to see their child. Which intervention by the triage nurse is best for this situation? a. Politely ask the parents to take a seat in the waiting room. b. Tell the parents to wait for the doctor in the ED waiting area. c. Escort the parents immediately to a quiet, private room. d. Tell the parents, "I'm sorry, but your child didn't make it."

Answer: c. Escort the parents immediately to a quiet, private room. Feedback: The best nursing intervention is to give the parents an appropriate environment before they are told the news, so that they may begin grieving privately. Asking parents to wait and telling them the news in public are uncaring and insensitive. Nurses as well as primary healthcare providers are capable of breaking bad news to families with caring and empathy.

A 2-year-old was admitted to the hospital in critical condition after ingesting about 20 children's chewable vitamins with iron 2 days ago. The mother said, "Since it was his vitamins, I didn't think it was a poison." Which is the most appropriate nursing intervention in this situation? a. Question the mother regarding her knowledge of other child safety risks. b. Teach the mother about the dangers of iron poisoning. c. Explain the child's condition and what is being done at this time for the child. d. Explain the open visiting policy for parents.

Answer: c. Explain the child's condition and what is being done at this time for the child. Feedback: Nurses must be nonjudgmental, not punitive, to facilitate trust with families. Now is not an appropriate time to teach the mother about iron poisoning; this will reinforce her guilt. The parents' most important identified need is for information about their child's condition and the child's medical and nursing interventions. The visiting policy is secondary.

Which instructions would the nurse provide to the family of a child who has undergone a hypospadias repair? (Select all that apply.) a. Avoid tub baths until the catheter is removed. b. Notify the primary healthcare provider if there is blood in the urine. c. The child should avoid the straddling position with play. d. It is important that the catheter be left in place. e. Notify the primary healthcare provider if the child goes more than 30 minutes without urine output.

Answer: a. Avoid tub baths until the catheter is removed; c. The child should avoid the straddling position with play; d. It is important that the catheter be left in place. Feedback: The nurse should discuss with the family the importance of leaving the catheter in place, notifying the primary healthcare provider if the child goes more than 1 hour without urine output, notifying the primary healthcare provider if the child avoids the straddling position with play, and avoiding baths until the catheter is removed. It is normal to see blood-tinged urine for several days after surgery.

For what condition does the nurse taking care of a 5-year-old newly diagnosed with Crohn disease teach the parents that their son may be at risk later? a. Cancer b. Malabsorption c. Atresia d. Hepatitis

Answer: a. Cancer Feedback: The risk of cancer is greatly increased for the child diagnosed with Crohn disease. Symptoms of Crohn disease include cramped abdominals followed by diarrhea, fever, anorexia, growth failure or weight loss, general malaise, and joint pain. The risks for malabsorption, atresia, and hepatitis do not increase in clients with Crohn disease.

A community health nurse is educating a high school class about sexually transmitted infections (STIs). Which information should be included in the presentation? a. Chlamydia can be asymptomatic. b. Ejaculation must occur for gonorrhea to be transmitted. c. A condom will protect teenagers from getting herpes. d. Intercourse is the only means of transmitting STIs.

Answer: a. Chlamydia can be asymptomatic. Feedback: Abstinence from all forms of sexual contact will protect a teenager from getting an STI. Many people have Chlamydia without knowing it, as it can be asymptomatic. A condom does not always protect a teenager from getting herpes, because the herpes lesion might not be covered by the condom and the condom might break. Gonorrhea can be transmitted without ejaculation.

The mother of a 2-year-old calls the clinic nurse in a panic, stating, "I think my child swallowed a marble!" Which signs does the nurse know are indicative of a foreign-body aspiration? a. Coughing and dysphonia b. Fear and wheezing c. Hypoxia and choking d. Nasal flaring and crying

Answer: a. Coughing and dysphonia Feedback: Clinical manifestations of foreign body aspiration include a sudden onset of choking, spasmodic coughing, shortness of breath, or dysphonia. Fear, wheezing, hypoxia and nasal flaring are later signs of progressing respiratory distress.

A parent asks the nurse why limiting the amount of time the child feeds is important in the care of the child with congestive heart failure. Which response by the nurse is the most appropriate? a. Resting is essential in the care of the newborn with congestive heart failure. b. Calories are not a major concern in congestive heart failure. c. Extending feeding time consumes calories required for the infant to gain weight. d. Limiting fluids is necessary in congestive heart failure.

Answer: c. Extending feeding time consumes calories required for the infant to gain weight. Feedback: An infant with congestive heart failure requires more calories than a healthy infant. Prolonged feedings use more calories and increase the workload of the heart.

A nurse is caring for an 11-month-old infant admitted for watery, green diarrhea; vomiting; and fever. He is diagnosed with gastroenteritis with no known source at this time. Which nursing diagnosis should be the highest priority? a. Altered Nutrition b. Anxiety related to hospitalization c. Fluid Volume and Electrolyte Imbalance d. Altered Family Coping

Answer: c. Fluid Volume and Electrolyte Imbalance Feedback: Fluid and electrolyte imbalance is a safety issue and a potentially life-threatening event. Although all of the diagnoses should be addressed, this takes precedence.

A child is recently diagnosed with juvenile rheumatoid arthritis (JRA). What is of priority for this child and family? a. Anxiety reduction b. Optimum nutrition c. Growth and development d. Education

Answer: c. Growth and development Feedback: Although all of the answer choices are important, promoting growth and development is essential for a child in order for her to meet developmental tasks.

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

Answer: c. Knowledge Deficit (parent): Potential Side Effects of Vaccines related to lack of correct information Feedback: The father has incorrect information on immunizations, and is experiencing a knowledge deficit. The other nursing diagnoses are appropriate for the child, not the father, in this situation.

A hospitalized 9-year-old states that he does not understand why he needs to have an operation. Based on this statement, what is the most appropriate nursing diagnosis for this child? a. Social Isolation related to hospitalization b. Fear of Mutilation related to surgical procedure c. Knowledge Deficit: Need for Surgery related to lack of previous teaching d. Anxiety related to surgery

Answer: c. Knowledge Deficit: Need for Surgery related to lack of previous teaching Feedback: Although all of the diagnoses might be appropriate, the one that corresponds directly to the child's statement is Knowledge Deficit related to need for surgery.

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

Answer: a. Helmet use when riding a bike Feedback: Helmets, knee pads, and elbow pads all decrease the chance of injury with activities such as biking, Rollerblading, riding scooters, and roller-skating. The use of protective gear at roller-skating rinks generally is not a common practice. In general, a fall at the skating rink would not cause nearly the amount of severe injury as a bad fall would cause a child who bikes without a helmet. The child who rides a bicycle without a helmet is at highest risk for severe head injury.

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

Answer: c. Numeric scale Feedback: The FLACC scale is an observation scale used primarily with infants and preverbal children. Although the FACES scale and poker chip tool can be used for adolescents, a client this age should be very capable of using a numeric scale. The FACES scale and the poker chip tool are most appropriate with preschool- and young school-age children.

How does the nurse provide continuity of care for a family of six who has a mentally disabled 7-year-old? a. Include all family members in all decision making. b. Support the family by developing an IEP. c. Assist the family in identifying a caretaker. d. Provide guidance and resources for the family

Answer: a. Include all family members in all decision making. Feedback: When providing continuity of care for a child with a chronic condition, the nurse should include the family and older child in all decision making. The IEP is an education plan that is made with the school administrator, teacher, parents, and other special support professionals as appropriate for the child's condition. The nurse can identify appropriate resources to help the family connect with local community resources to identify services needed for supportive care of the child and family.

A child is diagnosed with lupus and is placed on steroid therapy. Which diet should be included in the child's plan of care? a. Increased calcium b. Increased protein c. Increased carbohydrates d. Increased iron

Answer: a. Increased calcium Feedback: Iron is needed in anemia, protein is needed to promote tissue healing, and carbohydrates are needed for increased energy. An increase in calcium is needed for persons undergoing steroid therapy.

Which condition is a special consideration the nurse keeps in mind when taking care of a child with a brain tumor? a. Increased urination b. Headache and night sweats c. Seizures d. Nausea and vomiting

Answer: a. Increased urination Feedback: Diabetes insipidus is a special consideration in children with brain tumors, so the nurse needs to watch for an increase in urine production. Headaches may be a sign of brain tumor, but night sweats are not. Seizures, nausea, and vomiting may all occur with brain tumor, but are not the priority consideration.

Which statement by a 17-year-old girl indicates the need for additional counseling regarding the use of medications for TB treatment? a. Isoniazid: "I should take this when I eat." b. Rifampin: "My contact lenses will turn orange." c. Isoniazid: "No more drinking parties for me." d. Rifampin: "I need to stop taking my birth control pills."

Answer: a. Isoniazid: "I should take this when I eat." Feedback: Isoniazid should be taken 1 hour before or 2 hours after meals. All of the other statements are correct.

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

Answer: a. Knowledge Deficit regarding dangers of smoking related to developmental focus on the present Feedback: The adolescent who smokes does not have regard for the future effects of smoking on his body. He is preoccupied with fitting in with peers. Increased education is needed to verify that teens are aware of the dangers of cigarette smoke. Cigarette smoke does not impair thought processes or alter the sensorium. The diagnosis of Hopelessness related to stressful home environment cannot be made based only on the fact that the teen smokes.

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

Answer: a. Maintaining contact with her friends by telephone Feedback: Telephone contact with friends should be encouraged for the hospitalized adolescent. Disposable equipment is contaminated and should be discarded. In this situation, peer visitation would not be encouraged, because the client is in respiratory isolation for possible tuberculosis. She would not want to expose her friends to the disease. Drawing pictures symbolizing her feelings to give to her friends is not age-appropriate.

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

Answer: a. Monitor weight daily. Feedback: When managing a child with severe dehydration, the nurse must weigh the child daily with the same scale and without clothing to compare past weights and calculate weight loss. A dehydrated child will not have crackles in the lungs. Level of consciousness and serum sodium levels will be monitored, but the priority is hydration.

A child has been seen six times in the clinic in the last month because of "severe vomiting." The child's physical exam is normal, electrolytes are within normal limits, and the child is gaining weight appropriately. The mother expresses to the nurse that she is very concerned about her child's health. Based on this information, the child should be further evaluated for which of the following conditions? a. Munchausen syndrome by proxy b. Sexual abuse c. Physical abuse d. Physical neglect

Answer: a. Munchausen syndrome by proxy Feedback: Munchausen syndrome by proxy (MSBP) is a type of child abuse involving fabrication of signs and symptoms of a health condition in a child. Vomiting is one of the most commonly fabricated symptoms. Because the child has no signs of illness, is gaining weight, and has normal electrolyte values, suspicion should be raised. Although the child might not be a victim of MSBP, further evaluation should be performed to confirm the diagnosis or to rule it out.

A 10-year-old was in a motor vehicle crash with her father and presents to the emergency department in critical condition. Which life-threatening condition does the nurse suspect? a. Myocardial contusion b. Commotio cordis c. Cardiogenic shock d. Tetralogy of Fallot

Answer: a. Myocardial contusion Feedback: Myocardial contusion is a potentially life-threatening condition that most often occurs upon striking the steering wheel of a motor vehicle during a crash or during a crush injury or a fall. Commotio cordis is a blunt, nonpenetrating blow to the precordium caused by participation in sports such as baseball, softball, ice hockey, and lacrosse. Cardiogenic shock in children may be caused by pump failure, severe obstructive congenital heart disease, cardiomyopathy, myocarditis, or severe electrolyte or acid-base imbalance. Tetralogy of Fallot is a congenital birth defect of the heart.

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

Answer: a. Normal saline Feedback: Only saline should be used. To decrease the risk of hemolysis, no dextrose-containing fluid or hypotonic fluids should be administered.

A 12-year-old is being treated for acute respiratory distress syndrome. Which assessment finding would be indicative of the nursing diagnosis Impaired Gas Exchange? a. Oxygen saturation of 62% b. Heart rate of 100 bpm c. Respiratory rate of 30/min d. Bicarbonate level of 38

Answer: a. Oxygen saturation of 62% Feedback: The incorrect options do not contain evidence of abnormal gas exchange values. Pallor, tachycardia, hypertension, and fever can occur with impaired gas exchange but alone do not yield that nursing diagnosis. Bradycardia, lethargy, appearing flushed, and hypothermia could be true in unusual circumstances but are not the typical picture of Impaired Gas Exchange. Elevated bicarbonate, metabolic alkalosis, irritability, and pallor do not reflect gas exchange abnormalities.

For which reasons do nurses recognize that children are more vulnerable than adults during a bioterrorism attack? (Select all that apply.) a. Passively acquired maternal antibodies b. Immunization is not complete. c. Immature immune system and immature blood-brain barrier d. Slower respiratory rate e. Large blood volume

Answer: a. Passively acquired maternal antibodies; b. Immunization is not complete; c. Immature immune system and immature blood-brain barrier Feedback: Newborns and infants are especially vulnerable to infectious diseases because their immune systems are immature, their passively acquired maternal antibodies provide limited protection, and disease protection through immunization is not yet complete. Being closer to the ground and having a faster (not slower) respiratory rate increase inhalation of heavy chemical and biological aerosolized agents. Children have a smaller blood volume in proportion to adults.

The nurse notices that the 7-year-old brother of an 8-month-old female with Down syndrome is acting out during the infant's check-up. What should the nurse address with the family? a. The sibling's feelings of powerlessness b. Discipline of the 7-year-old while out in public c. How to take care of both children without disruption of attention d. How to provide emotional support to both children

Answer: a. The sibling's feelings of powerlessness Feedback: The sibling of a child with a chronic condition may feel powerless and may receive less attention from their parents than the ill child does. The nurse's role is to help promote positive parenting behaviors for both the ill child and the sibling. Disciplining the child in public may reinforce negative behaviors for attention; the nurse should teach the parents how to cope with taking care of and emotionally support both children during disruptions.

The nurse is working with a 3-year-old client. Which finding is the most indicative of abuse in a toddler? a. The toddler is extremely compliant with the nurse during the initial assessment. b. The child tries to push the nurse away during the assessment. c. The nurse observes that the child has multiple bottle caries. d. The toddler cries when the nurse does her assessment.

Answer: a. The toddler is extremely compliant with the nurse during the initial assessment. Feedback: The toddler who is indiscriminately friendly with unfamiliar adults is demonstrating behavior inconsistent with his developmental stage. This is a clinical manifestation of abuse. Toddlers in general are fearful of strangers and would not openly accept the nurse initially. It is developmentally appropriate for the child to cry and to push the nurse away during the assessment. Multiple bottle caries might be indicative of neglect but are not indicative of abuse.

Which outcome indicates a successful transition from hospital to home for the family of a 2-year-old child with a tracheostomy due to bronchopulmonary dysplasia? a. The parents demonstrate how to take the child's vital signs at home. b. The parents demonstrate proper technique of suctioning tracheostomy in the hospital. c. The family provides appropriate home care for the child while maintaining family routines. d. The child demonstrates self-care skills prior to discharge.

Answer: c. The family provides appropriate home care for the child while maintaining family routines. Feedback: Maintenance of family routines while successfully caring for the ill child is the only answer choice that addresses the hospital-to-home transition. The child is too young to do self-care. Suctioning the child's tracheostomy and taking the child's vital signs are skills required of the parents before discharge, but performance of skills does not indicate that the parents will successfully navigate the transition to home care.

A nurse obtains a history from a single, breastfeeding mother with a small but hydrated 3-month-old infant who is listless following what the mother describes as a seizure. Which question would be most important for the nurse to ask? a. "Did you have gestational diabetes during pregnancy?" b. "Is this your first baby?" c. "Are you sure you didn't hurt the baby?" d. "Has your baby had seizures before?"

Answer: d. "Has your baby had seizures before?" Feedback: "Are you sure you didn't hurt the baby?" is judgmental and closed-ended. Questions should be open-ended. The nurse should be nonjudgmental in attitude and expressions.

The home health nurse is taking care of a 5-year-old with mumps and teaches his mother about his care. Which statement by the parent indicates understanding? a. "I have to keep my son out of school until the swelling subsides." b. "He can have all the orange juice he wants to keep him hydrated." c. "He will be contagious as long as his parotids are swollen." d. "I will watch him closely because he might contract viral meningitis."

Answer: d. "I will watch him closely because he might contract viral meningitis." Feedback: Viral meningitis is rare, but may occur. The parent should be alert for complications. Keep children out of school or child care until 5 days after parotid swelling occurs. Avoid foods and beverages that increase salivary flow and cause pain (e.g., citrus, spices, and candies). The child is contagious up to 5 days before and after the onset of parotid swelling.

A nurse is discharging an infant after a pyloric stenosis repair. Which statement by the mother would indicate the need for further instructions prior to discharge? a. "I should call the doctor if my infant's temperature rises above 101 degrees." b. "I should fold the diaper down so it does not irritate the incision." c. "My infant's incision will need to be observed for redness, swelling, or discharge." d. "If my infant vomits, I should hold feedings for 6 hours."

Answer: d. "If my infant vomits, I should hold feedings for 6 hours." Feedback: It is normal for an infant to vomit occasionally after having surgery for pyloric stenosis. The infant should be fed on a normal feeding schedule. All other statements about checking the incision site, folding the diaper, and calling the doctor if there is a fever are true.

A mother questions the nurse regarding feeding her baby cow's milk before the age of 1 year. Which is the most appropriate response? a. "Infants require cow's milk because of the need for increased fat." b. "Cow's milk is fine as long as there is vitamin supplementation." c. "The fat content of cow's milk is harmful to infants." d. "The baby's GI system is underdeveloped, and the milk might cause bleeding."

Answer: d. "The baby's GI system is underdeveloped, and the milk might cause bleeding." Feedback: An infant's gastrointestinal (GI) system is immature and exposure to cow's milk may cause inflammation, damaging the mucosa, and subsequently, GI bleeding. Cow's milk is not acceptable because of GI bleeding; fat content is not harmful for infants.

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

Answer: d. A life-threatening reaction to the influenza vaccine Feedback: This child's reaction describes angioedema, laryngeal edema, and respiratory distress, indicating impending anaphylactic shock. All the other answer choices are possible reactions to immunizations but are not life-threatening.

The nurse is assessing an 11-year-old client receiving conscious sedation to set a fractured leg. Which assessment finding indicates that the client might need respiratory support? a. Sleeping b. Regular respiratory rate c. Coughing d. Absent gag reflex

Answer: d. Absent gag reflex Feedback: The child who does not have a gag reflex is demonstrating signs of deep sedation. In deep sedation, protective reflexes are lost and respiratory support is needed. A child with a regular respiratory rate does not require respiratory support. Coughing is an indicator that the airway is intact. The child who is sleeping might just be under light sedation. This alone is not an indicator for respiratory support.

The nurse is caring for a child following cardiac catheterization. Which instruction to the child's parents would have the highest priority? a. Monitor the child's intake and output. b. Leave the bandage in place until given instructions to remove it. c. Report any dizziness to the nurse. d. Alert the nurse if the bandage becomes bloody.

Answer: d. Alert the nurse if the bandage becomes bloody. Feedback: Although all answer options would be things that the nurse would discuss with the parents, alerting the nurse if the bandage becomes bloody would be the priority instruction, as this is an action that would prevent a serious complication.

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

Answer: d. Allow the child to choose what to eat for meals. Feedback: Although all options can be utilized to promote nutrition, allowing the preschooler choices meets two issues: nutrition and developmental tasks.

The nurse teaches parents about pediatric immunizations. What is considered an absolute contraindication to pediatric immunizations? a. Respiratory illness with low-grade fever b. Soreness, redness, and swelling at the previous injection site c. Febrile seizure 1 month after the previous injection of vaccine d. Anaphylactic reaction to previous immunization

Answer: d. Anaphylactic reaction to previous immunization Feedback: Anaphylaxis is a life-threatening reaction to an allergen or antigen and can occur again if the client is exposed to the offending allergen or antigen. Immunizations may be given if the child has a mild illness with or without fever. Redness and soreness are common reactions, not contraindications, to immunizations. One month is too long a time for febrile convulsions to be related to vaccine administration.

A mother of a 5-year-old child asks the nurse questions regarding the importance of vigilant use of sunscreen. Which information is most important for the nurse to convey to the mother? a. A child's skin is delicate and burns easily. b. In addition to causing skin cancer, repeated sun exposure predisposes the child to other forms of cancer. c. Repeated exposure to the sun causes premature aging of the skin. d. Appropriate use of sunscreen decreases the risk of skin cancer.

Answer: d. Appropriate use of sunscreen decreases the risk of skin cancer. Feedback: Although all of the answers may be correct, recommending the use of sunscreen to decrease the incidence of skin cancer is the best response.

3. A preschool-age child diagnosed with AIDS has developed respiratory compromise. Which technique would the nurse utilize to encourage effective lung expansion? a. Incentive spirometry b. Chest physiotherapy c. Coughing and deep breathing d. Bubble blowing

Answer: d. Bubble blowing Feedback: Bubble blowing is most appropriate for the preschool-age group. Preschool-age children are at a developmental level where the other choices would be less appropriate. Although those choices could be done with the preschooler, they would require more time, and the child would be less compliant. Chest physiotherapy is directed primarily at promoting airway clearance.

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

Answer: d. Chronic Pain related to JRA Feedback: Based on the information in the stem, the child experiences pain on a regular basis related to JRA, which is a chronic illness. There are no data given to suggest that the child has acute pain, coping deficit, or knowledge deficit.

A parent of a child with cyanotic heart defects expresses concerns regarding potential developmental problems due to lack of oxygen to the brain. Which of the following is the most appropriate response by the nurse? a. "Expressive therapy might be needed." b. "Speech therapy might be needed." c. "Physical therapy might be needed." d. "Developmental specialists might be needed."

Answer: d. Developmental specialists might be needed. Feedback: The child with cyanotic heart defects might need developmental specialists to help him meet goals. Physical therapy, speech therapy, and expressive therapy all might be needed, but developmental specialists address the development needs more adequately.

Which assessment finding would lead the nurse to suspect esophageal atresia in an infant? a. Hypotonicity b. Excessive crying c. Abdominal distention d. Excessive drooling

Answer: d. Excessive drooling Feedback: The classic symptoms in an infant with esophageal atresia are excessive drooling often accompanied by cyanosis, choking, and coughing. Low blood pressure, excessive crying, and hypotonicity are not common signs of esophageal atresia.

Arterial blood gases results indicate pH 7.33 and PCO2 of 38 mmHg following arrest and subsequent resuscitation of a 3-year-old child. Which nursing intervention should be utilized to attempt to correct this metabolic disorder? a. Assess the effectiveness of the respiratory pattern. b. Determine whether the endotracheal tube is positioned correctly. c. Administer sodium bicarbonate 1 mEq/kg IV. d. Treat the cause of the acidosis.

Answer: d. Treat the cause of the acidosis. Feedback: Sodium bicarbonate is used to correct serious metabolic acidosis. Metabolic acidosis is present, but sodium bicarbonate is given only in serious imbalance. We do not have enough information to determine whether that is the case. The medication often complicates acid-base imbalance. Airway always is important to assess, but the PCO2 level indicates that respirations are not contributing to the problem. The best answer is to find and treat the cause of the acidosis.

The school nurse is concerned about physical inactivity at the middle school. For which disease process should the nurse screen the children? a. Scoliosis b. Thyroid disease c. Depression d. Type 2 diabetes

Answer: d. Type 2 diabetes Feedback: The incidence of obesity and, subsequently, type 2 diabetes in children and adolescents has increased considerably over the past several years. This is attributed to increased inactivity in children secondary to increased use of computers, video games, and other sedentary activities. Physical inactivity in the school population as a whole does not indicate the need to screen for the other conditions.

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

Answer: d. Use Band-Aids or bandages after invasive procedures to reassure the child that his body will not leak and that body parts will not fall out. Feedback: Preschool-age children fear bodily injury and mutilation and are concerned that they will leak or that body parts will fall out when they have had an operation or when they have had a procedure involving a needlestick. Band-Aids and bandages help reassure them that their body will remain intact. Parents should be allowed to be present for the procedure, but they should be there for support, not restraint. Preparation for procedures is essential to decrease the preschooler's anxiety.

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

Answer: d. Use standard precautions. Feedback: Only standard precautions are needed in the care of the child. Standard precautions are hand hygiene and use of gloves.

In determining whether to permit parents to be present during a resuscitation attempt, which is the most important question the nurse must consider? a. Are the parents step-parents or biological parents? b. Will the parents' presence make the physicians and nurses uncomfortable? c. Will the physicians and nurses object on grounds of fearing a lawsuit? d. Will the child be comforted by the parents' presence?

Answer: d. Will the child be comforted by the parents' presence? Feedback: The child's needs take priority, and then the parents' needs take precedence over the needs, feelings, and objections of the staff. Primary healthcare providers and nurses prepared to perform resuscitation competently should not feel uncomfortable or fear a lawsuit with parents present. Whether the parents are step-parents or biological parents is irrelevant in this situation.

The mother of a 15-year-old boy with facial trauma brings him into the emergency department. Upon completion of the admission history, the nurse suspects that another person intentionally caused the child's injuries. What are the appropriate nursing actions in this situation? (Select all that apply.) a. Calling the police b. Calling Protective Services c. Asking the intern to validate the nurse's suspicion d. Following the facility's policy e. Questioning the client without the parent present

Answer: d. Following the facility's policy; e. Questioning the client without the parent present Feedback: All clients brought into the emergency department are to be asked about injuries related to abuse. The boy is safe in the hospital at this time, so immediate notification or protection is not necessary. Laws vary from state to state, but all states have protective laws for children. Each facility has policies and procedures reflecting implementation of those laws, and these must be followed when a nurse suspects abuse.

A child is 24 hours postoperative following major trauma, and has received a total of eight units of packed red blood cells during the perioperative period. The child is flaccid, and has diarrhea and peaked T-waves on the electrocardiogram. About which electrolyte abnormality would the nurse call the primary healthcare provider to obtain an electrolyte panel? a. Hypercalcemia b. Hypernatremia c. Hypermagnesemia d. Hyperkalemia

Answer: d. Hyperkalemia Feedback: Hypernatremia is associated with dehydration and thirst. Hypercalcemia causes neuromuscular depression and constipation. Etiology is related to malignancy, overintake, and parathyroid disorder. Hypermagnesemia symptoms are similar to hyperkalemia, but the etiology is different. Hypermagnesemia is due to renal failure or administration. This client could be experiencing renal failure but that information is not given.

Which nursing diagnosis would be appropriate for a child with hyperlipidemia? a. Decreased Cardiac Output b. Activity Intolerance c. Fluid Volume Deficit d. Knowledge Deficit

Answer: d. Knowledge Deficit Feedback: Knowledge Deficit is appropriate because children with hyperlipidemia will require education on diet to decrease the amount of fat that they consume. Fluid Volume Deficit is more appropriate for a diagnosis of congestive heart failure, Activity Intolerance is more appropriate for a diagnosis of congestive heart failure, and Decreased Cardiac Output is more appropriate for a diagnosis of arrhythmias.

Teaching is a significant role of the nurse caring for children with congenital cardiac defects. When planning teaching interventions for the families of these clients, which content area should be taught first? a. Nutrition needs b. Elimination alterations c. Growth and development concerns d. Medication administration

Answer: d. Medication administration Feedback: Although all of the answers are important teaching concerns, medication administration is taught first to decrease the risk of potentially life-threatening complications.

A nurse is assessing a 3-year-old for hemolytic uremic syndrome (HUS). Which assessment finding would be most characteristic of HUS? a. Fever b. Severe cough c. Diarrhea d. Oliguria

Answer: d. Oliguria Feedback: HUS is characterized by the classic triad of symptoms: thrombocytopenia, hemolytic anemia, and acute renal failure. Severe cough, fever, or diarrhea alone is not a sign of HUS. The problem usually is preceded by a urinary tract infection, upper respiratory infection, or acute gastroenteritis 1-2 weeks prior to the HUS.

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

Answer: d. Respiratory depression Feedback: Carefully monitor for signs of respiratory depression (a major life-threatening complication), especially during drug-specific peak action time. Nausea and vomiting, constipation, and sedation are side effects from opioid administration, but are not the priority.

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

Answer: d. Support the family in anticipatory grieving. Feedback: A family with a child who is not expected to live will experience anticipatory grieving. Referral to social services and a support group assumes that the child will be discharged. Orientation to the unit is not a priority nursing intervention over supporting the family in anticipatory grieving.

A mother of a child with juvenile rheumatoid arthritis (JRA) asks the nurse what activities the child can enjoy. Which would be the most appropriate response based on knowledge of the physiologic aspects of JRA? a. Bicycling b. Running c. Skiing d. Swimming

Answer: d. Swimming Feedback: High-impact activities and activities that overuse the joints are not indicated in a child with JRA.

A child admitted in diabetic ketoacidosis also has a nursing diagnosis of Anxiety (child) related to separation from parents. The goal for this nursing diagnosis is that the child will exhibit or express an increased sense of security. Which outcome is observed when the nurse evaluates the goal to be met? a. The parents room in with their child. b. The child is well prepared for painful procedures. c. The parents are more informed about their child's condition. d. The child sleeps soundly, and is calm and relaxed when awake.

Answer: d. The child sleeps soundly, and is calm and relaxed when awake. Feedback: The nurse must observe the child's behavior to determine whether the goal is met. Rooming in is an appropriate nursing intervention, not an outcome, for the goal. The remaining two answers are goals for nursing diagnoses involving knowledge deficits.

9. The nurse is providing care for a hospitalized 10-year-old. Which assessment data collected by the nurse validates that the child is in the appropriate stage of development? a. The child does not participate in his care. b. The child cries whenever his parents leave. c. The child kicks and screams when venipuncture is performed. d. The child states that he wants to help remove the bandage from his abdomen.

Answer: d. The child states that he wants to help remove the bandage from his abdomen. Feedback: The school-age child is developing independence. The child who asks to help remove his dressing is demonstrating the development of industry. A child who will not participate is showing signs of regression. School-age children might want parents to stay, but they should not be demonstrating signs of separation anxiety at this age. A 10-year-old who kicks and screams with procedures is not demonstrating coping mechanisms characteristic of most school-age children.

The classic clinical triad of intussusception is intermittent, severe, crampy ____ ____; a palpable sausage-shaped mass on the right side of the _____; and currant ____ ____.

abdominal pain, abdome, jelly stools

21) The nurse is taking care of a child who is showing signs of imminent death. Which manifestations should the nurse expect to assess related to the cardiovascular system? 1. An increase in the volume of Korotkoff sounds 2. Cool and clammy skin, mottling 3. Peripheral pulses will remain when the heart beat is not heard on auscultation. 4. An increase in cardiac output

Answer: 2 Explanation: 1. A change in pulse pressure and a decrease in the volume of Korotkoff sounds indicate imminent death. 2. Peripheral circulation decreases, leading to diaphoresis, clammy and cool skin, and changes in skin coloring such as mottling or cyanosis. 3. The heart rate might initially increase as hypoxia develops, then the heart rate and blood pressure decrease, resulting in decreased cardiac output. 4. The heart rate and blood pressure decrease, resulting in decreased cardiac output, which is a sign of imminent death.

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

Answer: 2 Explanation: 1. A physical demonstration may help the children recognize the long-term effects of smoking, but information from adults is not likely to influence children of this age more than the pressure of their peers will. 2. While all of the strategies are good, the most effective would be to have a local high school basketball star come to talk to the students about the importance of not smoking because students at this age are more likely to listen to and attempt to emulate someone of their own peer group. 3. Information from posters is not likely to influence children of this age more than the pressure of their peers will. 4. Information from signed contracts is not likely to influence children of this age more than the pressure of their peers will.

19) A school-age child diagnosed with classic hemophilia is admitted to the hospital for hemorrhage into the knee joint. Which nursing diagnosis should the nurse use to plan care for this child? 1. Risk for Impaired Physical Mobility related to joint stiffness and contractures 2. Risk for Impaired Tissue Perfusion (cerebral) related to blood loss. 3. Activity Intolerance related to bleeding 4. Disturbed Body Image related to swollen knee

19) A school-age child diagnosed with classic hemophilia is admitted to the hospital for hemorrhage into the knee joint. Which nursing diagnosis should the nurse use to plan care for this child? 1. Risk for Impaired Physical Mobility related to joint stiffness and contractures 2. Risk for Impaired Tissue Perfusion (cerebral) related to blood loss. 3. Activity Intolerance related to bleeding 4. Disturbed Body Image related to swollen knee

2) Which is a common fear, in addition to separation anxiety, for the hospitalized pediatric client between the ages of 6 and 18 months? 1. Disfigurement 2. Death 3. Stranger anxiety 4. Bodily injury

2) Which is a common fear, in addition to separation anxiety, for the hospitalized pediatric client between the ages of 6 and 18 months? 1. Disfigurement 2. Death 3. Stranger anxiety 4. Bodily injury Answer: 3 Explanation: 1. Infants do not fear disfigurement. 2. Infants and toddlers do not fear death. 3. In addition to separation anxiety, infants between 6 and 18 months of age might display stranger anxiety when confronted with strangers such as healthcare providers. 4. Infants and toddlers do not fear bodily injury.

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

Answer: 1 Explanation: 1. AIDS is not curable, so the problem nurses can anticipate, for all families, is Anticipatory Grieving. 2. AIDS is not curable, so the problem nurses can anticipate, for all families, is Anticipatory Grieving. Risk for Impaired Parenting might be present, but further information is needed to anticipate this problem. 3. AIDS is not curable, so the problem nurses can anticipate, for all families, is Anticipatory Grieving. Compromised Family Coping might be present, but further information is needed to anticipate this problem. 4. AIDS is not curable, so the problem nurses can anticipate, for all families, is Anticipatory Grieving. Parental Role Conflict might be present, but further information is needed to anticipate this problem.

2) Which nursing diagnosis should the nurse include in the plan of care for an infant diagnosed with acute bronchiolitis due to respiratory syncytial virus (RSV)? 1. Activity Intolerance 2. Ineffective Peripheral Tissue Perfusion 3. Acute Pain 4. Decreased Cardiac Output

Answer: 1 Explanation: 1. Activity Intolerance is a problem because of the imbalance between oxygen supply and demand. 2. Tissue perfusion (peripheral) is not affected by this respiratory disease process. 3. Acute Pain is not usually associated with acute bronchiolitis. 4. Cardiac Output is not compromised during an acute phase of bronchiolitis.

15) A 2-year-old child with a fever is prescribed amoxicillin clavulanate 250 mg/5 mL 3 times daily by mouth for 10 days for otitis media. Which is the priority teaching instruction for the parents of this child? 1. Giving the antibiotic for the full 10 days 2. Measuring the prescribed dose in a household teaspoon 3. Spreading the dose evenly during daylight hours 4. Stopping the antibiotic when the child is afebrile

Answer: 1 Explanation: 1. Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. 2. A household teaspoon could contain less than 5 mL, and the full dose must be given. 3. The antibiotic should be administered around the clock to maintain a blood level. 4. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms.

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

Answer: 1 Explanation: 1. As children grow, they develop immunity through immunization or exposure to the natural disease. As children mature and become more active, they interact more frequently with other children and adults and increase their exposure to infectious agents. 2. Children cannot acquire diseases from family members who have had the disease 3. Acquiring disease from other children would not give children immunity. 4. Newborns are not born with diseases in their systems.

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

Answer: 1 Explanation: 1. As healthy children are exposed to more infections, they naturally develop antibodies. 2. Being exposed to infections will not lead to healthy children. 3. Exposure to infections will not lead children to acquire terminal illnesses. 4. Exposure to infectious disease will not weaken children's immune systems.

16) The nurse works in a clinic for medically fragile children who require home care. The nurse has noticed that a high percentage of the families parents divorce. In an attempt to reduce the divorce rate among the parents, the nurse creates an educational session for parents of medically fragile children. Which should be the focus of this session? 1. Communication 2. Financial stability 3. Ways to meet the child's physical needs 4. The state laws that have relevance to the medically fragile child.

Answer: 1 Explanation: 1. Both partners need to be able to communicate honestly and frequently to maintain the marriage relationship. 2. Finances will be a problem for the family as the cost of care of medically fragile child can be high. Nurses may refer to community resources but cannot solve all financial problems. 3. The nurse will teach parents how to meet the child's physical needs on a one-to-one basis, not in a group session. 4. This will not reduce the divorce rate.

8) Which menu choices for a child who is diagnosed with renal failure and experiencing hyperkalemia indicate the need for further instruction by the nurse? 1. Carrots and green, leafy vegetables 2. Spaghetti and meat sauce with breadsticks 3. Hamburger on a bun and cherry gelatin 4. Chips, cold cuts, and canned foods

Answer: 1 Explanation: 1. Carrots and green, leafy vegetables are high in potassium. 2. Spaghetti and meat sauce with breadsticks would be acceptable choices for a low-potassium diet. 3. Hamburger on a bun with cherry gelatin would be acceptable choices for a low-potassium diet. 4. Chips, cold cuts, and canned foods are high in sodium but not necessarily in potassium.

3) A mother of two children, an 8-year-old and a 10-year-old, tells you that her husband has recently been deployed to the Middle East. The mother is concerned about the children's constant interest in watching TV news coverage of activities in the Middle East. Which suggestion by the nurse to the mother is most appropriate? 1. "Spend time with your children, and take cues from them about how much they want to discuss." 2. "Allow the children to watch as much television as they want. This is how they are coping with their father's absence." 3. "The less that you discuss this, the quicker the children will adjust to their father's absence. Try to keep them busy and use distractions to keep their mind off of it." 4. "It will just take some time to adjust to their father's absence and then everything will return to normal."

Answer: 1 Explanation: 1. Children need to be able to discuss their feelings and concerns with an adult; otherwise, their emotional distress could increase. 2. Constant viewing of the TV coverage of the war might increase the children's anxiety and fear for their father's safety. 3. Children need to be able to discuss their feelings and concerns with an adult; otherwise, their emotional distress could increase. 4. The mother should be aware that even though the children might appear to have adjusted, there could be delayed reactions or regressions in behavior.

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

Answer: 1 Explanation: 1. Children with hemophilia should be encouraged to participate in noncontact sports activities. Bicycling is an excellent option, and is recommended, along with swimming. However, the child should always use knee pads, elbow pads, and a helmet when participating in any physical sport. 2. Biking is an acceptable sport as long as protective equipment is worn, and the child should be encouraged to make choices when possible. 3. Discouraging a child from joining a club would not foster growth and development. 4. Participating only in the social aspects of the club would not encourage physical activity.

11) The nurse is conducting an educational program for parents of children with chronic conditions. Which parental statement indicates the need for further instruction? 1. "I know my child will get better and not have to take any more medication." 2. "I know my child will need assistance with activities of daily living." 3. "I know my child may need specialized education." 4. "I know my child will have to stay on a special diet."

Answer: 1 Explanation: 1. Chronic conditions might require lifetime dependence on medication. 2. Children with chronic conditions typically need assistance with daily living activities. 3. A child with a chronic condition may require specialized education. 4. Depending on the diagnosis, children with chronic conditions might require a special diet.

7) The nurse is preparing medication instruction for a child who has undergone a kidney transplant and is prescribed cyclosporine. The parents ask the nurse about the reason for the cyclosporine. Which rationale for this medication should the nurse include in the response? 1. Suppress rejection 2. Decrease pain 3. Improve circulation 4. Boost immunity

Answer: 1 Explanation: 1. Cyclosporine is given to suppress rejection. 2. Cyclosporine does not decrease pain. 3. Cyclosporine does not affect circulation. 4. Cyclosporine does not boost immunity.

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

Answer: 1 Explanation: 1. Due to inadequate respirations, the child retains CO2 and develops respiratory acidosis. 2. This statement is incorrect as the child retains carbon dioxide. 3. The pH would be acidic, but the pH would be high. 4. The child would have a low pH (acidosis) and high PCO2.

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

Answer: 1 Explanation: 1. Early signs of digoxin (Lanoxin) toxicity are bradycardia and arrhythmias 2. Digoxin (Lanoxin) toxicity does not cause tinnitus (ringing in the ears). 3. Digoxin (Lanoxin) toxicity does not cause ataxia (unsteady gait). 4. Digoxin (Lanoxin) toxicity does not cause hypotension (low blood pressure).

17) Prior to discharging the child from the hospital, what routine discharge instructions should the nurse discuss with the family? 1. Monitoring signs and symptoms specific to condition 2. Instruction on performing a medical examination on the child 3. No instructions are needed; the family is familiar with the child. 4. A list of all diagnostic tests obtained during the hospitalization and their results

Answer: 1 Explanation: 1. Families need support and education as they continue to be anxious or stressed over their child's hospitalization. Standard discharge plans for routine hospital discharge include monitoring signs and symptoms specific to the condition and care at home. 2. The family does not need to know how to complete a medical examination on the child. 3. The family knows the child but needs teaching regarding the signs and symptoms to watch for in case of recurrence or complications arise. 4. This information was shared with the family as the tests were performed and results received.

8) Which symptoms should the nurse include in the teaching plan for the family of a recently child diagnosed with aplastic anemia? 1. Fatigue and fever 2. Runny nose and cough 3. Nausea and vomiting 4. Cyanosis and bradycardia

Answer: 1 Explanation: 1. Fatigue secondary to anemia and fever related to infection secondary to neutropenia are common symptoms. 2. Aplastic anemia is not associated with upper respiratory infections. 3. Nausea and vomiting are not symptoms of aplastic anemia. 4. The child would exhibit tachycardia rather than bradycardia, and there is no reason for cyanosis.

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

Answer: 1 Explanation: 1. The infant's immune system is not fully developed at birth, and the infant has low levels of antibodies due to lack of exposure to antigens. 2. Newborns and young infants do have high levels of maternal antibodies, but this answer is incorrect because it does not explain the susceptibility of newborns and young infants to infection. 3. Newborns and young infants do have passive transplacental immunity, but this answer is incorrect because it does not explain the susceptibility of newborns and young infants to infection. 4. Newborns and young infants do have exposure to microorganisms during the birth process, but this answer is incorrect because it does not explain the susceptibility of newborns and young infants to infection.

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

Answer: 1 Explanation: 1. The risks and benefits of vaccines far outweigh the risks from communicable diseases and resulting complications. 2. The immunization schedule is not completed by the time the child starts school. Immunizations continue throughout the life of the individual. 3. It is important that the families realize that to be fully protected, many vaccinations will need to be repeated at specified times. 4. Vaccinations can cause illness or injury. No medication is 100% safe.

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

Answer: 1 Explanation: 1. These are symptoms of withdrawal resulting from reducing the dose too quickly. 2. A child who is being withdrawn from opioids too quickly will be tachycardic and have hot flashes and sweating. 3. The child who is being withdrawn from opioids too quickly will be hypertensive and wakeful. 4. Nausea, abdominal pain, diarrhea, and hypertonicity would be symptoms of withdrawal.

19) The mother of an adolescent with multiple medical and developmental issues says to the nurse: "There are times that I think about just walking out of the house and not coming back." Which would be an appropriate nursing diagnosis for this mother? 1. Caregiver Role Strain related to providing 24-hour care for a child with medical and developmental issues 2. Risk for Injury (maternal) related to overwhelming demands of the medically fragile child 3. Knowledge Deficit (maternal) related to nursing care of the child 4. Health-seeking Behaviors (maternal) related to interest in learning to care for her child

Answer: 1 Explanation: 1. This diagnosis describes the effect of this child's care on the mother. 2. There is no indication of a risk for injury in the stem. 3. This question does not indicate a lack of knowledge by the mother but frustration due to the daily demands of caring for her child. 4. There is no indication in the stem that the mother wants to learn more about medical care for her child.

11) Which is the priority nursing action when providing care to a pediatric client who has documented allergies to cow's milk, peanuts, and latex? 1. Evaluating the hospital room for equipment containing latex 2. Ordering an EpiPen for the child 3. Notifying dietary of the milk and peanut allergy 4. Placing a sign on the door which identifies all allergies

Answer: 1 Explanation: 1. This is appropriate as latex allergies can be life threatening. Many pieces of medical equipment may contain latex. 2. Nurses do not prescribe or dispense medication, so this is inappropriate. 3. This action should be taken but is not the priority. 4. Depending on hospital policy, there may be some sign to indicate allergies, but this is not the priority.

13) Which independent nursing action is appropriate for a 2-month-old infant who is a direct admission to the pediatric unit with a diagnosis of ALTE (apparent life-threatening event)? 1. Place the child on an apnea monitor. 2. Place the child on nasal cannula oxygen. 3. Draw blood for arterial blood gases. 4. Place the child on contact isolation.

Answer: 1 Explanation: 1. This is appropriate monitoring of the infant. 2. Oxygen is a dependent order except under emergency situations. There is no evidence the child needs oxygen. 3. Laboratory tests are not an independent action. 4. There is no indication of a respiratory infection. At this time, contact isolation is not indicated.

24) Which is the priority action by the school nurse for an adolescent who drops to the ground and is unresponsive during a high school basketball game? 1. Initiating cardiopulmonary resuscitation (CPR) 2. Calling 911 3. Offering the parents comfort 4. Assessing for hemorrhage

Answer: 1 Explanation: 1. This situation is an example of cardiac concussion. Survival chances improve if CPR is initiated immediately. 2. Other people can call 911. Cardiac resuscitation must be initiated immediately. 3. This is an appropriate action but not a priority. 4. This type of injury often has no external symptoms of injury.

21) The nurse is providing care to a pediatric client who is receiving sedation for a painful procedure. Which are the priority nursing actions? Select all that apply. 1. Monitoring respirations 2. Assessing for manifestations of deep sedation 3. Ensuring a crash cart is available 4. Administering the prescribed opioid 5. Administering the prescribed benzodiazepine

Answer: 1, 2, 3 Explanation: 1. A priority nursing action for a pediatric client who is receiving sedation for a painful procedure is to monitor the child's respirations. 2. A priority nursing action for a pediatric client who is receiving sedation for a painful procedure is to assess for manifestations associated with deep sedation. 3. A priority nursing action for a pediatric client who is receiving sedation for a painful procedure is ensuring a crash cart is available. 4. A priority nursing action for a pediatric client who is receiving sedation for a painful procedure is to have an opioid antagonist available if respiratory depression occurs. 5. A priority nursing action for a pediatric client who is receiving sedation for a painful procedure is to have a benzodiazepine antagonist available, if needed.

21) The nurse is assessing a pediatric client who is experiencing metabolic acidosis. Which assessment questions should the nurse include when interviewing the child's parents? Select all that apply. 1. "Has your child consumed any aspirin?" 2. "Has your child consumed any boric acid?" 3. "Has your child consumed any antifreeze?" 4. "Has your child consumed any baking soda?" 5. "Has your child consumed any antacids?"

Answer: 1, 2, 3 Explanation: 1. An overdose of aspirin is associated with metabolic acidosis. 2. Consumption of boric acid can cause metabolic acidosis. 3. Accidental consumption of antifreeze can cause metabolic acidosis. 4. Consumption of baking soda is associated with metabolic alkalosis. 5. Consumption of antacids is associated with metabolic alkalosis.

24) Which assessment findings, indicative of a hematologic emergency, should the nurse report to the healthcare provider due to the need for immediate intervention? Select all that apply. 1. Anemia 2. Thrombocytopenia 3. Disseminated intravascular coagulation 4. Cardiac arrhythmias 5. Tetany

Answer: 1, 2, 3 Explanation: 1. Anemia is a clinical manifestation associated with a hematologic emergency necessitating the need for immediate intervention. 2. Thrombocytopenia is a clinical manifestation associated with a hematologic emergency necessitating the need for immediate intervention. 3. Disseminated intravascular coagulation is a clinical manifestation associated with a hematologic emergency necessitating the need for immediate intervention. 4. Cardiac arrhythmias are associated with metabolic, not hematologic, emergencies. 5. Tetany is associated with metabolic, not hematologic, emergencies.

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

Answer: 1, 2, 3 Explanation: 1. Blowing bubbles or popping bubbles can be a distraction for a young school-age child. 2. Listening to music or singing can be used as distraction for this age group. 3. Guided imagery is a means of encouraging relaxation and mental images to manage pain. 4. Under hypnosis, the child is an altered state of awareness; this is not a form of distraction. 5. Sucrose solution is used for infants up to 12 months of age. This is a complementary therapy but not a method of distraction.

26) The nurse is assessing a child and suspects the child's mother is abusing an opiate. Which clinical manifestations exhibited by the child's mother lead the nurse to this conclusion? SATA 1. Constricted pupils 2. Mood swings 3. Impaired memory 4. Tremors 5. Psychosis

Answer: 1, 2, 3 Explanation: 1. Constricted pupils are a clinical manifestation associated with opiate abuse. 2. Mood swings are a clinical manifestation associated with opiate abuse. 3. Impaired memory is a clinical manifestation associated with opiate abuse. 4. Tremors are a clinical manifestation associated with alcohol, not opiate, abuse. 5. Psychosis is a clinical manifestation associated with hallucinogen, not opiate, abuse.

23) The nurse is providing care to a child who was admitted to the pediatric intensive care unit (PICU) after a motor vehicle crash. Which interventions should the nurse include in the plan of care to allow the parents to participate in their child's care? Select all that apply. 1. Encouraging the parents to brush the child's hair 2. Teaching the parents how to perform range of motion exercises with their child 3. Allowing the parents to read to their child 4. Explaining the child's condition to the parents 5. Providing permission for the parents to remain at the child's bedside

Answer: 1, 2, 3 Explanation: 1. Encouraging the parents to brush the child's hair is an intervention that allows the parents to participate in their child's care. 2. Teaching the parents how to perform range of motion exercises with their child is an intervention that allows the parents to participate in their child's care. 3. Allowing the parents to read to their child is an intervention that allows the parents to participate in their child's care. 4. Explaining the child's condition to the parents is an intervention that provides information; however, it does not allow the parents to participate in their child's care. 5. Providing permission for the parents to remain at the child's besides allow the parents to be close to their child; however, it does not allow the parents to participate in their child's care.

22) An adolescent tells the nurse that the new diagnosis of diabetes has him "stressed out." Which stress-reduction activities will the nurse recommend to this adolescent? Select all that apply. 1. Daily exercise, such as walking 2. Learning more about his illness 3. Practicing deep breathing and other relaxation techniques 4. Not thinking about his diagnosis 5. Allowing the parents control of his disease

Answer: 1, 2, 3 Explanation: 1. Exercise is an effective stress reducer. 2. Fully understanding his condition will reduce his stress. 3. Relaxation techniques can help reduce stress. 4. Keeping feelings and emotions in will increase stress in the adolescent. 5. Adolescents like to be in control of themselves and are working on separation from the parents, so it would be inappropriate to encourage the child to give control to others.

8) The nurse is planning care for the family of a child with a chronic illness. Which activities will the nurse recommend to decrease the risk for compassion fatigue? Select all that apply. 1. Fostering social relationships 2. Exercising 3. Developing a hobby 4. Moving away 5. Sleeping more than 9 hours per 24-hour period

Answer: 1, 2, 3 Explanation: 1. Fostering social relationships contributes to social and mental rest and restoration. 2. Exercising contributes to physical restoration. 3. Developing a hobby contributes to physical, spiritual, social, and mental rest and restoration. 4. Moving away is an avoidance behavior that does not address exhaustion from overwhelming caregiving responsibilities. 5. Sleeping more than the body requires is an avoidance behavior

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

Answer: 1, 2, 3 Explanation: 1. Most families have the capacity to develop resilience. One nursing action that can support the development of resilience to helping family members learn new skills. This occurs by teaching the family the skills they need to provide care. 2. Most families have the capacity to develop resilience. One nursing action that can support the development of resilience is to suggestion adaptations. This occurs by providing education related to alternative methods for discipline. 3. Most families have the capacity to develop resilience. One nursing action that can support the development of resilience is to provide positive reinforcement. This allows the family to gain confidence in their ability to manage the challenges of the child's health condition. 4. Defensive coping strategies promote dysfunction and not resilience. 5. While it is important to assess for family weaknesses, it is not appropriate to focus on these weakness when the goal is to develop resilience. Page Ref: 911

21) Which are the leading causes of pediatric abdominal injuries for which the nurse should provide client teaching during scheduled health maintenance visits? Select all that apply. 1. Motor vehicle crashes 2. Falls 3. Blunt trauma 4. Stabbing 5. Impalement

Answer: 1, 2, 3 Explanation: 1. Motor vehicle crashes are a leading cause of pediatric abdominal injuries. The nurse should provide education related to proper use of seat belts during health maintenance visits to decrease the incidence of abdominal injuries. 2. Falls are a leading cause of pediatric abdominal injuries. The nurse should include education regarding age-appropriate pediatric fall prevention during health maintenance visits. 3. Blunt trauma is a leading cause of pediatric abdominal injuries. The nurse should include prevention strategies during health maintenance visits. 4. While stabbing can cause abdominal injury, this is not a common cause in the pediatric population. 5. While impalement can cause abdominal injury, this is not a common cause in the pediatric population.

23) The nurse is providing care to a child who experienced an anaphylactic reaction to an unknown allergen. Which high-risk foods should the nurse question the family about regarding recent consumption? 1. Peanut butter 2. Shrimp 3. Eggs 4. Milk 5. Soda

Answer: 1, 2, 3 Explanation: 1. Peanut products, such as peanut butter, are considered a high-risk food allergen. The nurse should question the family about the consumption of this product. 2. Shellfish, such as shrimp, is considered a high-risk food allergen. The nurse should question the family about the consumption of this product. 3. Egg whites are considered a high-risk food allergen. The nurse should question the family about the consumption of this product. 4. While milk allergies are common, they rarely cause anaphylaxis. 5. Soda is not a high risk for the nurse to include in the assessment process.

26) The nurse is providing care to an infant who is hospitalized for bronchiolitis. Which infant stressors should the nurse plan for when providing care for this infant? Select all that apply. 1. Separation anxiety 2. Stanger anxiety 3. Disrupted sleep-wake cycle 4. Loss of self-control 5. Fear of the dark

Answer: 1, 2, 3 Explanation: 1. Separation anxiety is an infant stressor that the nurse should plan for when providing care to the hospitalized infant. 2. Stranger anxiety is an infant stressor that the nurse should plan for when providing care to the hospitalized infant. 3. A disrupted sleep-wake cycle is an infant stressor that the nurse should plan for when providing care to the hospitalized infant. 4. Loss of the control is a stressor for the hospitalized toddler, not the infant. 5. Fear of the dark is a stressor for the hospitalized toddler, not the infant.

23) Which are discharge criteria the nurse includes in the plan of care for a client who has received sedation? Select all that apply. 1. Stable vital signs 2. Patent airway 3. Ability to sit up without assistance 4. Adequate fluid intake 5. Ability to urinate

Answer: 1, 2, 3 Explanation: 1. Stable vital signs are a criterion for discharge for a pediatric client who has received sedation. 2. A patent airway is one criterion for discharge for the pediatric client who has received sedation. 3. The ability to sit up without assistance is one criterion for discharge for the pediatric client who has received sedation. 4. Fluid intake is not essential as some sedation medications stimulate vomiting. 5. Ability to urinate is not an essential criterion for discharge for the pediatric client who has received sedation.

14) Which strategies would be helpful for nurses who work with terminally ill children to avoid burnout? Select all that apply. 1. Participating in a mentoring relationship with experienced hospice nurses 2. Participating in support groups with mental health professionals 3. Participating in team decisions regarding the dying child's plan of care 4. Declining the family's invitation to attend the child's funeral 5. Planning the child and family's care alone as the primary nurse

Answer: 1, 2, 3 Explanation: 1. Team decisions, mentorship, and support groups all alleviate the responsibility of providing nursing care and coping with the death of a child alone. 2. Team decisions, mentorship, and support groups all alleviate the responsibility of providing nursing care and coping with the death of a child alone. 3. Team decisions, mentorship, and support groups all alleviate the responsibility of providing nursing care and coping with the death of a child alone. 4. Distancing oneself from the family can result in unresolved grief. 5. Planning the child's care alone might result in an excessive burden of guilt.

18) Which actions should the nurse implement when assessing the physical growth for a child who is diagnosed with chronic renal failure? Select all that apply. 1. Asking the child to step on the scale 2. Measuring the child's height 3. Measuring the child's head circumference 4. Using the Denver II with the child 5. Monitoring the child's blood pressure

Answer: 1, 2, 3 Explanation: 1. Weight is a physical growth assessment parameter the nurse uses for a child diagnosed with chronic renal failure. 2. Height is a physical growth assessment parameter the nurse uses for a child diagnosed with chronic renal failure. 3. Head circumference is a physical growth assessment parameter the nurse uses for a child diagnosed with chronic renal failure. 4. The Denver II is a developmental assessment tool. It is not used to assess physical growth. 5. Blood pressure is not a criterion used to measure physical growth.

17) Which concepts should the nurse include in the discharge instructions for a child who has undergone a hematopoietic stem cell transplantation (HSCT)? Select all that apply. 1. Keeping the child on a high-calcium diet 2. Practicing good hand washing 3. Avoiding live plants and fresh vegetables 4. Avoiding influenza vaccinations 5. Returning the child to school within 6 weeks

Answer: 1, 2, 3 Explanation: 1. The child should be placed on calcium supplements to reduce the risk of osteopenia. Hand washing is essential to prevent the spread of infection. Live plants and fresh vegetables can carry bacteria; they should be avoided to decrease the risk of infection. 2. The child should be placed on calcium supplements to reduce the risk of osteopenia. Hand washing is essential to prevent the spread of infection. Live plants and fresh vegetables can carry bacteria; they should be avoided to decrease the risk of infection. 3. The child should be placed on calcium supplements to reduce the risk of osteopenia. Hand washing is essential to prevent the spread of infection. Live plants and fresh vegetables can carry bacteria; they should be avoided to decrease the risk of infection. 4. The child cannot return to school for 6 to 12 months after an HSCT. In-hospital or in-home schooling is required. The child and the family should be encouraged to get a yearly influenza vaccination. 5. The child cannot return to school for 6 to 12 months after an HSCT. In-hospital or in-home schooling is required. The child and the family should be encouraged to get a yearly influenza vaccination

20) Which nutritional interventions should the nurse include in the plan of care for a pediatric client who is receiving peritoneal dialysis in the treatment of chronic renal failure? Select all that apply. 1. Provide small, frequent meals. 2. Avoid battles over nutritional intake. 3. Administer supplements by tube feedings, if needed. 4. Implement hand hygiene frequently. 5. Perform daily catheter site care.

Answer: 1, 2, 3 Explanation: 1. The child will feel full with smaller amounts of food because of the dialysate. 2. The child will be more inclined to eat if there is less stress. 3. Adequate nutrition is important for growth and development, and must be supported if oral intake is inadequate. 4. This intervention is appropriate to prevent infection; it is not a nutritional intervention. 5. This intervention is appropriate to prevent infection; it is not a nutritional intervention.

18) Which should the nurse assess to determine oxygenation during the respiratory assessment for a pediatric client? Select all that apply. 1. Mucous membranes 2. Nail beds 3. Skin 4. Sclerae 5. Corneas

Answer: 1, 2, 3 Explanation: 1. The nurse assesses the mucous membranes to determine oxygenation during the respiratory assessment for a pediatric client. 2. The nurse assesses the nail beds to determine oxygenation during the respiratory assessment for a pediatric client. 3. The nurse assesses the skin to determine oxygenation during the respiratory assessment for a pediatric client. 4. The sclerae are not assessed to determine oxygenation during the respiratory assessment for a pediatric client. 5. The corneas are not assessed to determine oxygenation during the respiratory assessment for a pediatric client.

13) The nurse is caring for a 17-year-old client with a chronic condition who will be transitioning into adulthood. When planning care for this client, which should the nurse consider? Select all that apply. 1. Ability to work 2. Ability to live independently 3. Psychosocial needs 4. Parental needs 5. Sibling needs

Answer: 1, 2, 3 Explanation: 1. The nurse must consider the client's ability to live independently when planning care for a client with a chronic condition who is transitioning into adulthood. 2. The nurse must consider the client's ability to live independently when planning care for a client with a chronic condition who is transitioning into adulthood. 3. The nurse must consider the client's ability to live independently when planning care for a client with a chronic condition who is transitioning into adulthood. 4. The parent's needs are not considered when planning care for a client with a chronic condition who is transitioning into adulthood. 5. The needs of the client's siblings are not considered when planning care for a client with a chronic condition who is transitioning into adulthood.

29) Which nursing actions are appropriate for teaching the family of a pediatric client requiring skilled care prior to discharge? SATA 1. Teaching how to use home equipment 2. Educating on symptoms that indicate distress 3. Encouraging participation in a cardiopulmonary resuscitation course 4. Recommending that one parent take a leave of absence from work 5. Discouraging participation in case coordination activities

Answer: 1, 2, 3 Explanation: 1. The nurse will educate the family regarding equipment that will be used after discharge. It is essential that the family perform a successful return demonstration. 2. The nurse will teach the family symptoms that indicate the client is experiencing distress and include information on who to contact if these symptoms should occur. 3. The nurse will encourage the family to participate in a cardiopulmonary resuscitation course prior to discharge. 4. While it is appropriate for the nurse to educate the family on the Family Medical Leave Act (FMLA), it is not appropriate for the nurse to recommend that one parent take a leave of absence from work. 5. The nurse should encourage the family to participate in care coordination for their child if they indicate they would like to learn about this portion of the child's healthcare management.

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

Answer: 1, 2, 3 Explanation: 1. When an infant with TOF has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). 2. When an infant with TOF has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). 3. When an infant with TOF has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). 4. The nurse would not draw blood until the episode had subsided because unpleasant procedures are postponed. 5. Benadryl is not appropriate for this child.

22) Which are the priority nursing assessments when providing care to a pediatric client who is receiving sedation? Select all that apply. 1. Respiratory effort 2. Chest wall movement 3. Skin color 4. Level of consciousness 5. Pain

Answer: 1, 2, 3, 4 Explanation: 1. A respiratory effort assessment is a nursing priority for the pediatric client who is receiving sedation. 2. Assessing chest wall movement is a nursing priority for the pediatric client who is receiving sedation. 3. Assessing skin color is a nursing priority for the pediatric client who is receiving sedation. 4. Assessing level of consciousness is a nursing priority for the pediatric client who is receiving sedation. 5. Assessing the client's pain is not a priority when providing care to a pediatric client who is receiving sedation.

15) Which treatment options should the nurse anticipate for a 10-month-old infant admitted to the emergency department with supraventricular tachycardia? Select all that apply. 1. Administering intravenous adenosine (Adenocard) 2. Administering intravenous amiodarone (Cardarone) 3. Preparing for cardioversion 4. Applying ice to the face 5. Having the child perform a Valsalva maneuver

Answer: 1, 2, 3, 4 Explanation: 1. Adenosine or amiodarone may be given when vagal maneuvers are unsuccessful. Cardioversion is used in an urgent situation. 2. Adenosine or amiodarone may be given when vagal maneuvers are unsuccessful. Cardioversion is used in an urgent situation. 3. Adenosine or amiodarone may be given when vagal maneuvers are unsuccessful. Cardioversion is used in an urgent situation. 4. Supraventricular tachycardia episodes are initially treated with vagal maneuvers to slow the heart rate including the application of ice or iced saline solution to the face to reduce the heart rate. 5. A 10-month-old child cannot be instructed to hold her breath and bear down as with a bowel movement

28) Which are barriers to successful discharge planning that the nurse may need to plan for when providing care to a pediatric client who is approaching discharge? Select all that apply. 1. Financial concerns 2. Parental unavailability for teaching 3. Lack of equipment 4. Poor teamwork 5. Insurance payment for services

Answer: 1, 2, 3, 4 Explanation: 1. Financial concerns related to the cost associated with care that is needed after discharge is one barrier to successful discharge planning when providing care to the pediatric client who is approaching discharge. 2. Parents who are not available for discharge instruction is one barrier to successful discharge planning when providing care to the pediatric client who is approaching discharge. 3. Not having the equipment the family will use after discharge is one barrier to successful discharge planning when providing care to the pediatric client who is approaching discharge. 4. Poor teamwork is one barrier to successful discharge planning when providing care to the pediatric client who is approaching discharge. 5. Insurance payment for services is not a known barrier to successful discharge planning when providing care to the pediatric client who is approaching discharge.

28) Which strategies should the nurse recommend for a school-age client who is at risk for developing hypertension as an adult? Select all that apply. 1. Using seasoning substitutes for salt 2. Providing a list of foods high in sodium 3. Decreasing television time 4. Increasing physical activity 5. Monitoring blood pressure daily

Answer: 1, 2, 3, 4 Explanation: 1. Habits that are implemented during childhood will decrease the likelihood of developing hypertension as an adult. The nurse should recommend the use of seasoning substitutes to replace added salt. 2. Habits that are implemented during childhood will decrease the likelihood of developing hypertension as an adult. The nurse should provide a list of foods that are high in sodium. 3. Habits that are implemented during childhood will decrease the likelihood of developing hypertension as an adult. The nurse should recommend a decrease in television screen time. 4. Habits that are implemented during childhood will decrease the likelihood of developing hypertension as an adult. The nurse should recommend an increase in physical activity. 5. Monitoring blood pressure daily is not an activity that reduces the child's likelihood of developing hypertension as an adult.

11) The nurse is providing care to a pediatric client who is receiving chemotherapy to treat acute lymphocytic leukemia (ALL). Which nursing diagnoses should the nurse include in the plan of are based on the side effects associated with the treatment? Select all that apply. 1. Risk for Injury 2. Impaired Skin Integrity 3. Risk for Electrolyte Imbalance 4. Risk for Infection 5. Sleep Deprivation

Answer: 1, 2, 3, 4 Explanation: 1. Risk for Injury is an appropriate nursing diagnosis for a pediatric client due to the potential hemorrhagic cystitis, a common side effect for chemotherapy. 2. Impaired Skin Integrity is an appropriate nursing diagnosis for the pediatric client due to mouth sores, a common early side effect of chemotherapy. 3. Nausea and vomiting are common early side effects of chemotherapy; therefore, Risk for Electrolyte Imbalance is an appropriate nursing diagnosis for this pediatric client. 4. Risk for Infection is an appropriate nursing diagnosis as chemotherapy due to bone marrow suppression. 5. Sleep Deprivation is not a nursing diagnosis related to the administration of chemotherapy for a pediatric client.

18) The nurse is preparing to collect data for a family assessment. Which nursing actions are appropriate? Select all that apply. 1. Conducting interviews 2. Observing interactions 3. Reviewing reports from the healthcare provider 4. Monitoring daily living patterns 5. Asking a family friend his or her opinion of the family

Answer: 1, 2, 3, 4 Explanation: 1. The nurse collects data when conducting a family assessment by conducting interviews with the members of the family. 2. The nurse collects data when conducting a family assessment by observing interactions between the members of the family. 3. The nurse collects data when conducting a family assessment by reviewing reports from the healthcare provider. 4. The nurse collects data when conducting a family assessment by monitoring daily living patterns among the family members. 5. Interviewing a family friend without first getting permission from the family is a confidentiality violation.

25) The nurse of the family who is assuming the role of care coordinator is providing education regarding the use of a healthcare log. Which will the nurse encourage the family to include on this log? Select all that apply. 1. Role of each provider 2. Date of each appointment 3. Prescribed interventions 4. Future treatments 5. Out-of-pocket cost

Answer: 1, 2, 3, 4 Explanation: 1. The nurse will encourage the family to include the role of each provider on the healthcare log. 2. The nurse will encourage the family to include the date of each appointment on the healthcare log. 3. The nurse will encourage the family to include the prescribed interventions on the healthcare log. 4. The nurse will encourage the family to include future treatments on the healthcare log. 5. Out-of-pocket cost is not something the nurse encourages the family to keep on the healthcare log.

15) A child is brought to the emergency department in a coma. The mother thinks the child may have ingested a poison. Which will the nurse assess based on this information? Select all that apply. 1. For oral burns 2. The child's breath 3. The child's vomitus 4. Hair samples 5. Blood and urine toxicology screens

Answer: 1, 2, 3, 5 Explanation: 1. Corrosives often leave evidence of burns on the mouth and gums. 2. The breath may have characteristic odors that may help identify the poison. 3. The vomitus may contain leaves, indicating the child has eaten a plant or other items that may provide information on the toxin. 4. Hair samples can be used to test drug use over a period of time. It would not contain any valuable information for this child. 5. These tests will look for a wide variety of toxins.

24) The nurse is providing care to a child who is admitted to the hospital due to environmental exposure to a toxic agent. Which questions should the nurse ask the child and the parent during the assessment process? SATA 1. "Do you work around harmful substances that could have been brought to the home environment?" 2. "What year was your home built?" 3. "Does your child have a hobby that includes working with glue?" 4. "Does your home have a smoke detector?" 5. "Does your home have a carbon monoxide detector?"

Answer: 1, 2, 3, 5 Explanation: 1. It is appropriate for the nurse to ask the parents if any harmful substances could be brought home from the job to the home. 2. Many homes built before the 1970s were painted with lead paint. This is an appropriate question for the nurse to ask during the assessment process. 3. It is appropriate for the nurse to assess the use of glue to determine environmental exposure to a toxic agent. 4. Asking the family about a smoke detector is important to determine if there are safety features in the house. This question will not assess the child's risk for environmental exposure to a toxic agent. 5. Carbon monoxide could lead to environmental exposure to the child leading to toxicity. This question is appropriate for the nurse to include in the assessment process.

23) Which nursing interventions should the nurse implement for a school-age child who is the victim of physical abuse by a parent? Select all that apply. 1. Referring members of the family for appropriate counseling 2. Protecting the child from further injury 3. Allowing the child to wear clothing during the examination process 4. Discouraging parental participation in the plan of care 5. Documenting the child's response to parental interaction

Answer: 1, 2, 3, 5 Explanation: 1. It is appropriate for the nurse to refer members of the family for appropriate counseling. 2. It is appropriate for the nurse to protect the child from further injury. 3. It is appropriate for the nurse to allow the child to wear clothing during the examination process. 4. The nurse should encourage the parents to participate in the child's plan of care; however, the nurse should closely monitor interactions between the child and parent. 5. It is appropriate for the nurse to document the child's response to parental interaction.

19) The nurse is constructing a genogram as part of the family assessment process. Which will the nurse include in the genogram? Select all that apply. 1. Social class 2. Occupation 3. Place of residence 4. Social networks 5. Ethnicity

Answer: 1, 2, 3, 5 Explanation: 1. Social class is included when constructing a family genogram. 2. Occupation is included when constructing a family genogram. 3. Place of residence is included when constructing a family genogram. 4. Social networks are explored through the use of a family ecomap, not a genogram. 5. Ethnicity is included when constructing a family genogram.

12) Which risks of undescended testes should the nurse include in the teaching session for the parents of a newborn diagnosed with this condition? Select all that apply. 1. Sperm production will be affected after puberty. 2. Abdominal testes are subject to injury. 3. Abdominal testes have a higher risk of developing cancer. 4. Hormonal production will be affected. 5. The testes are at greater risk of torsion.

Answer: 1, 2, 3, 5 Explanation: 1. Sperm production by abdominal testes is affected by the heat of the body. 2. Positioning of the testes in the scrotum reduces the risk of injury. 3. Statistics have shown this statement is correct. 4. Production of hormones is not affected by the location of the testes. 5. Abdominal testes have a higher risk of twisting on its blood supply.

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

Answer: 1, 2, 3, 5 Explanation: 1. The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness. 2. The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness. 3. The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness. 4. High energy is not felt during the mourning period. 5. The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness.

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

Answer: 1, 2, 3, 5 Explanation: 1. This diagnosis is appropriate for the child's parents in this situation. 2. This diagnosis is appropriate for the child's parents in this situation. 3. This diagnosis is appropriate for the child's parents in this situation. 4. The diagnosis of knowledge deficit is not possible in this situation. Although planning for discharge begins with admission, it is too early to begin teaching the parents about home care. The astute and experienced nurse is prepared to recognize current problems and intervene appropriately. 5. This diagnosis is appropriate for the child's parents in this situation.

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

Answer: 1, 2, 4 Explanation: 1. A nurse who is functioning as a first responder after a natural disaster such as a tornado will provide first aid to the walking wounded. 2. A nurse who is functioning as a first responder after a natural disaster such as a tornado will assess for panic reactions. 3. It is not appropriate for the nurse to allow a child to leave the scene unaccompanied by an adult. 4. A nurse who is functioning as a first responder after a natural disaster such as a tornado will provide immunizations, if necessary. 5. It is not appropriate for the nurse to discuss the situation with the local media. A hospital representative is someone who can discuss the situation with the local media.

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

Answer: 1, 2, 4 Explanation: 1. Active listening encourages the parents to talk if they feel the need. 2. This behavior indicates willingness to listen. 3. This is no longer considered inappropriate and allows the parents to know that the nurse feels sadness at the loss. 4. This would be appropriate and helpful to the parents. 5. The nurse should provide support to the parents. Often just sitting in the room quietly is an appropriate intervention.

23) Which factors in the maternal medical history should cause the nurse concern regarding the development of cleft lip or cleft palate during pregnancy? Select all that apply. 1. Cigarette smoking 2. Alcohol use 3. Excessive folate intake 4. Glucocorticoid use 5. Anticoagulant use

Answer: 1, 2, 4 Explanation: 1. Cigarette smoking during pregnancy is a risk factor for cleft lip and cleft palate. 2. Alcohol use during pregnancy is a risk factor for cleft lip and cleft palate. 3. Excessive folate intake is not a risk factor for cleft lip and cleft palate. A folate deficiency is often the cause for these disorders. 4. Glucocorticoid use is a risk factor for cleft lip and cleft palate. 5. Anticoagulant use is not a risk factor for cleft lip and cleft palate.

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

Answer: 1, 2, 4 Explanation: 1. Juvenile idiopathic arthritis is a condition that necessitates the inclusion of interventions to treat chronic pain in the plan of care. 2. Sickle cell disease arthritis is a condition that necessitates the inclusion of interventions to treat chronic pain in the plan of care. 3. ADHD is not a condition that necessitates the inclusion of interventions to treat chronic pain in the plan of care. 4. Cancer is a condition that necessitates the inclusion of interventions to treat chronic pain in the plan of care. 5. HIV is a condition that necessitates the inclusion of interventions to treat chronic pain in the plan of care.

26) Which cardiovascular manifestations should the nurse anticipate for a pediatric client diagnosed with early compensated hypovolemic shock? Select all that apply. 1. Tachycardia 2. Weak distal pulses 3. Thready distal pulses 4. Normal blood pressure 5. Decrease in systolic blood pressure

Answer: 1, 2, 4 Explanation: 1. Tachycardia is a cardiovascular manifestation the nurse anticipates for the pediatric client who is diagnosed with early compensated hypovolemic shock. 2. Weak distal pulses are cardiovascular manifestations the nurse anticipates for the pediatric client who is diagnosed with early compensated hypovolemic shock. 3. Thready distal pulses are cardiovascular manifestations the nurse anticipates for the pediatric client who is diagnosed with moderate uncompensated hypovolemic shock. 4. Normal blood pressure for age is a cardiovascular manifestation the nurse anticipates for the pediatric client who is diagnosed with early compensated hypovolemic shock. 5. A decrease in systolic blood pressure is a cardiovascular manifestation the nurse anticipates for the pediatric client who is diagnosed with moderate uncompensated hypovolemic shock.

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

Answer: 1, 2, 4, 5 Explanation: 1. Narcotics, such as morphine, are used to control the pain and reduce sickling. 2. NSAIDs may be used in combination with narcotics to control the pain. 3. Cold application is inappropriate in this situation as it would increase the sickling. 4. Oral fluids will help "thin" the blood and reduce sickling. 5. Bed rest will reduce the oxygen requirements of the body and prevent further sickling.

10) Which actions are expected for a nurse who works in the school environment? Select all that apply. 1. Developing a plan for emergency care of injured children 2. Teaching a class on wellness to teachers and staff 3. Prescribing antibiotics for streptococcal pharyngitis 4. Diagnosing an ear infection 5. Screening for head lice

Answer: 1, 2, 5 Explanation: 1. Screening of students for certain conditions; educating students, teachers, and staff; and developing emergency plans are all roles of the school nurse. 2. Screening of students for certain conditions; educating students, teachers, and staff; and developing emergency plans are all roles of the school nurse. 3. Prescribing medication for a new illness is beyond the scope of practice for the school nurse unless the nurse is licensed as an advanced practice nurse. 4. Diagnosing acute illness is beyond the scope of practice for the school nurse unless the nurse is licensed as an advanced practice nurse. 5. Screening of students for certain conditions; educating students, teachers, and staff; and developing emergency plans are all roles of the school nurse.

25) Which respiratory findings assessed by the nurse indicate that a child is close to death? Select all that apply. 1. Tachypnea 2. Dyspnea 3. Diaphoresis 4. Confusion 5. Accumulation of secretions in the throat

Answer: 1, 2, 5 Explanation: 1. Tachynpea is a respiratory finding that may indicate the child is close to death. 2. Dyspnea is a respiratory finding that may indicate the child is close to death. 3. Diaphoresis is a cardiovascular, not respiratory, finding indicating the child is close to death. 4. Confusion is a neurologic, not respiratory, finding indicate the child is close to death. 5. As the child approaches death, the muscles relax and secretions accumulate in the oropharynx and bronchi, causing noisy breathing as air passes through the secretions.

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

Answer: 1, 2, 5 Explanation: 1. The DTap vaccine is appropriate for the nurse to administer to a 6-month-old infant during a scheduled well-child visit. 2. The Hib vaccine is appropriate for the nurse to administer to a 6-month-old infant during a scheduled well-child visit. 3. The HPV4 vaccine is not appropriate to administer to a 6-month-old infant during a scheduled well-child visit. This vaccine is not administered until a child is 11 to 12 years of age. 4. The MMR vaccine is not appropriate to administer to a 6-month-old infant during a scheduled well-child visit. This vaccine is not administered until a child is 12 to 15 months of age. 5. The PCV13 vaccine is appropriate for the nurse to administer to a 6-month-old infant during a scheduled well-child visit.

20) Which statements should the nurse include in a presentation related to the general function of the gastrointestinal (GI) system for parents of pediatric clients? Select all that apply. 1. "The GI tract is responsible for the ingestion and absorption of food." 2. "Newborns have smaller stomachs but increased peristalsis." 3. "All children require smaller, more frequent feedings." 4. "Infants lack certain digestive enzymes which increases the risk for regurgitation." 5. "By the second year of life a child is able to accommodate three meals each day."

Answer: 1, 2, 5 Explanation: 1. This statement is correct. The GI system is responsible for the ingestion and absorption of food. 2. This statement is correct. Newborns have smaller stomachs but an increased rate of peristalsis. 3. This statement is false. All children do not require smaller, more frequent feedings. This statement is true for newborns and infants. 4. This statement is false. While infants do lack certain digestive enzymes, this does not increase regurgitation but causes abdominal distention due to gas. 5. This statement is true. By the second year of life children are able to accommodate three

17) Which assessment questions should the nurse include in the psychosocial assessment to determine the effects of chronic renal failure treatments on the growth and development of a school-age child? Select all that apply. 1. "How does it make you feel to have to follow a special diet?" 2. "Do you take your medications every day?" 3. "How does it make you feel to undergo dialysis treatments?" 4. "Do you attend school each day?" 5. "How does it make you feel when your parents come home late from work?"

Answer: 1, 3 Explanation: 1. School-age children are often embarrassed about being seen as different from peers. It is appropriate for the nurse to ask the child how it feels to have to follow a special diet. 2. While it is important to assess medication use, this question is not appropriate for the psychosocial portion of the assessment. 3. School-age children are often embarrassed about being seen as different from peers. It is appropriate for the nurse to ask the child how it feels to have to undergo dialysis treatments. 4. While it is important to determine if the child attends school every day, this question is not appropriate for the psychosocial portion of the assessment. 5. This question will not help the nurse to determine the effects of the treatments for chronic renal failure on the child's growth and development.

22) Which topics should the nurse include in discharge instructions related to enhanced safety for a pediatric client who experienced an abdominal injury after a biking accident? Select all that apply. 1. Use of hand signals 2. Age-appropriate use of child safety seats 3. Age-appropriate bicycles 4. Use of a helmet 5. Avoid assigning blame

Answer: 1, 3, 4 Explanation: 1. Information related to appropriate hand signals when riding a bicycle is an injury prevention strategy that the nurse should include in the teaching session. 2. The use of an age-appropriate child safety seat is not an appropriate discharge instruction for a child who experienced an abdominal injury after a biking accident. 3. Information related to an age-appropriate bicycle is an injury prevention strategy that the nurse should include in the teaching session. 4. Information related to the use of a helmet is an injury prevention strategy that the nurse should include in the teaching session. 5. While the nurse should avoid assigning blame when providing care for a child who experienced an abdominal injury as a result of a biking accident, this is not an appropriate injury prevention topic to include in the discharge teaching session.

27) The nurse is providing care to a hospitalized adolescent client. Which should the nurse include in the adolescent's plan of care related to stressors? Select all that apply. 1. Loss of privacy 2. Fear of the dark 3. Loss of identity 4. Fear of altered body image 5. Separation anxiety

Answer: 1, 3, 4 Explanation: 1. Loss of privacy is a stressor the nurse should plan for when providing care to a hospitalized adolescent client. 2. Fear of the dark is a stressor for the hospitalized toddler and preschool-age client not the adolescent client. 3. Loss of identity is a stressor the nurse should plan for when providing care to a hospitalized adolescent client. 4. A fear of altered body image is a stressor the nurse should plan for when providing care to a hospitalized adolescent client. 5. Separation anxiety is a stressor for the hospitalized infant, toddler, and preschool-age child not the adolescent.

16) Which risks should the nurse closely assess a pediatric client for during the posttransplant phase of hematopoietic stem cell transplantation (HSCT)? 1. Hemorrhage 2. Thrombosis 3. Pancytopenia 4. Infection 5. Fluid volume overload

Answer: 1, 3, 4 Explanation: 1. Suppression of platelets increases the risk for bleeding. 2. There is no increased risk for thrombosis. 3. It takes 2 to 4 weeks for the bone marrow to begin producing cells; the client will show evidence of suppression until that time. 4. Suppression of white blood cells increases the client's risk for infection. 5. There is no increased risk of excess fluid; the client is at greater risk for dehydration.

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

Answer: 1, 3, 4 Explanation: 1. The child does not need to understand the surgical activity while asleep. 2. Care must be utilized in selecting terminology for the child. To the child, the heart is not just a muscle, but the center of the child's love. A "broken" heart may be discarded. 3. This is appropriate as parents are the child's main source of support. 4. Children of this age often have security objects; the child should be allowed to hold the object for comfort. Care must be taken that the teddy bear be labeled and returned to the child after the surgical procedure. 5. The child is awake in the holding room. It is better to wait until the child is under anesthesia to insert the catheter.

2) Which general manifestations should the nurse monitor for when conducting a physical assessment for a pediatric client who is diagnosed with cancer? Select all that apply. 1. Infection 2. Polycythemia 3. Petechiae 4. Pain 5. Cachexia

Answer: 1, 3, 4, 5 Explanation: 1. Infection is often a general manifestation associated with cancer caused by altered immune function. 2. Anemia, not polycythemia, is a general manifestation associated with cancer. 3. Hemorrhagic spots, or petechiae, are general manifestations associated with cancer. 4. Pain is often a general manifestation of cancer resulting from neoplasms directly or indirectly affecting nerve receptors. 5. Cachexia is a state that is often associated with cancer. Specific symptoms include anorexia, nausea, and vomiting.

18) Which age groups can best tolerate separation from parents during hospitalization? Select all that apply. 1. Infants birth to 5 months 2. Infants 5 months to 1 year 3. Toddlers and preschoolers 4. School-age children 5. Adolescents

Answer: 1, 4, 5 Explanation: 1. Infants in this age group do not recognize parents as separate from themselves so will not feel abandoned when parents do not stay. 2. Infants in this age group recognize object permanence and will be aware of the absence of their parents. 3. Both groups suffer from separation anxiety and fear of abandonment. 4. School-age children are accustomed to dealing with adults other than parents and can better tolerate separation. 5. Adolescents are able to understand separation and time and thus will not suffer from separation from parents.

25) Which nursing actions are important when providing care to a pediatric client who is on contact precautions due to a communicable disease? Select all that apply. 1. Encouraging frequent family visits 2. Scheduling physical therapy (PT) for the child 3. Providing age-appropriate stimulation and activities 4. Allowing the parents to have physical contact with the child 5. Educating the family about personal protective equipment (PPE)

Answer: 1, 3, 4, 5 Explanation: 1. It is important for the nurse to encourage frequent family visits to decrease the sense of isolation that can occur for the pediatric client who is on contact precautions. 2. This nursing action is more appropriate for a client who is receiving rehabilitative care versus a client who is on contact precautions. 3. It is important for the nurse to provide age-appropriate stimulation and activities due to limited contact with other children and family members while on contact precautions. 4. It is important to allow parents to have physical contact with their child when the child is on contact precautions. PPE should be limited to only what is needed to protect the parent from being exposed to the communicable disease. 5. It is important for the nurse to educate the family regarding which PPE to use and how to properly wear it when providing care to a child on contact precautions.

11) A neonate is born with a bilateral cleft lip that was not detected during the pregnancy. The parents are distressed about the appearance of their infant. Which nursing actions are appropriate to assist the parents to bond with their newborn? Select all that apply. 1. Calling the newborn by the chosen name 2. Keeping the newborn's lower face covered with the blanket 3. Smiling and talking to the newborn in the parents' presence 4. Showing the parents before and after pictures of other children with cleft lips 5. Discussing positive features of the baby

Answer: 1, 3, 4, 5 Explanation: 1. This behavior humanizes the child to the parents and is appropriate. 2. This indicates that the infant's appearance is distressing. Although the nurse would want to shield the child from a visitor's stare, the nurse would not want to hide the child from her own family. 3. This indicates acceptance of the infant by the nurse. 4. It is usually not appropriate to show before and after pictures as you cannot predict the success of the surgery on this child. But in the case of cleft lip, the improvement will be significant and it is considered acceptable to show before and after pictures. 5. Statements like, "Your baby is the sweetest thing—she never cries," can help the parents recognize positive features about their baby.

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

Answer: 1, 3, 4, 5 Explanation: 1. Regression is a common defense mechanism portrayed by the pediatric client in response to a life-threatening illness. 2. Anticipating is a coping mechanism, not a defense mechanism, that may be portrayed by the pediatric client in response to a life-threatening illness. 3. Denial is a common defense mechanism portrayed by the pediatric client in response to a life-threatening illness. 4. Repression is a common defense mechanism portrayed by the pediatric client in response to a life-threatening illness. 5. Bargaining is a common defense mechanism portrayed by the pediatric client in response to a life-threatening illness.

25) Which pediatric cancer diagnoses necessitate priority assessment by the nurses for clinical manifestations associated with emergencies related to space-occupying lesions? Select all that apply. 1. Hodgkin disease 2. Leukemia 3. Neuroblastoma 4. Melanoma 5. Lymphoma

Answer: 1, 3, 5 Explanation: 1. A pediatric client diagnosed with Hodgkin disease is at risk for emergencies related to space-occupying lesions. 2. Leukemia is not a pediatric cancer associated with emergencies related to space-occupying lesions. 3. A pediatric client diagnosed with neuroblastoma is at risk for emergencies related to space-occupying lesions. 4. Melanoma is not a pediatric cancer associated with emergencies related to space-occupying lesions. 5. A pediatric client diagnosed with lymphoma is at risk for emergencies related to space-occupying lesions.

19) Which nursing actions are appropriate to assess growth and development for an adolescent client diagnosed with chronic renal failure? Select all that apply. 1. Using the Denver II during a health maintenance visit 2. Educating parents on normal milestones 3. Monitoring for delayed sexual maturation 4. Comparing blood pressure values from previous visit 5. Plotting height and weight measurements

Answer: 1, 3, 5 Explanation: 1. The Denver II is a developmental assessment tool that is appropriate for the nurse to use when assessing growth and development for an adolescent client diagnosed with chronic renal failure. 2. It is appropriate for the nurse to educate the client's parents on normal milestones; however, this is not a nursing assessment. 3. Monitoring for delayed sexual maturation is appropriate when assessing growth and development for an adolescent client diagnosed with chronic renal failure. 4. Blood pressure is not a growth and development parameter. 5. Plotting height and weight measurements is an appropriate nursing action to assess growth and development for an adolescent client diagnosed with chronic renal failure.

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

Answer: 1, 4 Explanation: 1. Children who are immunodeficient should not share cups with other members of the family, as this increases the child's risk for developing an infection. 2. Utensils should be washed in warm water or placed in the dishwasher to ensure that contaminates are properly cleansed. 3. Fresh fruit should be washed and peeled prior to allowing the child who is immunocomprised to eat it. 4. Hand hygiene before handling the child, after changing diapers, and prior to feeding the child is essential to decrease the risk for infection. 5. The diaper area should be cleaned with mild soap and allowed to dry. The use of alcohol will increase the risk for skin breakdown and infection.

20) Which rationale should the nurse include in the teaching session, related to infant iron deficiency anemia, when a parent asks why it is inappropriate to switch from formula to cow's milk prior to 1 year of age? Select all that apply. 1. Cow's milk is a poor source of iron. 2. The child may be exposed to an antibiotic in processed milk. 3. Cow's milk has a high fat content. 4. In young children, cow's milk can lead to bleeding from the gastrointestinal tract. 5. Cow's milk contains no vitamin C, which is necessary for iron absorption.

Answer: 1, 4 Explanation: 1. This information is correct. 2. This would not be a reason for delaying the entry of milk into the diet. 3. Because there are low-fat varieties of cow's milk, this would not be a reason to delay introducing it. 4. This information is correct. 5. While the amount of vitamin C in milk is limited, this is not the reason for delaying introducing cow's milk into the child's diet.

9) After a severe allergic reaction, an EpiPen is prescribed for the school-age child. Which instructions should the nurse provide to this child's parents based on the current data? Select all that apply. 1. "It is important that your child always has access to this medication." 2. "Your child is too young to self-administer this medication." 3. "If you are able to administer the medication, there is no need for follow-up care." 4. "It is important to check the expiration date on the medication and replace if expired." 5. "Your child should wear a Medic Alert bracelet at all times."

Answer: 1, 4, 5 Explanation: 1. This is appropriate care. 2. Both the child and family members should be taught administration of the EpiPen. 3. The EpiPen effect is good for approximately 20 minutes. The child should be transported to the hospital immediately after administering the EpiPen. 4. An expired EpiPen may have less than desired effects. 5. If the child is unable to speak due to anaphylaxis, it is important that rescuers have information about the child's allergies.

12) The nurse is providing care to a 3-year-old client whose mother states, "I am not sure that I have enough money to buy both food for the rest of the month and the antibiotic for my child's ear infection." Which nursing intervention would be beneficial for the child and this family? 1. Talking with the mother about keeping the child's ear clean by using a Q-tip 2. Putting the mother in contact with a local agency that provides food on a regular basis to needy families and helps them access other resources in the community 3. Providing the mother with samples of food and food stamps for the child 4. Giving the mother free samples of an antibiotic

Answer: 2 Explanation: 1. Cleaning the ear with a Q-tip will not clear the ear infection. 2. Putting the mother in contact with a local agency is most likely to meet the family's basic need for food and possibly connect the mother to a resource that could supply her with the antibiotic for her child. 3. The nurse will have neither food samples nor food stamps at her disposal. 4. The course of treatment is usually 10 days. Free samples may not be for the appropriate antibiotic or be sufficient to treat the infection. A better intervention will be to provide help that will extend beyond the immediate period.

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

Answer: 2 Explanation: 1. Coworkers will also have a difficult time with the death. 2. Mentorship with experienced hospice nurses as well as additional educational experiences could help promote professional nursing care. 3. The unit manager also might have a difficult time with the impending death. 4. The spouse might not fully understand why this is affecting the nurse.

6) A child who has beta-thalassemia is receiving numerous blood transfusions and deferoxamine (Desferal) therapy. The parents ask how the deferoxamine will help their child. Which response by the nurse is accurate? 1. "It stimulates red blood cell production." 2. "It prevents iron overload." 3. "It provides vitamin supplementation." 4. "It decreases the risk of transfusion reactions."

Answer: 2 Explanation: 1. Desferal does not stimulate red blood cell production. 2. Iron overload can be a side effect of a hypertransfusion therapy. Desferal is an iron-chelating drug that binds excess iron so it can be excreted by the kidneys. It does not prevent blood transfusion reactions, stimulate red blood cell production, or provide vitamin supplementation. 3. Desferal does not provide vitamin supplementation. 4. Desferal does not prevent blood transfusion reactions.

3) Which urinalysis result should the nurse anticipate for a child who is admitted with acute glomerulonephritis? 1. Bacteriuria and increased specific gravity 2. Hematuria and proteinuria 3. Proteinuria and decreased specific gravity 4. Bacteriuria and hematuria

Answer: 2 Explanation: 1. Glomerulonephritis is an inflammation of the glomeruli of the kidneys. Bacteriuria is not present. But because the urine is concentrated, the specific gravity is increased. 2. Glomerulonephritis is an inflammation of the glomeruli of the kidneys. The clinical manifestation of glomerulonephritis is grossly bloody hematuria with mild to moderate proteinuria, and because the urine is concentrated, the specific gravity is increased. 3. Glomerulonephritis is an inflammation of the glomeruli of the kidneys. Because the urine is concentrated, the specific gravity is increased. 4. Glomerulonephritis is an inflammation of the glomeruli of the kidneys. Bacteriuria is not present.

1) Which assessment finding indicates adequate peripheral perfusion for a child after a cardiac catheterization? 1. Capillary refill is greater than 3 seconds. 2. Lower extremities are warm, with a capillary refill of less than 3 seconds. 3. Sensation is decreased with a weakened dorsalis pedis pulse. 4. Dorsalis pedis pulse is palpable but posterior tibial pulse is weak.

Answer: 2 Explanation: 1. If the capillary refill is over 3 seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate. 2. The nurse checks the extremity to determine adequacy of circulation following a cardiac catheterization. An extremity that is warm with capillary refill of less than 3 seconds has adequate circulation. Other indicators of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate sensation, and pinkness of skin color. 3. If the capillary refill is over 3 seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate. 4. If the capillary refill is over 3 seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.

2) A premature neonate is at greater risk for infection than a full-term newborn because of a reduced number of which immunoglobulin? 1. IgE 2. IgG 3. IgA 4. IgM

Answer: 2 Explanation: 1. IgE does not cross the placenta and is not present at birth in either preterm or full-term infants. 2. Maternal IgG crosses the placenta. Newborns' levels are similar to their mothers'. Premature infants have lower levels of IgG obtained from their mothers and are at greater risk for infection. 3. IgA does not cross the placenta and is not present at birth in either preterm or full-term infants. 4. IgM does not cross the placenta. The levels are low at birth in both preterm and full-term infants.

10) A preschool-age age child with severe head trauma is intubated and on a respirator. The child has three flat electroencephalograms (EEGs) completed 24 hours apart. The electrocardiogram (ECG) shows a rate of 90 beats per minute in a normal sinus rhythm. Which term should the nurse use when documenting these findings? 1. Imminent death 2. Brain death 3. Natural death 4. Heart-lung death

Answer: 2 Explanation: 1. Imminent death means physical death is inevitable within a period of time. 2. Cerebral death, or brain death, is the irreversible cessation of all brain functions, including those of the cerebral cortex and brainstem, manifested by the absence of brain waves on EEG. 3. Natural death is allowing cessation of all body functions without extraordinary medical interventions. 4. Heart-lung death, the irreversible cessation of cardiorespiratory functions, has not occurred because the child is being mechanically ventilated.

5) The nurse is teaching a preschool-age child and parents the importance of hand washing after using the toilet. Which rationale for this practice should the nurse include in the teaching session? 1. Children's immune systems are not fully developed. 2. It is the main way to limit the transmission of disease. 3. Not all bathrooms are clean. 4. Children do not like to have dirty hands.

Answer: 2 Explanation: 1. Underdeveloped immune systems will not transmit disease. 2. The fecal-oral and respiratory routes are the most common sources of transmission in children. 3. Children usually do not wash their hands after toileting unless they are closely supervised. 4. This is not a reason for washing hands after using the toilet.

6) The nurse receives a phone call from the parent of a child who is prescribed rifampin (Rimactane) for treatment of tuberculosis because she saw that the child's urine was orange. Which response by the nurse is accurate? 1. "Encourage your child to drink cranberry juice." 2. "An orange discoloration of urine is expected while your child is on this medication." 3. "Bring your child to the clinic for a urinalysis." 4. "Bring your child to the clinic for a radiograph of the kidneys."

Answer: 2 Explanation: 1. Orange urine does not mean the child has a urinary tract infection, and a urinalysis, radiograph, and encouragement of cranberry juice would not be options. 2. Rifampin can color the urine orange, so the parents and child should be taught that this is an expected side effect. 3. Orange urine does not mean the child has a urinary tract infection, and a urinalysis, radiograph, and encouragement of cranberry juice would not be options. 4. Orange urine does not mean the child has a urinary tract infection, and a urinalysis, radiograph, and encouragement of cranberry juice would not be options.

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

Answer: 2 Explanation: 1. PCA should always be controlled by the individual receiving the medication. It is inappropriate to have the parents control the medication administration. 2. This provides continuous blood levels of the opioid. 3. By waiting until symptoms are present, the child's blood level will drop, making it more difficult to control the pain. 4. Parenteral administration controls pain more effectively than oral medication as oral absorption may be modified by stomach activities. In addition, providing analgesics on a scheduled basis is preferred over prn.

5) A 2-month-old infant with bronchopulmonary dysplasia (BPD) is being prepared for discharge from the neonatal intensive care unit. The infant will continue to receive oxygen via nasal cannula at home. Prior to discharge, the home health nurse assesses the home. Which finding poses the greatest risk to this infant? 1. Paint peeling on the walls 2. A wood stove used for heating 3. A sibling who has an ear infection 4. Small toys strewn on the floor

Answer: 2 Explanation: 1. Paint peeling from the wall will pose a choking risk to the older infant who is crawling. 2. Assessment of the home environment is essential prior to discharge of a medically fragile infant. The use of a wood stove poses great risk to the infant who already has fragile lungs and is a fire hazard when using oxygen in the home environment. 3. Ear infections are not contagious. 4. Small toy pieces will pose a choking risk to the older infant who is crawling.

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

Answer: 2 Explanation: 1. Parents do not need to know the names of the medications the child will receive. 2. The nurse explains visual and auditory experiences, such as a surgical gown, cap, shoe covers, and the parents' role during induction. The nurse offers the parents an opportunity to ask questions and voice concerns. 3. The nurse should tell the parents what to expect but not how they will feel while they watch their child. 4. The nurse should never ignore a request made by parents.

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

Answer: 2 Explanation: 1. Parents never should be asked to take part in emergency efforts unless absolutely necessary. 2. Parents should be helped to support their child through emergency procedures, if they are able. 3. Merely watching the resuscitation serves no purpose for the child. 4. If the parents interfere with resuscitation efforts, or are unable to tolerate the situation, they can be asked to leave later.

4) Which nursing action is appropriate for the parents of a 4-month-old infant who died due to sudden infant death syndrome (SIDS)? 1. Sheltering parents from the grief by not giving them any personal items of the infant, such as footprints 2. Allowing parents to hold, touch, and rock the infant 3. Advising parents that an autopsy is not necessary 4. Interviewing parents to determine the cause of the incident

Answer: 2 Explanation: 1. Parents will want any personal items available. 2. The parents should be allowed to hold, touch, and rock the infant, giving them a chance to say good-bye to their baby. 3. The death of an infant without a known medical condition is an indication for an autopsy. 4. The parents need to know that SIDS is not their fault.

5) The nurse is providing care to a pediatric client who is newly diagnosed with a chronic condition. The parents ask, "When will our child be able to assume more responsibility for managing the disease?" Which age group will the nurse include in the response to the parents? 1. Preschooler 2. School-age 3. Adolescent 4. Toddler

Answer: 2 Explanation: 1. Preschoolers do not have the cognitive and psychomotor skills for these tasks. 2. School-age children are developing a sense of industry and can begin assuming responsibility for self-care. 3. Adolescents should already be well accomplished at self-care. 4. Toddlers do not have the cognitive and psychomotor skills for these tasks.

14) The nurse is providing care to a child who is diagnosed with Lyme disease. The mother wants to know how to protect her other children from contracting this disease from the infected child. Which should the nurse include in the teaching session regarding the transmission of this disease process? 1. Lyme disease is passed from person to person. 2. Lyme disease is passed from animals to person. 3. Lyme disease is passed from adults to children. 4. Lyme disease is passed from person to insects.

Answer: 2 Explanation: 1. Some infectious diseases are transmitted by insects or animals and are not communicable from person to person. Lyme disease is not communicable from person to person. 2. Zoonosis describes infectious diseases that are transmitted by animals and are not communicable from person to person. Lyme disease is an example of this type of infectious disease. 3. Some infectious diseases are transmitted by insects or animals and are not communicable from person to person. Lyme disease is not communicable from adults to children. 4. Some infectious diseases are transmitted by insects or animals and are not communicable from person to person. Lyme disease is not passed from people to insects.

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

Answer: 2 Explanation: 1. Telling the mother she will be asked to leave will only worsen the situation. 2. Nursing techniques include informing the family of potential problems that could occur. If the child's condition changes, make every effort to inform the family immediately. 3. The mother is already angry because of the lack of information sharing. The nurse should not "pass the buck" to the healthcare provider. 4. The mother is already angry, and informing her that her behavior will upset the child will only anger her more.

4) The pediatric group is providing care to a group of hospitalized clients. Which client is at the greatest risk for developing separation anxiety if the parents are unable to stay with the child at all times? 1. 6 month old 2. 18 month old 3. 4 year old 4. 6 year old

Answer: 2 Explanation: 1. The 6-month-old child does not experience separation anxiety, which usually begins at around 1 year of age. 2. The young toddler is at greatest risk. Toddlers are the group most at risk for a stressful experience when hospitalized. Separation from parents increases this risk greatly. 3. The 4-year-old child is past the age when separation anxiety would be most prevalent. 4. The 6-year-old child is attending school and is used to short periods of separation from parents.

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

Answer: 2 Explanation: 1. The CRIES Scale was developed for preterm and full-term neonates. 2. A 5-year-old child should be able to use the Faces Scale to choose which face best matches the child's pain level. 3. The SUN Scale was developed for use in newborns. 4. The PIPP Scale was developed for premature infants.

7) In which position should the nurse place a child who is experiencing an anaphylactic shock reaction? 1. Trendelenburg position 2. Flat, with legs slightly elevated 3. High Fowler position 4. Reverse Trendelenburg position

Answer: 2 Explanation: 1. The Trendelenburg position has the head of the bed lowered and is no longer recommended for the treatment of shock, as it causes abdominal organs to press against the diaphragm, which impedes respirations and decreases coronary artery filling. 2. Flat, with legs slightly elevated, is the position that is used for a client experiencing shock. This allows for the blood pressure to be maintained during this critical time. 3. The high Fowler position has the head of the bed elevated and will not be effective to maintain a blood pressure when shock is occurring. 4. The reverse Trendelenburg position has the head of the bed elevated and will not be effective to maintain a blood pressure when shock is occurring.

1) The mother of a toddler-age client states, "My daughter seems to be at an increased risk for complications associated with respiratory infections." Which response by the nurse is accurate? 1. "You are incorrect in your assessment." 2. "The younger child's airways are smaller and more easily occluded." 3. "Air passages are more likely to become blocked with mucus because younger children make more mucus than older children." 4. "Toddlers do not breathe as deeply as do older children."

Answer: 2 Explanation: 1. The mother is correct in her statement. 2. Airways are smaller in the younger child and are more easily occluded when mucus is produced. 3. Blockage of air passages with mucus is not related to the age of the child but more to the etiology of mucus production and the continuation of the causative agent. 4. Depth of breathing is not age dependent.

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

Answer: 2 Explanation: 1. The mother recognizes that death is near and is accepting of it. 2. The mother has come to terms with her loss. 3. The request for prayer is not an example of bargaining. In her acceptance of her child's impending death, she is including her religious beliefs as a support. 4. There is sadness in her message, but the overall message is one of acceptance.

12) Which nursing action is appropriate when providing care to a newborn with a respiratory rate of 102 breaths per minute with lungs that are clear to auscultation? 1. Administering the bath to the neonate in the nursery 2. Transferring to the neonatal intensive care unit for further observation 3. Allowing the neonate to room-in to promote bonding 4. Providing the first feeding in the nursery

Answer: 2 Explanation: 1. The newborn is tachypneic. Bathing will only add to the respiratory distress and should be avoided. 2. This newborn needs to remain under constant observation due to the respiratory rate. 3. The newborn needs to be monitored. 4. With a respiratory rate this high, aspiration is likely so feeding should be avoided.

4) The home health nurse is providing care to a 2-week-old newborn, and notes that the baby has a necklace with a charm around the neck. The parents state that they believe the charm will keep the baby healthy. Which nursing action is most appropriate? 1. Report the parent to Social Services for endangering the child. 2. Respect the parents' wishes and leave the necklace in place. 3. Remove the necklace and inform the parents that it is dangerous. 4. Ask the parents to remove the necklace.

Answer: 2 Explanation: 1. The nurse should honor the practices of the family. To do otherwise would lead to loss of trust from the family. The nurse can provide anticipatory guidance to the family that includes safety principles as the infant grows. 2. Families of different cultural backgrounds might have specific beliefs about health care. These beliefs might differ from those of the nurse. The nurse should honor the practices of the family. 3. The nurse should honor the practices of the family. To do otherwise would lead to loss of trust from the family. The nurse can provide anticipatory guidance to the family that includes safety principles as the infant grows. 4. The nurse should honor the practices of the family. To do otherwise would lead to loss of trust from the family. The nurse can provide anticipatory guidance to the family that includes safety principles as the infant grows.

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

Answer: 2 Explanation: 1. The nurse supports the family, but remains nonjudgmental about accident details. 2. The priority is to prepare the parents for the child's changed appearance. 3. The priority is to prepare the parents for the child's changed appearance. Truthful statements about the child's condition can be introduced after the parents have seen the child and grasped the situation. 4. The priority is to prepare the parents for the child's changed appearance. The nurse must not offer false reassurance or project future stressful events.

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

Answer: 2 Explanation: 1. The physician does not make the decision whether the parents stay with the child; the parents make the decision. 2. 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. 3. Parents should be allowed to stay with their child if they wish instead of going to the waiting room where they lack privacy. 4. The parents need to make the decision about staying with their child without input from the nurse.

5) During the nurse's initial assessment of a school-age child, the child reports a pain level of 6 out of 10. The child is lying quietly in bed watching television. Which nursing action is appropriate? 1. Reassess the child in 15 minutes to see if the pain rating has changed. 2. Administer the prescribed analgesic. 3. Do nothing, since the child appears to be resting. 4. Ask the child's parents if they think the child is hurting.

Answer: 2 Explanation: 1. There is no need to reassess, as the child needs pain medication now. 2. School-age children are old enough to report their pain level accurately. A pain score of 6 is an indication for prompt administration of pain medication. The child might be trying to be brave or might be lying still because movement is painful. 3. The child might be lying quietly because movement increases the pain. 4. School-age children can answer for themselves and do not need the parents to answer for them.

13) Which assessment finding, after the dialysate is drained during peritoneal dialysis for a child experiencing acute renal failure, would warrant further action by the nurse? 1. The dialysate is clear on return. 2. The volume of drained dialysate is less than the volume infused. 3. The child is restless, wanting to get up and play. 4. The child's vital signs are basically the same as were noted on infusion.

Answer: 2 Explanation: 1. This is a normal finding and does not require reporting. 2. This indicates fluids are being retained and is not desirable. The healthcare provider should be notified. 3. This could indicate the child is feeling better. It is a desired effect and does not require reporting to the healthcare provider. 4. This is an expected finding. No dramatic differences in vital signs should be noted.

19) A child is admitted to the emergency department (ED) for scald burns to the buttocks and thighs. According to the mother, she was preparing the child's bath and before she could test the water, the child fell in and was scalded. Which would cause the nurse to suspect abuse? 1. The burns are uneven, with some burns deeper than others. 2. The child's hands and feet are free of burns. 3. In addition to the main burn site, there are splash burns surrounding the area. 4. The mother was home alone with the child.

Answer: 2 Explanation: 1. This might occur in an accidental scald burn. 2. Someone who falls in hot water would immediately try to get out by using the hands and feet. 3. This would be a logical finding. 4. It is not unusual for a mother to be home alone with a child.

10) An infant presents to the emergency department (ED) with physical injuries. The nurse is taking the child's history. Which parental statement would cause the nurse to be suspicious of abuse? 1. "I was walking up the steps and slipped on the ice and fell while carrying my baby." 2. "The baby's 18-month-old brother was trying to pull the baby out of the crib and dropped the baby on the floor." 3. "I placed the baby in the infant swing. His 6-year-old brother was running through the house and tripped over the swing, causing it to fall." 4. "I did not realize that my baby was able to roll over yet, and I was just gone a minute to check on dinner when the baby rolled off of the couch and onto our tile floor."

Answer: 2 Explanation: 1. This statement is plausible from a developmental perspective; therefore, the nurse would not be suspicious of abuse. 2. Developmentally, it would be very difficult for an 18-month-old child to pull an infant out of a crib. 3. This statement is plausible from a developmental prospective; therefore, the nurse would not be suspicious of abuse. 4. This statement is plausible from a developmental prospective; therefore, the nurse would not be suspicious of abuse.

21) A recently divorced mother who must return to work is concerned about the effects of placing her child in day care full-time. In counseling the mother, the nurse knows that which factor is most influential in determining whether day care has a positive or negative effect on the child? 1. The amount of time that the children spend playing outside 2. The closeness of the parent-child relationship 3. The ratio of day care workers to children 4. The cleanliness of the day care facility

Answer: 2 Explanation: 1. While the amount of time children are able to spend playing outdoors can contribute to whether child care is a positive or negative experience, the closeness of the parent—child relationship is more likely to impact how resilient the child is, and this has a greater impact on the effects of the child care experience. 2. The closeness of the parent—child relationship is more likely to impact how resilient the child is, and this has a greater impact on the effects of the child care experience. 3. While the ratio of day care workers to children can contribute to whether child care is a positive or negative experience, the closeness of the parent-child relationship is more likely to impact how resilient the child is, and this has a greater impact on the effects of the child care experience. 4. While the cleanliness of the facility can contribute to whether child care is a positive or negative experience, the closeness of the parent-child relationship is more likely to impact how resilient the child is, and this has a greater impact on the effects of the child care experience.

3) The nurse is planning care for a school-age child who requires oxygen, enteral tube feedings, and IV medications during the school day. To which category of chronic illness does this child belong? 1. Dependent on special diet 2. Dependent on medical technology 3. Increased use of healthcare services 4. Functional limitations

Answer: 2 Explanation: 1. While this child does have a special diet, this category is not comprehensive enough to describe the child's needs. 2. This child requires oxygen, enteral tube feedings, and IV medications, which indicates the child is dependent on medical technology. 3. While this child does have increased use of healthcare services, this category is not comprehensive enough to describe the child's needs. 4. While this child may have functional limitations, this category is not comprehensiveenough to describe the child's needs.

16) Which is the priority nursing action when it is suspected that an infectious agent has been used as a weapon by terrorists? 1. Separating clients according to age 2. Initiating airborne and contacts precautions 3. Separating clients according to level of development 4. Disposing of blood-contaminated needles in the lead-lined container

Answer: 2 Explanation: 1. Separating clients according to age will do nothing to stop terrorism. 2. When clients present with the same type of infectious symptoms, the priority nursing action is to initiate airborne and contact precautions prior to diagnosis. 3. Separating clients according to level of development will do nothing to stop terrorism. 4. Proper disposal of blood-contaminated needles in the sharps container is appropriate nursing actions but does not relate to terrorism.

14) The nurse is providing care to a toddler-age client newly diagnosed with a chronic condition. Which nursing action will prepare the family for providing care to the toddler once discharged from the hospital setting? 1. Suggesting that the parents use a mobile to provide sensory stimulation 2. Helping the parents recognize their child's capabilities 3. Allowing the child to choose the color of the gown during hospitalization 4. Suggesting the child be enrolled in a special camp to learn about the diagnosis

Answer: 2 Explanation: 1. A mobile is not an appropriate toy to provide sensory stimulation to the toddler. This suggestion is appropriate for an infant. 2. It is important for the nurse to help the parents recognize their child's capabilities and to encourage the parents to allow enough time to practice and learn a new skill. 3. This is an appropriate nursing action when the child is hospitalized; however, this is not a nursing action that will prepare the family for providing care to the toddler with a chronic condition after discharge. 4. Enrollment in a special camp would be appropriate for a school-age child, not the toddler.

20) Which pediatric clients would require a nursing assessment for blunt chest trauma? Select all that apply. 1. A preschool-age client who is admitted after a house fire. 2. A toddler-age client who is admitted for injuries sustained in a motor vehicle accident. 3. A school-age client who is admitted for observation after a skateboarding accident. 4. An adolescent client admitted for an asthma exacerbation. 5. An infant admitted to rule out cystic fibrosis.

Answer: 2, 3 Explanation: 1. A preschool-age client admitted after a house fire would require assessment for smoke-inhalation injury not blunt chest trauma. 2. A toddler-age client admitted for injuries sustained in a motor vehicle accident would require assessment to determine blunt chest trauma. 3. A school-age client admitted for observation after a skateboarding accident would require assessment to determine blunt chest trauma. 4. An asthma exacerbation would not necessitate a nursing assessment for blunt chest trauma. 5. An infant admitted to rule out cystic fibrosis would not necessitate a nursing assessment for blunt chest trauma.

29) The nurse is providing care to a pediatric client who is diagnosed with leukopenia. Which disorders should the nurse suspect based on this information? Select all that apply. 1. Cardiovascular 2. Immune 3. Bone marrow 4. Respiratory 5. Neurologic

Answer: 2, 3 Explanation: 1. Cardiovascular disorders are not associated with leukopenia. 2. Immune disorders are associated with leukopenia. 3. Bone marrow disorders are associated with leukopenia. 4. Respiratory disorders are not associated with leukopenia. 5. Neurologic disorders are not associated with leukopenia.

26) Which assessment findings may indicate to the nurse that the child is experiencing renal failure and is close to death? Select all that apply. 1. Decreased oral fluid intake 2. Decreased urine production 3. Increased urinary incontinence 4. Urinary stones noted 5. Increased diaphoresis

Answer: 2, 3 Explanation: 1. Decreased oral intake is a gastrointestinal, not urinary, manifestation associated with impending death. 2. Decreased urine output is a clinical manifestation associated with renal failure that occurs with impending death. 3. Increased urinary incontinence is a clinical manifestation associated with renal failure that occurs with impending death. 4. Urinary stones are not a clinical manifestation associated with renal failure that occurs with impending death. 5. Increased diaphoresis is a cardiovascular, not renal, manifestation associated with impending death.

17) The nurse is providing discharge instructions to the family of a child who experienced an anaphylactic reaction. Which parental statements indicate accurate understanding of the action that histamine plays during this type of reaction? Select all that apply. 1. "Histamine releases IgE antibodies, which help to stop the reaction." 2. "Histamine causes smooth muscle contraction, which causes the wheezing." 3. "Histamine causes increased capillary permeability, which is what causes difficulty breathing." 4. "Histamine causes vasoconstriction leading to respiratory issues." 5. "Histamine causes the destruction of red blood cells, which is why we administer the EpiPen."

Answer: 2, 3 Explanation: 1. IgE antibodies cause the release of histamine, not the other way around. 2. Smooth muscle contraction causes the constriction of the bronchioles, which causes the wheezing and respiratory distress. 3. Increased capillary permeability causes the plasma to leak into surrounding tissues, including the lungs, leading to pulmonary edema. 4. Anaphylaxis causes vasodilation, not vasoconstriction. 5. Histamine does not cause red cell destruction.

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

Answer: 2, 3 Explanation: 1. Immunoglobulins provide passive immunity. No active immunity is acquired. 2. This immunization will stimulate antibody production in the child which is active immunity. 3. This immunization will also stimulate antibody production in the child. 4. Antibiotic therapy provides no immunity. 5. Antiviral therapy provides no immunity.

19) A hospitalized preschool-age child will be left alone for short periods of time for the mother to return home to care for the child's siblings. The mother asks the nurse what is the best way to leave. Which response by the nurse is appropriate? Select all that apply. 1. "Leave after your child falls asleep so he won't know you are going." 2. "Tell your child you are leaving and identify when you will return after dinner." 3. "Leave an article of clothing behind to comfort your child." 4. "Tell the nurse on duty when you are leaving so that the nurse can stay with your child while you are gone." 5. "Plan to leave when your child is having procedures performed as the child will be busy and less aware of the parents' absence."

Answer: 2, 3 Explanation: 1. The child will awaken and feel mom has disappeared. When mom returns, the child may be unwilling to fall asleep again for fear she will disappear again. 2. The child cannot tell time, so it is appropriate to associate time of return with an event that the child recognizes rather than give a specific time. It is appropriate for the mother to tell the child she is leaving and promise to return. 3. The child recognizes that mother will return for her clothing, and this may provide comfort. 4. The nurses need to know that the child is alone, but staffing demands will not allow a nurse to sit with the child during the parent's absence. 5. Whenever possible, the parents should be present when procedures are being performed.

23) Which age-appropriate techniques should the nurse implement in order to encourage a young child to participate in deep breathing exercises? Select all that apply. 1. Showing the child how to use the "blow bottle" 2. Using a pinwheel that the child plays with and asking the child to blow until it turns 3. Asking the child to blow bubbles in a glass of water using a straw 4. Having the child blow scraps of paper across the bedside table with a straw 5. Telling the child that a "shot" will be needed if the child does not follow the nurse's

Answer: 2, 3, 4 Explanation: 1. A blow bottle is appropriate for an older pediatric client, not a young child. 2. Asking the young child to blow on a pinwheel is an age-appropriate intervention to facilitate deep breathing. 3. Asking the child to blow bubbles into a glass of water is an age-appropriate intervention to facilitate deep breathing. 4. Having the child blow scraps of paper across the bedside table with a straw is an age-appropriate intervention to facilitate deep breathing. 5. Telling the child that an injection will be administered if the nurse's directions are not followed is not therapeutic nor age appropriate.

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

Answer: 2, 3, 4 Explanation: 1. A regional nerve block involves injecting medications in an area that controls pain for a region of the body. It does not provide nonpharmacologic relief. 2. Massage and rubbing of the skin as well as swaddling and kangaroo care are nonpharmacologic means of relieving pain. 3. The use of heat (and cold) may help reduce pain sensations and utilizes no pharmacologic agents. 4. Electrical stimulation to the skin uses the gate control theory to relieve pain. 5. EMLA cream is a mixture of lidocaine and prilocaine that is applied to the intact skin. It is a pharmacologic pain relief method.

15) After the infant is diagnosed with a chronic health condition, the family is assigned a nurse case manager. Which will the nurse include in the explanation to the infant's parents regarding this role? SATA 1. Limiting the number of visits to the healthcare facility 2. Preventing duplication of services 3. Improving the quality of life for the child and parents 4. Recognizing the equipment needs of the child and providing assistance with equipment acquisition 5. Visiting the child in the home to assist with physical care

Answer: 2, 3, 4 Explanation: 1. Although well-managed care may reduce illnesses and thus visits to the healthcare facility, limiting visits is not a function of the case manager. 2. Because many children who are chronically ill are seen by many healthcare providers and clinics, there is often a duplication of services. Case managing coordinates between the various clinics and healthcare providers to prevent duplication. 3. Case managing has many modes of improving the quality of life for children and parents. By coordinating care, the child can often be seen by several healthcare providers during the same visit, thus improving the quality of life. 4. The case manager will assist the family in meeting the needs of the child, including helping with identifying and acquiring equipment necessary for caring for the child. 5. The case manager does not provide direct client care.

14) Which statements, made by the adolescent following dietary teaching for Crohn disease, indicate correct understanding of the content presented by the nurse? Select all that apply. 1. "I can promote solid stools by increasing fiber in my diet." 2. "Small, frequent meals are preferred over three meals a day." 3. "I should identify foods that cause distress and eliminate them from my diet." 4. "High-calorie dietary supplement shakes can help me to meet my nutritional requirements." 5. "Socialization during my meal times is important even if my parents do not agree with my food choices."

Answer: 2, 3, 4 Explanation: 1. Fiber should be decreased, not increased, as diarrhea is one of the symptoms of Crohn disease. 2. This is correct information. 3. This is individualizing the diet and is appropriate. 4. This addition provides an easy way to meet the nutritional needs. 5. Stress should be avoided at mealtimes.

17) Which data collected during the respiratory assessment would indicate the pediatric client is compromised? Select all that apply. 1. Lung sounds clear to auscultation 2. Stridor 3. Substernal retractions 4. Nasal flaring 5. Strong cry

Answer: 2, 3, 4 Explanation: 1. Lung sounds that are clear to auscultation do not indicate respiratory compromise. 2. Stridor is an adventitious breath sound that may indicate respiratory compromise. 3. Substernal retractions may indicate respiratory compromise. 4. Nasal flaring may indicate respiratory compromise. 5. A weak, not strong, cry may indicate respiratory compromise.

21) The school-age child is admitted to the pediatric neurologic unit with a suspected craniopharyngioma. Which assessment data collected by the nurse supports the suspected diagnosis? Select all that apply. 1. Evening nausea 2. Excessive urination 3. Nystagmus 4. Headaches 5. Orbital ecchymosis

Answer: 2, 3, 4 Explanation: 1. Nausea is a common symptom of a brain tumor due to effect on the vomiting center of the brain. However, it occurs primarily in the morning on arising. 2. Diabetes insipidus is common in tumors involving the pituitary gland, such as craniopharyngioma. 3. Nystagmus is a symptom of pressure on the optic nerve chiasm. 4. The headaches may be due to the increased bulk in the cranium and/or the ventricular blockage leading to hydrocephalus. 5. Orbital ecchymosis is seen in neuroblastoma secondary to metastasis to the bone.

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

Answer: 2, 3, 4 Explanation: 1. The hospital administrator will be unable to meet their needs or to calm their anger. 2. Parents grieve for the loss of the perfect child. This is a normal reaction. 3. The nursing staff will continue to provide physical and emotional care to the child and family. 4. It is appropriate to offer the hospital chaplain and other mental health workers in addition to continued support from the nursing staff. 5. This option is a resolution for the nursing staff but not for the parents.

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

Answer: 2, 3, 4 Explanation: 1. This information is not pertinent. 2. The site should be recorded. 3. This information should be recorded in case a problem develops. 4. This should be recorded. 5. This information is not pertinent.

23) The nurse is preparing to assist with a lumbar puncture for a pediatric client who is diagnosed with cancer. Which statements should the nurse include in the teaching session for the client and family? Select all that apply. 1. "This procedure assesses the bone marrow." 2. "This procedure assesses cerebrospinal fluid." 3. "This procedure confirms the diagnosis of acute lympoblastic leukemia." 4. "The procedure determines if malignant cells are affecting the nervous system." 5. "This procedure assesses cellular components of the blood."

Answer: 2, 4 Explanation: 1. A bone marrow aspiration, not a lumbar puncture, is used to assess bone marrow. 2. A lumbar puncture is used to assess cerebrospinal fluid. 3. A bone marrow aspiration, not a lumbar puncture, is used to confirm the diagnosis of acute lymphoblastic leukemia. 4. A lumbar puncture is used to assess if malignant cells are affecting the central nervous system. 5. A complete blood count with differential, not a lumbar puncture, is used to assess the cellular components of the blood. Page Ref: 1316

her child needed hospitalization since her school-age nephew had the same symptoms and was treated at home. Which should the nurse include in the explanation to the infant's mother? Select all that apply. 1. Infants have a lower proportion of their body weight as water. 2. The percentage of extracellular fluid is higher in the infant than the school-age child. 3. School-age children have a larger body surface area. 4. The school-age child's kidneys are more mature and better able to conserve water. 5. The metabolic rate of the school-age child is higher.

Answer: 2, 4 Explanation: 1. Infants have a higher percentage of body weight as water. 2. This statement is accurate. 3. Body surface area (BSA) is an assessment of skin surface. BSA compares the height and weight of the child and is greatest in infancy. 4. This statement is accurate. 5. Infants have a higher metabolic rate than a school-age child.

26) The nurse is providing care to a pediatric client who will require surgery as a portion of the treatment regimen. Which topics should the nurse include in the teaching session related to long- term ramifications associated with this treatment option? 1. Scoliosis 2. Adhesions 3. Hypothyroidism 4. Visual impairment 5. Cardiotoxicity

Answer: 2, 4 Explanation: 1. Scoliosis is a long-term ramification associated with radiation, not surgical, intervention for cancer. 2. Adhesions are a long-term ramification associated with surgical intervention for cancer. 3. Hypothyroidism is a long-term ramification associated with radiation, not surgical, intervention for cancer. 4. Visual impairment is a long-term ramification associated with surgical intervention for cancer. 5. Cardiotoxicity is a long-term ramification associated with radiation, not surgical, intervention for cancer.

20) Which characteristics of abusers should the nurse include in the teaching session for elementary school teachers regarding child abuse? Select all that apply. 1. Physical illness 2. Alcoholism 3. Many friends and families nearby 4. Unrealistic expectations for their child 5. The abuser has no relationship to the child.

Answer: 2, 4 Explanation: 1. This is not a common finding in abusers. 2. Drug addiction and alcoholism are common findings in the abuser. 3. The child abuser is often socially isolated. 4. Abusive parents often feel the child is misbehaving for activities, such as soiling their diapers. 5. Most abusers are parents or people who have contact with the child on a regular basis.

24) The nurse care coordinator is supporting a family who wishes to become their child's care coordinator. Which statements will the nurse include in the teaching session to prepare the family for this task? Select all that apply. 1. "You won't need to set aside much time to properly coordinate your child's care." 2. "Care coordination requires ongoing assessment of your child's needs." 3. "Since you are the parent you will not be required to use cost-efficient strategies when coordination your child's care." 4. "Care coordination requires you to be educated regarding your child's diagnosis." 5. "There is a care coordination workshop provided by hospital educators that will help you to learn this role."

Answer: 2, 4, 5 Explanation: 1. Care coordination is time consuming. This statement is not appropriate for the nurse to include in the teaching session. 2. Care coordination requires ongoing assessment of the child's needs. This statement is appropriate to include in the teaching session. 3. All care coordination efforts should include the implementation of cost-efficient strategies for care. This statement is not appropriate for the nurse to include in the teaching session. 4. In order to be a successful care coordinator it is essential to have an adequate knowledge base regarding the diagnosis. This statement is appropriate to include in the teaching session. 5. When parents wish to assume the role of care coordinator is often necessary that they receive extensive training, which is often provided by hospital educators. This statement is appropriate to include in the teaching session

14) Which instructions should be provided to the parents of a 4-year-old girl who has experienced chronic urinary tract infections (UTIs) in the last 2 years? Select all that apply. 1. Wear only nylon underwear for better air flow. 2. Teach the child to wipe from front to back. 3. Encourage the child to take long baths by allowing the child bubbles and toys in the tub. 4. Encourage the child to drink additional fluids throughout the day. 5. Plan potty breaks every 2 hours throughout the day.

Answer: 2, 4, 5 Explanation: 1. The child should wear cotton underwear. 2. This prevents bacteria from the rectum from being introduced into the urethra. 3. Bubble baths should be avoided. 4. Extra fluids will "wash" bacteria out of the bladder. 5. Children get so involved in playing that they often hold their urine. Voiding every 2 hours will reduce the time for bacteria to grow in the bladder.

13) The mother of an infant tells the nurse that her maternity leave is almost over and she will be returning to work soon. The mother states that she will need to place her infant in a day care facility, and she asks the nurse how to know which day care facility is best. Which topics will the nurse include in the response to the mother? Select all that apply. 1. A day care facility that is close to her work in the event of an emergency 2. A day care facility that requires all staff have criminal background checks 3. A day care facility that is attractive in appearance, with bright colors and interesting visual stimulation 4. A day care facility that provides regular training of the staff and administration 5. A day care facility that has policies regarding child health and emergencies, such as immunization requirements and emergency medical forms

Answer: 2, 4, 5 Explanation: 1. This may be convenient and helpful, but it does not insure that the day care facility will provide quality care. 2. This is a safety feature and provides some protection against child abuse and other incidents. 3. Although this is valuable in a day care setting, it does not mean that the environment is safe or appropriate for the child. 4. This information is appropriate as it provides information about the abilities of the staff to provide a safe and stimulating environment. 5. This information identifies the .day care facility is prepared for emergency situations.

11) Which positions are appropriate for the nurse to include in a plan of care for the infant who is diagnosed with acute respiratory distress? Select all that apply. 1. Upright 2. Semi-Fowler position 3. Prone position 4. With the infant's head hyperextended 5. With the infant's head in a sniffing position

Answer: 2, 5 Explanation: 1. An infant cannot be placed in an upright position. 2. The semi-Fowler position elevates the head of bed. This allows better movement of the diaphragm. 3. Prone positioning will not promote respirations. 4. The head should not be hyperextended as that position does not open the airway in an infant. 5. A sniffing position straightens and shortens the airway and is the position that is best.

19) The nurse is providing care to a newborn client who presents in the pediatric clinic for a 2-week health maintenance visit. The parents of the newborn are concerned, as their baby has "gas all the time." Which responses from the nurse are appropriate? Select all that apply. 1. "Your baby has a relaxed lower esophageal sphincter, which is causing the gas." 2. "Your baby lacks the enzyme amylase, which is causing the gas." 3. "Your baby lacks the enzyme insulin, which is causing the gas." 4. "Your baby has an immature liver, which is causing the gas." 5. "Your baby lacks an enzyme that helps to digest fats, which is causing the gas."

Answer: 2, 5 Explanation: 1. Newborns and infants do have a relaxed lower esophageal sphincter; however, this is not responsible for gas but for frequent regurgitation of small amounts of oral feedings. 2. Newborns and infants lack several enzymes that assist with the digestive process. One of these enzymes is amylase, which assists with carbohydrate digestion. The lack of this enzyme causes abdominal distention due to gas. 3. Insulin is not an enzyme and is not lacking in the newborn. 4. While newborns and infants do have immature livers, that is not what is causing the gas. 5. Lipase is a digestive enzyme that assists in fat digestion. Infants and newborns do lack this enzyme, which would cause abdominal distention due to gas.

5) Which laboratory tests should the nurse prepare to draw when admitting a pediatric client with possible obstructive uropathy? Select all that apply. 1. Platelet count 2. Blood urea nitrogen (BUN) 3. Partial thromboplastin time (PTT) 4. Blood culture 5. Creatinine

Answer: 2, 5 Explanation: 1. Platelet count is drawn when a bleeding disorder is suspected. 2. BUN is a serum laboratory test for kidney function. Obstructive uropathy is a structural or functional abnormality of the urinary system that interferes with urine flow and results in urine backflow into the kidneys; therefore, the BUN will be elevated. 3. PTT is drawn when a bleeding disorder is suspected. 4. A blood culture is done when an infectious process is suspected. 5. Creatinine is a serum laboratory test for kidney function. Obstructive uropathy is a structural or functional abnormality of the urinary system that interferes with urine flow and results in urine backflow into the kidneys; therefore, the creatinine will be elevated.

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

Answer: 3 Explanation: 1. If prescribed medication is not relieving the pain to a satisfactory level, the healthcare provider should be notified. This statement indicates the parent understands and does not need additional teaching. 2. The child is expected to have some pain for a few days after surgery. This statement indicates the parent understands the teaching. 3. Increasing pain can be a sign of complication and should be reported to the healthcare provider; therefore, the nurse should clarify expectations for pain control. 4. The child should receive pain medication on a scheduled basis. This statement indicates the parent understands the teaching.

20) The school-age child, diagnosed with a medulloblastoma, will receive intrathecal chemotherapy injections after surgery. Which rationale for this type of chemotherapy administration should the nurse include in the medication teaching? 1. It reduces side effects. 2. It does not require the child being "stuck." 3. Many chemotherapy drugs do not cross the blood-brain barrier. 4. Intrathecal administration is less expensive than intravenous administration.

Answer: 3 Explanation: 1. Intrathecal administration does not reduce side effects. 2. Intrathecal administration is through a spinal tap, so the child will be "stuck" for administration. 3. This is correct for the selection of intrathecal administration of chemotherapy. 4. This is not accurate and would not be a reason to change administration modes.

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

Answer: 3 Explanation: 1. Killed virus vaccines are safe to administer to the child with AIDS as there is no risk of acquiring an infection. 2. A toxoid vaccination is made of a toxin that has been produced by the organism but does not include living organisms. 3. A child with an immune disorder should not be immunized with a live varicella vaccine because of the risk of contracting the disease. 4. Acellular pertussis vaccine contains a protein from pertussis rather than the whole cell.

3) Which parental statement indicates correct understanding of preventive techniques for heat-related illnesses when children exercise? 1. "Wearing dark clothing during exercise is recommended." 2. "Water is the fluid of choice to replenish fluids." 3. "During activity, stop for fluids every 15 to 20 minutes." 4. "Hydration should occur at the end of an exercise session."

Answer: 3 Explanation: 1. Light-colored, light clothing is best to wear during exercise activities; wearing of dark colors can increase sweating. 2. A combination of water and sports drinks is best to replace fluids during exercise. 3. During activity, stopping for fluids every 15 to 20 minutes is recommended. 4. Hydration should occur before and during the activity, not just at the end.

24) The healthcare provider orders laboratory tests following the initiation of treatment for a child diagnosed with iron deficiency anemia. Which laboratory result should the nurse share with the child's family as an indication of improvement? 1. Low hemoglobin 2. Normal platelet count 3. High reticulocyte count 4. Low hematocrit

Answer: 3 Explanation: 1. Low hemoglobin is a typical finding in iron deficiency anemia. 2. Platelet count is unrelated to iron deficiency anemia. 3. Reticulocytes are immature red blood cells and indicate new cells are being produced. 4. This would be a typical finding in iron deficiency anemia.

12) Which is the rationale for ensuring the irrigation of blood products and ensuring that they are cytomegalovirus (CMV)-negative prior to administering a blood transfusion for a pediatric client diagnosed with severe combined immune deficiency (SCID)? 1. Transfusion reaction from lymphocytes and platelets in the donor blood. 2. Transfusion reaction and infection from lymphocytes in the donor blood. 3. Infection and graft-versus-host disease from lymphocytes in the donor blood. 4. Infection and graft-versus-host disease from erythrocytes in the donor blood.

Answer: 3 Explanation: 1. Lymphocytes in the donor blood are responsible for infection and graft-versus-host disease. 2. Lymphocytes in the donor blood are responsible for infection and graft-versus-host disease. 3. Lymphocytes in the donor blood are responsible for infection and graft-versus-host disease. 4. Lymphocytes in the donor blood are responsible for infection and graft-versus-host disease.

10) An adolescent female client is diagnosed with systemic lupus erythematosus (SLE). Which should the nurse include in the teaching session regarding an activity that should be avoided? 1. Receiving a manicure and a pedicure 2. Washing the hair with shampoo daily 3. Using a tanning bed 4. Attending late night parties and dances

Answer: 3 Explanation: 1. Manicures and pedicures do not place the teenager at any risk. 2. Although one symptom of SLE can be alopecia, gentle shampooing is not a cause of this symptom. 3. Individuals with SLE have photosensitivity, and tanning beds can lead to exacerbations as well as skin damage from sun burns. 4. Although adequate rest is important for the teenager with SLE, the teenager can "catch up" on her sleep the next day. Page Ref: 1248

10) The nurse is conducting a nursing assessment of the parent and child with severe cerebral palsy during a routine clinic visit. Which nursing action is appropriate based on the current data? 1. Measuring the urine output 2. Measuring the child's head circumference 3. Observing the parent-child relationship 4. Observing how the child interacts during play

Answer: 3 Explanation: 1. Measuring urine output is not important unless there are problems with the bladder. 2. Measuring the child's head circumference is not an important assessment at this time. 3. Observing the parent-child relationship is important to the success of health supervision for both the child and parents. 4. Playtime is not important during this time.

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

Answer: 3 Explanation: 1. Telling the parents that they cannot visit their child will only increase their anger. 2. Calling the healthcare provider might be appropriate at some point, but the nurse must assume the role of supporter in this situation to promote a sense of trust. 3. Hospitalization of the child in a PICU is a great stressor for parents. If the parents feel that they are not informed or involved in the care of their child, they might become angry and upset. 4. Calling the chaplain could be appropriate at some point, but the nurse needs to collaborate with the parents about the care the child receives.

6) A school-age client is in the playroom when the respiratory therapist arrives to give a scheduled breathing treatment. Which is the most appropriate nursing action? 1. Escorting the child to his room and asking the child-life specialist to bring toys to the bedside 2. Rescheduling the treatment for a later time 3. Assisting the child back to his room for the treatment but reassuring him that he may return when the procedure is completed 4. Showing the respiratory therapist to the playroom so the treatment can be performed

Answer: 3 Explanation: 1. The child should be allowed to return to the playroom as soon as the procedure is completed; bringing toys to the bedside is unnecessary. 2. Scheduled respiratory treatments should be performed on time. 3. It is important for scheduled treatments to occur on time, so the child should go back to his room. He can return to the playroom as soon as the treatment is completed. 4. Procedures should not be performed in the playroom.

8) Which nursing intervention should the nurse include in the plan of care for a child who is sedated, unconscious, and on a mechanical ventilator? 1. Out-of-bed transfer to wheelchair 2. Whirlpool baths 3. Maintenance of intravenous (IV) hydration 4. Active range-of-motion (ROM) exercises

Answer: 3 Explanation: 1. The child would not be permitted to be transferred to a wheelchair. 2. The child would not be permitted to be transferred to take whirlpool baths. 3. The child who is unconscious is unable to take anything by mouth, and will need IV therapy for hydration. 4. The nurse may perform passive ROM exercises on the child, but the child is incapable of doing active ROM exercises.

7) The nurse is working with the parents of a child with a chronic condition. Which statement made by the child's parents indicates the need for intervention related to overwhelming caregiver burden? 1. "My mother moved in and helps us with the care of our family." 2. "I chose to quit my job to be home with my child, and my husband helps in the evening when he can." 3. "I have to care for my child day and night, which leaves little time for me." 4. "Our health insurer sent us a rejection letter for my child's brand-name medication, and we must fill out forms to get the generic."

Answer: 3 Explanation: 1. The family's pitching in to help indicates family support. 2. The mother chose to care for the child and receives help from the husband. 3. No respite time from caregiving responsibilities could lead to overwhelming caregiver burden. 4. Substituting generic for brand-name medications will not result in caregiver burden.

2) Which parental statement indicates correct understanding of information presented regarding the treatment for infant anemia? 1. "We will add green leafy vegetables to our child's low-iron formula." 2. "We will discontinue the use of vitamin C supplements by 6 months of age." 3. "We will begin an iron-fortified infant cereal at 4 to 6 months of age." 4. "We will introduce cow's milk by 6 months of age."

Answer: 3 Explanation: 1. The infant's maternal iron stores are depleted by 6 months. Infants who are not breastfed should get iron-fortified formula. Green leafy vegetables, while iron fortified, are not appropriate for the infant. 2. Vitamin C should be started at 6 to 9 months of age and continued because foods rich in vitamin C improve iron absorption. 3. Starting iron-fortified infant cereal at 4 to 6 months of age is recommended for prevention of iron deficiency in children. 4. Cow's milk should not be introduced until 12 months of age.

10) Which should the nurse include in a teaching session for the mother of a 3-year-old client who is concerned about her child choking? 1. Show the mother how to do cardiac compressions and rescue breathing. 2. Recommend the mother perform back blows and chest thrusts. 3. Teach the mother how to perform abdominal thrusts. 4. Tell the mother to do nothing until the child loses consciousness.

Answer: 3 Explanation: 1. The method of cardiac compressions and rescue breathing is not the first thing that the mother needs to know. 2. This is the treatment for a choking infant, not a child. 3. Giving abdominal thrusts is the correct intervention for a choking child. 4. The mother should respond to the choking child before the child loses consciousness.

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

Answer: 3 Explanation: 1. The normal pulse rate for children 2 to 5 years of age is between 70 and 120. 2. 90/55 is a normal finding for this age group. 3. This respiratory rate is on the low side for the age group and requires further evaluation to determine if the child's respirations are being depressed. 4. This is normal behavior for a 4-year-old child. Page Ref: 973

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

Answer: 3 Explanation: 1. This statement is accurate. This father understands this concept correctly. 2. Anger is a part of the grief process. This father has been able to look at his own behavior and recognize it as normal. 3. There is no standard period of grief. It is individual. This father has not heard the nurse's discussion. 4. This father has applied the knowledge of grief behaviors to his own behavior. He understands the discussion.

8) The child is receiving chemotherapy for acute lymphocytic leukemia (ALL). Which assessment data should the nurse immediately report to the healthcare provider due to a metabolic emergency? 1. Thrombocytopenia 2. Leukocytosis 3. Oliguria 4. Edema

Answer: 3 Explanation: 1. Thrombocytopenia is a clinical manifestation associated with a hematologic, not metabolic, emergency. 2. Leukocytosis is a clinical manifestation associated with a hematologic, not metabolic, emergency. 3. Tumor lysis causes a metabolic emergency caused by an electrolyte imbalance. Clinical manifestations associated with this include oliguria and altered levels of consciousness. 4. Edema is not indicative of a metabolic emergency. Page Ref: 1307

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

Answer: 3 Explanation: 1. Transfusion reaction does not occur this long after the transfusion. 2. Reactions generally occur at the onset or during the first 20 minutes of transfusion. 3. Blood reactions can occur as soon as the blood transfusion begins. The nurse should administer the first 20 mL of blood slowly and monitor for a reaction during this time frame. 4. Anyone can have a transfusion reaction during any transfusion.

9) A child with croup has an increased PCO2, a decreased pH, and a normal HCO3 blood gas value. Which does the nurse report to the healthcare provider based on these data? 1. Uncompensated metabolic alkalosis 2. Uncompensated metabolic acidosis 3. Uncompensated respiratory acidosis 4. Uncompensated respiratory alkalosis

Answer: 3 Explanation: 1. Uncompensated metabolic alkalosis has an increased pH, normal PCO2, and increased HCO3. 2. Uncompensated metabolic acidosis has a decreased pH, normal PCO2, and normal HCO3. 3. If the pH is decreased and the PCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. Also, croup can be a disease process that causes respiratory acidosis. 4. Uncompensated respiratory alkalosis has an increased pH, decreased PCO2, and normal HCO3.

6) An adolescent client has a long leg cast secondary to a fractured femur. Which nursing action is most appropriate in order to effectively facilitate the adolescent's return to school? 1. Develop an individualized health plan (IHP) that focuses on long-term needs of the adolescent. 2. Meet with all of the other students prior to the student's return to school to emphasize the special needs of the injured teen. 3. Meet with teachers and administrators at the school to make sure entrances and classrooms are wheelchair accessible. 4. Meet with parents of the injured student to encourage homebound schooling until a short leg cast is applied.

Answer: 3 Explanation: 1. While an IHP might be developed, short-term needs would be the focus. 2. It is not necessary to meet with all of the students to discuss the adolescent's needs. 3. An adolescent with a long leg cast secondary to a fractured femur will be dependent on a wheelchair for mobility. It is essential that the environment be wheelchair accessible prior to the adolescent's return to school. 4. There is no reason to encourage the adolescent to stay at home for schooling if the child is ready to return.

12) A child who is dependent on a ventilator is being discharged from the hospital. Which will the nurse recommend for the emergency plan of care for this family during the discharge instruction process? 1. Designating an emergency shelter site 2. Notifying the power company that the child is on life support 3. Acquiring a backup generator 4. Having an alternate heating source if power is lost

Answer: 3 Explanation: 1. While this action is very important, it is most essential that the ventilator have power to continue to function at all times. 2. While this action is very important, it is most essential that the ventilator have power to continue to function at all times. 3. Prior to discharge to home, it is essential that the family acquire a generator so that the child's life support will continue to function effectively should power be lost. 4. While this action is very important, it is most essential that the ventilator have power to continue to function at all times.

18) The nurse is teaching a pregnant client about fetal circulation. Which is the correct sequence of blood flow that indicates the pregnant client understands the information presented? 1. Ductus arteriosus 2. Ductus venosus 3. Foramen ovale

Answer: 3, 1, 2 Explanation: 1. The ductus arteriosus connects the pulmonary artery to the aorta and is the last structure that blood reaches. 2. The ductus venosus connects the umbilical vein to the inferior vena cava bypassing the liver. It is the first structure that blood reaches. 3. The foramen ovale connects the right atrium to the left ventricle and bypasses the lungs. It is the second structure that blood reaches.

4) The nurse is partnering with the family of a hospitalized premature neonate who suffered an intraventricular hemorrhage (IVH). After 3 months in the neonatal intensive care unit (NICU), the infant is being discharged. Which activities will the nurse suggest to the family to help stimulate the infant's development? Select all that apply. 1. Using a day care for stimulation 2. Discouraging sibling interaction 3. Holding and rocking the infant 4. Interacting face to face 5. Talking softly and singing to the infant

Answer: 3, 4, 5 Explanation: 1. A premature infant might not have a mature immune system; therefore, day care might present an infection issue. The needs of this child might not be met in a day care setting with many children. 2. Sibling interaction is important and should be encouraged. 3. Holding and rocking the infant stimulates the infant's sense of motion, facilitating parent-infant bonding. 4. Interacting face to face stimulates the infant's sense of vision, facilitating parent-infant bonding. 5. Talking softly and singing to the infant are activities that stimulate the infant's senses of hearing, touch, and motion, facilitating parent-infant bonding.

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

Answer: 3, 4, 5 Explanation: 1. Rubeola, or measles, is caused by a virus and is transmitted person to person. 2. Pertussis, or whooping cough, is caused by a gram-positive coccobacillus called Bordetella pertussis and is spread person to person. 3. Rocky mountain spotted fever is a vectorborne disease spread by a tick. 4. West Nile virus is transmitted by a mosquito, a vector, and is not transmitted person to person. 5. Lyme disease is also a vectorborne disease spread by a tick.

17) The school nurse is reviewing the records of all incoming kindergarten students. Which students will require an individualized education plan (IEP)? SATA 1. The child with diabetes controlled with insulin 2. The child with a casted arm due to a fracture 3. The child with a hearing deficit 4. The child with autism spectrum disorder 5. The child with an IQ of 60

Answer: 3, 4, 5 Explanation: 1. This child may need an individual health plan but does not require an IEP. 2. This is not a chronic problem and does not require an IEP. 3. This child will need modification of the educational plan in order to be successful. 4. The child diagnosed on the autism spectrum will have special educational needs that will be determined by the IEP. 5. The child with an IQ of 60 is intellectually disabled and will require an IEP.

18) Which gastrointestinal defects, often diagnosed shortly after birth, should the nurse include in the assessment process of all newborns? Select all that apply. 1. Pyloric stenosis 2. Biliary atresia 3. Hirschsprung disease 4. Umbilical hernia 5. Diaphragmatic hernia

Answer: 3, 5 Explanation: 1. Pyloric stenosis is not diagnosed in the newborn nursery, but in the 2- to 4-week-old infant. 2. Symptoms of biliary atresia would not be observable until several weeks of age. 3. Symptoms of Hirschsprung disease may be observable in the newborn nursery. 4. Umbilical hernia cannot be diagnosed at birth. 5. Diaphragmatic hernia will show symptoms immediately after birth due to compression of the lung.

27) Which cardiovascular manifestations should the nurse anticipate for a pediatric client diagnosed with moderate uncompensated hypovolemic shock? Select all that apply. 1. Tachycardia 2. Weak distal pulses 3. Thready distal pulses 4. Normal blood pressure 5. Decrease in systolic blood pressure

Answer: 3, 5 Explanation: 1. Tachycardia is a cardiovascular manifestation the nurse anticipates for the pediatric client who is diagnosed with early compensated hypovolemic shock. 2. Weak distal pulses are cardiovascular manifestations the nurse anticipates for the pediatric client who is diagnosed with early compensated hypovolemic shock. 3. Thready distal pulses are cardiovascular manifestations the nurse anticipates for the pediatric client who is diagnosed with moderate uncompensated hypovolemic shock. 4. Normal blood pressure for age is a cardiovascular manifestation the nurse anticipates for the pediatric client who is diagnosed with early compensated hypovolemic shock. 5. A decrease in systolic blood pressure is a cardiovascular manifestation the nurse anticipates for the pediatric client who is diagnosed with moderate uncompensated hypovolemic shock.

32) Which vaccines should the nurse prepare to administer to an 11-year-old child during a scheduled well-child visit? Select all that apply. 1. DTaP vaccine 2. Hib vaccine 3. HPV4 vaccine 4. MMR vaccine 5. MenACWY-D

Answer: 3, 5 Explanation: 1. The DTap vaccine is not appropriate for the nurse to administer to an 11-year-old child during a scheduled well-child visit. 2. The Hib vaccine is not appropriate for the nurse to administer to an 11-year-old child during a scheduled well-child visit. 3. The HPV4 vaccine is appropriate to administer to an 11-year-old child during a scheduled well-child visit. 4. The MMR vaccine is not appropriate for the nurse to administer to an 11-year-old child during a scheduled well-child visit. 5. The MenACWY-D vaccine is appropriate to administer to an 11-year-old child during a scheduled well-child visit.

11) A child who has had a tracheostomy for several years is scheduled to begin kindergarten in the fall. The teacher is concerned about this child being in the class, and consults the school nurse. Which nursing action is appropriate? 1. Making arrangements for the child to go to a special school 2. Recommending that the child be home schooled 3. Asking the parents of the child to provide a caregiver during school hour 4. Teaching the teacher how to care for the child in the classroom

Answer: 4 Explanation 1. Laws have been implemented to ensure that children with disabilities will receive a free education. 2. Laws have been implemented to ensure that all children with disabilities will receive a free education. While the parents may wish to home school their child, it is not appropriate for the nurse to recommend this to the parents. 3. Since the child has had a tracheostomy for several years, the child might need a little extra attention while in the school setting. If needed, a health aide may be assigned to the child, but this is not the responsibility of the parents. 4. Since the child has had a tracheostomy for several years, the child might need a little extra attention while in the school setting. The teacher should be taught how to care for the child, if needed, and taught the signs of distress.

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

Answer: 4 Explanation: 1. A 10-year-old child is able to reach any area of the house; more precautions need to be taken. 2. Teaching gun safety is appropriate to a family that has guns; however, it is not sufficient to protect the child. The guns must be secured at all times the adults are not supervising the guns. 3. It is recommended that guns and ammunitions be stored separately. 4. Statistics show that about 75% of unintentional deaths and suicides are committed with firearms found in the home. The safety measures of using a gun lock, keeping the gun and ammunition separate, and putting the guns in a locked cabinet will at least make the guns less accessible.

9) A nurse is preparing for the delivery of a newborn with a known diaphragmatic hernia defect. Which equipment should the nurse have on hand for the delivery? 1. Bag-valve-mask system 2. Sterile gauze and saline 3. Soft arm restraints 4. Endotracheal tube

Answer: 4 Explanation: 1. A bag-valve-mask system, or Ambu bag, could push air into the stomach and cause abdominal distension, increase pressure on the diaphragm, and impair breathing. 2. The defect is not external, so sterile gauze and saline are not needed. 3. Soft arm restraints might be necessary but at are not an immediate concern. 4. A diaphragmatic hernia (protrusion of abdominal contents into the chest cavity through a defect in the diaphragm) is a life-threatening condition. Intubation is required immediately so that the newborn's respiratory status can be stabilized.

8) In which situation will the school nurse collaborate with the family and other members of the healthcare team in order to develop an individualized health plan (IHP)? 1. For a child who recently developed a penicillin allergy 2. For a child who has been treated for head lice 3. For a child who has missed 2 weeks of school due to mononucleosis 4. For a child who is newly diagnosed with insulin-dependent diabetes mellitus.

Answer: 4 Explanation: 1. A child who is allergic to penicillin will not receive this medication anymore, and therefore should not encounter any problems related to it at school. 2. A child who has been treated for head lice can return to school, and does not need an IHP. 3. While a child who has missed 2 weeks of school will need to make arrangements for makeup work, an IHP is not needed. 4. An IHP that ensures appropriate management of the child's health care needs must be developed for a child newly diagnosed with a chronic illness such as diabetes.

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

Answer: 4 Explanation: 1. A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Risk for Ineffective Tissue Perfusion, peripheral, would not be a priority problem with this disease process. 2. A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Risk for Ineffective Thermoregulation would not be a priority problem with this disease process. 3. A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Risk for Fluid Volume Deficit would not be a priority problem with this disease process. 4. A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Risk for Infection is the priority nursing diagnosis.

12) Which is the priority nursing intervention for a pediatric client, diagnosed with leukemia, who has a granulocyte count of 250/mm3 and a platelet count of 150,000/mm3? 1. Fluid restriction 2. Mouth care 3. Neutropenic precautions 4. Hand hygiene

Answer: 4 Explanation: 1. A fluid restriction is not a priority nursing intervention based on the current data. Fluids should continue to be encouraged. 2. Platelet count is normal; mouth care should include brushing with a soft toothbrush and frequent rinsing. 3. The child should be isolated from anyone infectious, but neutropenic isolation is not necessary. 4. Hand hygiene is vital for preventing the spread of infection.

17) The parent of a child diagnosed with Ewing sarcoma asks why multiple drugs are needed to treat this cancer. Which rationale should the nurse use when responding to the client's mother? 1. The prescribed drug protocol is needed due to the aggressive nature of the cancer. 2. The prescribed drug protocol decreases side effects. 3. The prescribed drug protocol is used in specifically in children. 4. The prescribed drug protocol involves a group of drugs that work in different modes.

Answer: 4 Explanation: 1. A multiple drug protocol is not prescribed due to aggressive nature of Ewing sarcoma. 2. A multiple drug protocol is not prescribed to decrease side effects. 3. A multiple drug protocol is used in both children and adults. 4. A multiple drug protocal is used to attack the cancer cells from all angles.

4) A 7-year-old child is seen in the pediatric clinic 3 times in the last 2 months for complaints of abdominal pain. On each occasion, the physical examination and all ordered laboratory work have been normal. Which is the priority nursing assessment at this time? 1. The child's normal eating habits 2. Recent viral illnesses or other infectious symptoms 3. Review of the child's immunization history 4. Changes in school or home life

Answer: 4 Explanation: 1. Because of the abdominal complaints, the child's eating habits would have already been discussed. 2. With normal blood work and tests, the chance of any illness over the last few months is unlikely. 3. The immunization history would have been reviewed on the previous visits. 4. With a normal examination and laboratory work, there is a high probability that this child's abdominal pain is stress related, and it is most important to identify the possible stressors in this child's life to aid in diagnosis and treatment. Asking about changes in home or school life is most likely to get to information about recent stresses in the child's life.

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

Answer: 4 Explanation: 1. Children are unable to obtain deep sleep when experiencing acute pain. 2. When experiencing acute pain, children are less likely to cooperate with treatments. 3. It is difficult for children to concentrate when experiencing acute pain. 4. Young children in acute pain display a variety of behaviors, including loud crying, screaming, thrashing their arms and legs, lack of cooperation, clinging behavior, and restlessness and irritability.

13) A parent reports that her 5-year-old child, who has had all recommended immunizations, had a mild fever 1 week ago and now has bright red cheeks and a lacy red maculopapular rash on the trunk and arms. Which diagnosis does the nurse anticipate based on the current data? 1. Rubeola (measles) 2. German measles (rubella) 3. Chickenpox (varicella) 4. Fifth disease (erythema infectiosum)

Answer: 4 Explanation: 1. Children with rubeola have a high temperature and a blotchy maculopapular rash. Because there is a vaccination for rubeola, it is unlikely the child has it. 2. The rash of rubella is a pink, maculopapular rash that begins on the face and progresses downward to the trunk and extremities. The child is fully vaccinated, making this unlikely. 3. Varicella (chickenpox) and rubella (German measles) are unlikely if the child has had all recommended immunizations. 4. Fifth disease manifests first with a flu-like illness, followed by a red "slapped-cheek" sign. Then a lacy maculopapular erythematous rash spreads symmetrically from the trunk to the extremities, sparing the soles and palms.

12) Which is the priority nursing intervention when providing care to a pediatric client who is experiencing disseminated intravascular coagulation (DIC)? 1. Preparing the child for radiographic procedures 2. Implementing the prescribed fluid restriction for the child 3. Encouraging the child to frequently ambulate 4. Monitoring the child's oxygen saturation and vital signs

Answer: 4 Explanation: 1. DIC is not diagnosed with a radiographic examination but by serum laboratory studies. 2. Fluids need to be monitored but will not be restricted. 3. Ambulation places stress on joints and can promote bleeding. The child with DIC should be placed on bed rest. 4. In a child who has a bleeding and clotting disorder, the priority nursing intervention would be monitoring for life-threatening complications.

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

Answer: 4 Explanation: 1. DTaP is not administered by an ID injection. 2. DTaP is not administered by a SQ injection. 3. DTaP is administered by an IM injection. 4. DTaP is not administered via a nasal spray.

22) The heatlthcare provider prescribes a unit of packed red blood cells for a pediatric client. Which intravenous fluid should the nurse hang during the blood transfusion? 1. D5W 2. D5LR 3. D5 1/4NS 4. NS

Answer: 4 Explanation: 1. Dextrose should not be hung, as it will cause packed cells to clot. 2. D5 lactated Ringer solution also contains dextrose and should not be hung with packed cells. 3. Dextrose is inappropriate no matter what is the other component of the intravenous fluids. 4. Normal saline is appropriate to hang prior to initiating blood.

6) The nurse is caring for a child with rheumatoid arthritis. Which nonpharmacologic intervention should the nurse include in the plan of care for joint pain? 1. Elevation of the extremity 2. Immobilization 3. Massage 4. Application of moist heat

Answer: 4 Explanation: 1. Elevation of the extremity would not have an effect on reducing pain in rheumatoid arthritis. 2. Immobilization can lead to contractures. Range of motion to the involved joint should be maintained. 3. Massage of extremities should be avoided because of potential risk for emboli. 4. Moist heat can promote relief of pain and decrease joint stiffness.

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

Answer: 4 Explanation: 1. Epoetin alfa (human recombinant erythropoietin) stimulates red blood cell (RBC) production. 2. Ondansetron (Zofran) is an antiemetic. 3. Oprelvekin (Neumega) increases platelets. 4. Filgrastim (Neupogen) increases production of neutrophils, a specific WBC, by the bone marrow.

8) A nurse is planning care for a child with hyperkalemia. Which manifestation associated with the documented hyperkalemia requires immediate intervention by the nurse? 1. Hyperthermia 2. Respiratory distress 3. Seizures 4. Cardiac arrhythmias

Answer: 4 Explanation: 1. Excessive potassium is unrelated to the body temperature. 2. Potassium is needed for contractility of heart and skeletal muscles but not for the muscles of respiration. 3. Seizures are not an adverse outcome of hyperkalemia. 4. A child with hyperkalemia is at risk for cardiac problems that can be life threatening, such as arrhythmias.

9) The adolescent client is receiving methotrexate chemotherapy after undergoing limb-salvage surgery for osteogenic sarcoma. The healthcare provider also prescribes leucovorin therapy. Which adolescent statement indicates correct understanding for the administration schedule for this newly prescribed drug? 1. "I do not have any pain, so I will not need to take the leucovorin this time." 2. "I do not have any nausea, so I .will not need the leucovorin." 3. "I am glad I only need one dose of the leucovorin." 4. "It is important that I receive my leucovorin on time, as it protects my body from the methotrexate."

Answer: 4 Explanation: 1. Leucovorin is not administered for pain. 2. Leucovorin is administered for nausea. 3. One dose is not the recommended therapy. 4. Leucovorin (citrovorum factor) is a form of folic acid that helps to protect normal cells from the destructive action of methotrexate. It is started within 24 hours of methotrexate administration and is given along with hydration therapy. Usual administration is every 6 hours times 72 hours or until serum methotrexate is at the desired level.

9) Which parental statement indicates understanding of the process involved with a kidney transplant for a child with renal failure? 1. "We are happy our child will not have to take any more medicine after the transplant." 2. "We understand our child will not be at risk anymore for catching colds from other children at school." 3. "We will be glad we will not have to bring our child in to see the doctor again." 4. "We know it is important to see that our child takes prescribed medications after the transplant."

Answer: 4 Explanation: 1. Medications and general health promotion will be necessary. 2. The child will be on immunosuppressing drugs and will be at increased risk for colds and other illnesses. 3. Follow-up appointments will be necessary, as well as medications and general health promotion. 4. It is important that the nurse emphasizes compliance with treatments that will need to be followed after the transplant.

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

Answer: 4 Explanation: 1. Most adolescents do not want to be seen as "different" by their peers; therefore, it is unlikely that the adolescent will administer the prescribed insulin in front of the peer group. 2. Most adolescents do not want to be seen as "different" by their peers; therefore, it is unlikely that the adolescent will teach his or her peers about the disease process. 3. Adolescents will attempt to hide their health conditions from their classmates. 4. Adolescents have poorer eating habits than all other age groups, and adolescents with diabetes may not adhere to necessary dietary restrictions.

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

Answer: 4 Explanation: 1. Parental Role Conflict does not refer to the parents' argument in the PICU, but means a parent is conflicted or confused about some aspect of the parental role. 2. Each parent might be experiencing hopelessness and anxiety, but they are not coping well as a family unit. 3. Each parent might be experiencing hopelessness and anxiety, but they are not coping well as a family unit. 4. The parents are displaying ineffective coping behaviors as a family.

18) An adolescent female client, diagnosed with osteosarcoma, has a below-the-knee amputation as part of the treatment regimen. Which behavior, assessed by the nurse, indicates the client is beginning to accept the amputation? 1. Complaints of pain in the missing leg 2. Insists that a prosthetic be applied prior to participating in physical therapy. 3. Insists on covering the lower portion of the body prior to peer visitation. 4. Watches the dressing change

Answer: 4 Explanation: 1. Phantom pain is an expected finding after an amputation; however, this does not indicate acceptance. 2. This indicates she wants to return to mobility but has not yet accepted the stump. 3. Being in a wheelchair with a blanket cover indicates she doesn't want her friends to be aware of her amputation. 4. This indicates the girl is willing to look at the stump, which is a step toward acceptance.

1) The nurse is providing care to several pediatric clients in the hospital setting. Which client diagnosis is capable of producing chronic limitations for the child? 1. Pneumonia from the bacillus Haemophilus influenzae 2. Respiratory syncytial virus 3. Streptococcus pneumoniae, a gram-positive diplococcus 4. Congenital heart defect

Answer: 4 Explanation: 1. Pneumonia is not a chronic limitation. 2. Respiratory syncytial virus is a serious infection caused by a virus that affects infants. It does not result in permanent disability. 3. Streptococcus pneumoniae, a gram-positive diplococcus, is treatable and will not cause chronic limitation. 4. A congenital heart defect can leave a child with a permanent chronic condition.

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

Answer: 4 Explanation: 1. The nurse cannot know for certain that everything will be fine. 2. The pros and cons of the surgery would have been explained to the family prior to the decision to have the surgery. Restating the benefits will not reduce the stress of the client and family. 3. Telling them the surgeon is very good is not going to minimize stress for long. They need to be more familiar with what to expect in a familiar environment. 4. A variety of approaches can be used to provide information and allay fears. Tours of the hospital unit or surgical area are helpful. This activity assists the child and family to become familiar with the environment they will encounter.

21) Which age-appropriate information should the nurse provide to a 4-year-old girl who is being emotionally prepared for open heart surgery? 1. The name of the surgeon who will be performing the procedure 2. What the surgical procedure will entail 3. The purpose of the heart-lung machine used during the procedure 4. What the environment will look and sound like when the child wakes up

Answer: 4 Explanation: 1. The parents know the name of the surgeon. It will mean nothing to a 4-year-old child. 2. The child will be asleep during surgery and therefore does not need to know about the procedure. 3. This is beyond the understanding of a 4-year-old. 4. The child should be prepared in terms of what she will see, hear, smell, or feel.

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

Answer: 4 Explanation: 1. The pediatric client with a chronic or acute condition that does not directly affect the GI or electrolyte system is at a lower risk than is a toddler with a condition that increases insensible water loss. 2. The pediatric client with an acute condition that does not directly affect electrolytes is at a lower risk than is a client with a condition that increases insensible water loss. 3. The pediatric client with an acute condition, such as a client with cellulitis that does not affect the GI or electrolyte system, is at a lower risk than is a toddler with a condition that increases insensible water loss. 4. The pediatric client with the greatest risk is under 2 years of age and with a condition that increases insensible fluid loss.

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

Answer: 4 Explanation: 1. The spica cast might require alteration in family functioning; however, the situation describes no signs and symptoms to indicate this. In addition, fractures generally are not considered a significant long-term disability. 2. The need for a spica cast is not considered a newly acquired disability. Nothing about the situation describes caregiver role strain. 3. Lack of family members and lack of respite support were not mentioned in the scenario. 4. The situation describes multiple changes, or stressors, in the family's situation that compromise family coping skills.

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

Answer: 4 Explanation: 1. There is no indication that the father is not the actual parent. Both parents could be carriers of the disorder but unaware of their status. 2. Both parents must have the trait for the child to have a 25% chance of having this disease. 3. Both parents must have the trait for the child to have a 25% chance of having this disease. 4. Sickle-cell disease is an autosomal recessive disorder; both parents must have the trait in order for a child to have a 25% chance of having this disease.

2) A community assessment conducted by the nurse reveals that the number of serious injuries in children has doubled in the past year. Which is the most appropriate nursing diagnosis when planning care to address the increased number of injuries? 1. Altered Family Processes related to hospitalization of an injured child 2. Risk for Injury related to inadequate use of bicycle helmets 3. Noncompliance related to inappropriate use of child safety seats 4. Knowledge Deficit related to injury prevention in children

Answer: 4 Explanation: 1. This diagnosis might be appropriate in a specific situation, but Knowledge Deficit related to injury prevention in children is the only one that is general to the problem as a whole and is, therefore, the most appropriate community nursing diagnosis. 2. This diagnosis might be appropriate in a specific situation, but Knowledge Deficit related to injury prevention in children is the only one that is general to the problem as a whole and is, therefore, the most appropriate community nursing diagnosis. 3. This diagnosis might be appropriate in a specific situation, but Knowledge Deficit related to injury prevention in children is the only one that is general to the problem as a whole and is, therefore, the most appropriate community nursing diagnosis. 4. Knowledge Deficit related to injury prevention in children is general to the problem as a whole and is, therefore, the most appropriate community nursing diagnosis.

2) During a well-child examination, the parents of a 4-year-old client inform the nurse that they are thinking of buying a television for their child's bedroom and ask for advice as to whether this is appropriate. Which response by the nurse is most appropriate? 1. "It is okay for children to have a television in their room as long as you limit the amount of time they watch it to less than 2 hours per day." 2. "Research has shown that watching educational television shows improves a child's performance in school." 3. "Don't buy a television for your child's room; he is much too young for that." 4. "Research has shown that children with a television in their bedroom spend significantly less time playing outside than other children."

Answer: 4 Explanation: 1. This information is correct in that limiting television viewing to less than 2 hours per day is appropriate, but the probability of this occurring with a television in the child's room is low; the child will most likely be watching much more than 2 hours per day. 2. This statement might encourage the parents to allow the child to watch more television, and the child's developmental need for physical activity is greater than the benefit that he might obtain by watching educational programs. 3. This statement does not give parents a rationale, and it might seem opinionated to them. 4. Young children need to be physically active at this age. Research has shown that children with a television in their bedroom spend significantly less time playing outside than do other children, and physical inactivity in children has been linked to many chronic diseases, such as obesity and type 2 diabetes. Telling parents this is the best response because it gives the parents an evidence-based reason for not placing a television in the child's room.

17) A child is admitted to the hospital unit for physical injuries. The mother's boyfriend is suspected of child abuse. Which is the primary role of the nurse in addition to reporting the information to the proper authorities? 1. Gathering information about how the injuries occurred. 2. Collecting evidence against the suspected abuser. 3. Encouraging the child to talk about his experience. 4. Protecting the child from further injury.

Answer: 4 Explanation: 1. This is not a priority role for the nurse. 2. This would be a police function, not the nurse's responsibility. 3. The nurse and the psychologist will be meeting with the child to help the child work through the experience, but this is not the priority action for the nurse. 4. The nurse will monitor the child while in the presence of visitors. In addition, the nurse will talk with the social worker to assist in providing for the child's safety in the future. This is a priority.

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

Answer: 4 Explanation: 1. This mother is not concerned about other women; she is concerned about what is best for her child. 2. Nurses are responsible for helping parents make informed decisions. It is important that the mother has all the facts before she makes a decision. 3. The mother has the right to make the decisions for her child. The nurse's role is not to tell the parents what to do but to give them the information they need to make decisions. 4. Explaining that if her child contracts measles, mumps, or rubella, the child could have very serious and permanent complications from these diseases is correct; measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness.

16) Which is the priority nursing action for a child who presents in the emergency department after a motor vehicle accident with a sucking wound of the chest? 1. Placing the child in a Trendelenburg position 2. Beginning rescue breathing for the child 3. Beginning cardiac resuscitation for the child 4. Covering the child's wound with an air occlusive dressing

Answer: 4 Explanation: 1. This would not be the appropriate response to a sucking chest wound. 2. The child is conscious. Rescue breathing is not appropriate at this time. 3. There is no need for cardiac resuscitation at this time. 4. This prevents more air from entering the chest and is appropriate.

5) Which is the priority nursing diagnosis when planning care for a newborn who is born with esophageal atresia and tracheoesophageal fistula? 1. Ineffective Tissue Perfusion 2. Ineffective Infant Feeding Pattern 3. Acute Pain 4. Risk for Aspiration

Answer: 4 Explanation: 1. Tissue perfusion is not a primary problem with this condition. 2. The infant is always kept NPO (nothing by mouth) preoperatively, so ineffective feeding pattern would not apply. 3. Pain is not usually experienced preoperatively with this condition. 4. This is the most common type of esophageal atresia and tracheoesophageal fistula, where the upper segment of the esophagus ends in a blind pouch and a fistula connects the lower segment to the trachea. Preoperatively, there is a risk of aspiration of gastric secretions from the stomach into the trachea because of the fistula that connects the lower segment of the esophagus to the trachea.

3) The nurse admits a child with a ventricular septal defect (VSD) to the pediatric unit. Which is the priority nursing diagnosis for this child? 1. Hypothermia related to decreased metabolic state 2. Acute Pain related to the effects of a congenital heart defect 3. Ineffective Tissue Perfusion (peripheral) related to cyanosis secondary to congenital heart defect 4. Impaired Gas Exchange related to pulmonary congestion secondary to the increased pulmonary blood flow

Answer: 4 Explanation: 1. Ventricular septal defects do not cause pain, fever, or deficient fluid volume. 2. Ventricular septal defects do not cause pain, fever, or deficient fluid volume. 3. VSDs are left to right shunts, which increases pulmonary blood flow without cyanosis. 4. Because of the increased pulmonary congestion, impaired gas exchange would be an appropriate nursing diagnosis.

7) Which parental statement at the conclusion of a teaching session regarding environmental controls for childhood asthma indicates correct understanding of the information presented? 1. "We're glad the dog can continue to sleep in our child's room." 2. "We'll keep the plants in our child's room dusted." 3. "We'll be sure to use the fireplace often to keep the house warm in the winter." 4. "We will replace the carpet in our child's bedroom with tile."

Answer: 4 Explanation: 1. When possible, pets and plants should not be kept in the home. 2. When possible, pets and plants should not be kept in the home. 3. Smoke from fireplaces should be eliminated. 4. Control of dust in the child's bedroom is an important aspect of environmental control for asthma management.

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

Answer: 4 Explanation: 1. While a list of hospitals that treat children is an essential part of an EMS system, the aspect that is most indicative that EMS providers actually are prepared to take care of children is evidence of education related to assessment and emergency treatment. 2. While size-appropriate equipment is an essential part of an EMS system, the aspect that is most indicative that EMS providers actually are prepared to take care of children is evidence of education related to assessment and emergency treatment. 3. While size-appropriate equipment is an essential part of an EMS system, the aspect that is most indicative that EMS providers actually are prepared to take care of children is evidence of education related to assessment and emergency treatment. 4. The aspect that is most indicative that EMS providers actually are prepared to take care of children is evidence of education related to assessment and emergency treatment.

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

Answer: 4 Explanation: 1. While the child may be physically dependent, this is not the meaning of tolerance. 2. Addiction refers to a compulsive use of a substance despite harm. This is not the definition of tolerance. 3. Withdrawal occurs when the opioid is stopped suddenly. This is not the meaning of tolerance. 4. Tolerance occurs when the body has become accustomed to the presence of the drug in the system. When this happens, the child will need more of a drug or a stronger drug to get the same effect.

7) Which is the priority topic the nurse will include when teaching newly hired teachers at a child care center within the community? 1. How to take a temperature 2. The schedule for immunizations 3. How to interpret healthcare records 4. Principles of infection control

Answer: 4 Explanation: 1. While the teachers may need to monitor a child's temperature while working at the center, this is not the priority topic for the nurse to include in the teaching session. 2. While the teachers may need to review immunization records for the children, this is not the priority topic for the nurse to include in the teaching session. 3. While the teachers may need to review and interpret the children's healthcare records, this is not the priority topic for the nurse to include in the teaching session. 4. It is essential that teachers know principles of infection control to decrease the spread of germs that can cause disease in young children; therefore, this is the priority topic for the nurse to include in the teaching session.

16) Which clean-catch urinalysis finding should the nurse be most concerned for a child who is admitted to an urgent care center to rule out a urinary tract infection? 1. 2+ white blood cells 2. 1+ red blood cells 3. Urine appearance: cloudy 4. Specific gravity: 1009

Answer: 4 Explanation: 1. White blood cells are expected. 2. Red blood cells are common in the urine of a child with a urinary tract infection. 3. With white blood cells in the urine, this is a common finding. 4. This is a very dilute urine. With white blood cells (WBCs), red blood cells (RBCs), and bacteria in the urine, you would expect the urine to contain more solutes.

22) The nurse is assessing a pediatric client who is experiencing metabolic alkalosis. Which assessment questions should the nurse include when interviewing the child's parents? Select all that apply. 1. "Has your child consumed any aspirin?" 2. "Has your child consumed any boric acid?" 3. "Has your child consumed any antifreeze?" 4. "Has your child consumed any baking soda?" 5. "Has your child consumed any antacids?"

Answer: 4, 5 Explanation: 1. An overdose of aspirin is associated with metabolic acidosis. 2. Consumption of boric acid can cause metabolic acidosis. 3. Accidental consumption of antifreeze can cause metabolic acidosis. 4. Consumption of baking soda is associated with metabolic alkalosis. 5. Consumption of antacids is associated with metabolic alkalosis.

The mother of a 6-year-old calls the clinic because her child is wetting the bed. Which assessment question by the nurse is most important? a. "Is there a family history of renal or urinary problems?" b. "What happens when the child wets the bed?" c. "At what age was the child potty-trained?" d. "How is the child doing in school?"

Answer: a. "Is there a family history of renal or urinary problems?" Feedback: Enuresis more often occurs in children who have a positive family history, so the primary assessment question is to determine whether there is a family history. The other questions are important to ask when assessing a child with enuresis, but are not the priority.

23) The nurse is assigned as the care coordinator for a child with special healthcare needs. Which actions by the nurse enhance the family's ability to participate in their child's care coordination? Select all that apply. 1. Coordinating the healthcare team 2. Arranging the needed healthcare services 3. Modifying the home for care 4. Helping with decision making for meeting goals of care 5. Educating the family about the diagnosis

Answer: 4, 5 Explanation: 1. Coordinating the healthcare team is one of the responsibilities of the nurse case coordinator. This is not an action that will enhance the family's ability to coordinate care for their child. 2. Arranging needed healthcare services is one of the responsibilities of the nurse case coordinator. This is not an action that will enhance the family ability to coordinate care for their child. 3. Modifying the home for care is one of the responsibilities of the nurse case coordinator. This is not an action that will enhance the family ability to coordinate care for their child. 4. The nurse case coordinator helps the famly with decision making related to meeting the goals of care. This action enhances the family's ability to coordinate care for their child. 5. The nurse case coordinator educations the famly about the child's diagnosis. This action enhances the family's ability to coordinate care for their child.

28) A child is diagnosed with lymphocytopenia. Which parental statements indicate understanding of this diagnosis? Select all that apply. 1. "My child may be prone to allergic reactions." 2. "My child may have trouble initiating an inflammatory response." 3. "My child may require iron supplements to treat this disorder." 4. "My child may require further testing for leukemia." 5. "My child may have been exposed to tuberculosis."

Answer: 4, 5 Explanation: 1. Lymphocytopenia does not cause a child to be prone to allergic reactions. This statement indicates the need for further education regarding the diagnosis. 2. Lymphocytopenia does not impact the ability to mount an inflammatory response. This statement indicates the need for further education regarding the diagnosis. 3. Lymphocytopenia is not treated with iron supplements. This statement indicates the need for further education regarding the diagnosis. 4. Lymphocytopenia may indicate leukemia. This statement indicates correct understanding of the diagnosis. 5. Lymphocytopenia is often an indication of exposure to tuberculosis. This statement indicates correct understanding of the diagnosis.

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

Answer: 4, 5 Explanation: 1. Poliovirus is an example of a killed virus vaccine that is used to decrease the risk of communicable diseases. 2. Tetanus is an example of a toxoid vaccine that is used to decrease the risk of communicable diseases. 3. Measles is an example of a live virus vaccine that is used to decrease the risk of communicable diseases. 4. Acellular pertussis is an example of a recombinant vaccine that is used to decrease the risk of communicable diseases. 5. Hepatitis B is an example of a recombinant vaccine that is used to decrease the risk of communicable diseases.

Do not palpate this tumor because a piece can dislodge and spread cancerous cells: (SATA) A. Wilms Tumors B. Brain Tumors C. Neuroblastomas D. Soft tissue Tumors

Answer: A, C Neuroblastomas and Wilms Tumors are commonly located in the abdomen, thoracic area, adrenal glands and cervical areas. Palpating them in the abdomen can cause them to dislodge and spread cancerous cells.

The nurse takes care of a newborn diagnosed with Eagle-Barrett syndrome. Which comment by the parent indicates teaching was effective? a. "As a teen, my child might develop end-stage renal disease." b. "My infant has about 3 months to live due to severe renal problems." c. "The skin of his bottom looks like a prune due to poor peristalsis." d. "He has this syndrome from a recessive gene; my next baby will have it too

Answer: a. "As a teen, my child might develop end-stage renal disease." Feedback: Children with Eagle-Barrett syndrome (prune belly) will develop end-stage renal disease in childhood or adolescence because of inadequate renal function. The skin covering the abdominal wall is thin and resembles a wrinkled prune. Death occurs in the neonatal period due to pulmonary hypoplasia and severe renal dysfunction. Prune belly syndrome is thought to be related to a fetal urinary tract obstruction or a specific injury, not genetics

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

Answer: a. "Flying at high altitudes can be associated with less available oxygen, causing more red blood cells to assume the sickle shape." Feedback: The low concentration of oxygen at high altitudes increases metabolism, resulting in tissue hypoxia and increased sickling. Flying does not increase risk for infections or dehydration.

Which of the following describes an appropriate suggestion in order to lessen the parents' burden of communicating with family and friends regarding their critically ill child's condition? a. Designate one family member or friend to relay information to others. b. Require families to create a website to post updates on the child's condition to decrease the number of calls to the nurses' station. c. Allow open visiting hours for all family and all friends. d. Tell parents to respond to all calls and emails from all family and friends.

Answer: a. Designate one family member or friend to relay information to others. Feedback: The energy of close family members as well as that of the critically ill child must be protected from well-meaning extended family members and friends. While open visiting is preferable for close family, the nurse can serve as a gatekeeper for visiting hours for others. A website might be helpful, but requiring a website and telling the family to respond to all emails and calls might be overwhelming, and might add to the family's burden.

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

Answer: a. Drug abuse Feedback: The teen is exhibiting symptoms suggestive of drug abuse. There are no data that indicate that the teen is considering suicide or has started smoking. Although the teen might be drinking, the symptoms do not necessarily speak to current intoxication. Weight loss occurs over time. Intoxication is a current state.

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

Answer: a. Encephalopathy Feedback: The risk of encephalopathy from complications of measles and varicella is much greater than the risk of encephalopathy from being immunized. Wheals and urticaria are local non-life-threatening allergic reactions that can occur within minutes of any immunization. A mild fever is a common reaction 24-48 hours after administration of the diphtheria, tetanus toxoid, and acellular pertussis (DTaP) vaccine. A rash may occur 7-10 days after the administration of the measles, mumps, and rubella (MMR) vaccine.

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

Answer: a. Encourage parental involvement in the child's care and suggest rooming in if possible. Feedback: Parents should be encouraged to room in with their child and to participate in their child's care as much as possible. Asking the parents to leave the room will cause anxiety in the child. Parents should be encouraged to remain with and participate in the care of their hospitalized child. Parents should be encouraged to hold their child as much as the child's condition allows. The nurse should spend as much time as possible with the child when the parents are not present to decrease the amount of anxiety the child experiences.

An 8-year-old diagnosed with ALL is admitted to hospice. What can the nurse do to lessen the child's feelings of anxiety? a. Encourage the parents to bring family photos and toys from home. b. Encourage the child to explore his environment and ask questions as needed. c. Encourage participation in self-care. d. Encourage opportunities to incorporate rituals from home.

Answer: a. Encourage the parents to bring family photos and toys from home. Feedback: Make the child's bedside more personal and familiar by encouraging parents to bring in security objects, family photos, and favorite toys from home. The child derives comfort from presence of personal items. The child in hospice may not be able to explore his surroundings, but information will help reduce anxiety. Participation in self-care and incorporating rituals from home will help with a child's feelings of powerlessness.

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

Answer: a. Fluid and Electrolyte Imbalance Feedback: Although all of the nursing diagnoses are important, dehydration and electrolyte alteration secondary to vomiting may be life-threatening and are the priority for this client.

Which of the following are responsibilities of the pediatric nurse in the primary care setting? (Select all that apply.) a. Giving telephone advice to a parent of a child with diarrhea b. Administering a hepatitis vaccine to an infant c. Diagnosing an ear infection on a 1-year-old d. Prescribing albuterol for a toddler with asthma e. Measuring the head circumference of a 6-month-old

Answer: a. Giving telephone advice to a parent of a child with diarrhea; b. Administering a hepatitis vaccine to an infant; e. Measuring the head circumference of a 6-month-old Feedback: Responsibilities of the general pediatric nurse in an office or healthcare setting include giving telephone advice, administering immunizations, assessing lab values, and assessing measurements. Diagnosing illness and prescribing medications are roles of advanced practice nurses and primary healthcare providers.

The child post-stem cell transfusion tells a nurse that she has a rash, diarrhea, and abdominal pain. Which condition does the nurse suspect? a. Graft-versus-host disease b. Severe combined immunodeficiency disease c. Anaphylaxis d. Systemic lupus erythematosus

Answer: a. Graft-versus-host disease Feedback: Symptoms of graft-versus-host disease include a pruritic or painful rash, diarrhea, and abdominal pain. Symptoms of severe combined immunodeficiency disease include respiratory infections, diarrhea, and recurrent oral candidiasis, failure to thrive, and skin infections. Anaphylaxis is a hypersensitivity reaction with symptoms of hypotension, wheezing, stridor, vomiting, urticarial edema, and diarrhea. The symptoms of systemic lupus erythematosus include rash, fatigue, malaise, weight loss, nephritis, vasculitis, and arthritis.

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

Answer: b. Swimming Feedback: Swimming provides a safe way to exercise for a child. Biking, running, and baseball all are sports that may increase bleeding due to the impact placed on joints.

An 8-year-old child rescued from a house fire faces a lengthy hospitalization to recover from extensive burns. Which are activities the nurse should encourage to involve family members in the care of this child? (Select all that apply.) a. Personalizing the child's room with pictures of family and favorite articles from home b. Updating extended family members and friends with emails and phone messages c. Learning how to give the child oral medications d. Taking breaks with other parents in the burn unit e. Assessing the child's wound healing

Answer: a. Personalizing the child's room with pictures of family and favorite articles from home; b. Updating extended family members and friends with emails and phone messages; c. Learning how to give the child oral medications; d. Taking breaks with other parents in the burn unit Feedback: Personalizing the child's room, establishing a connection with other parents, making helpful suggestions that facilitate family communication, and learning a skill promote family involvement in the child's care. Keeping family members at a distance while dressings are changed does not actively involve them. Assessment of the child's wound healing is a nursing responsibility.

The nurse learns that a homeless 12-year-old brought into the clinic due to flu symptoms is also mentally handicapped. What other risk factors to healthcare might the family be experiencing? (Select all that apply.) a. Poverty b. Mental illness c. Lack of access to resources d. Financial stability e. Racial disparities

Answer: a. Poverty; b. Mental illness; c. Lack of access to resources; e. Racial disparities Feedback: Children who experience homelessness often have other risk factors to healthcare, such as poverty, physical and/or mental health problems, lack of access to resources, and racial disparities in health. Financial stability is not a factor.

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

Answer: a. Prevention of infection Feedback: Although all body systems are affected, prevention of infection is the key in immune disorders.

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

Answer: a. Push the exposed abdominal contents back into the abdomen. Feedback: Care of an infant with an omphalocele (congenital malformation where abdominal contents herniate through the umbilical cord covered by a translucent sac) is aimed at protection of abdominal contents. Aggressive attempts at replacing abdominal contents can lead to numerous problems, including increased abdominal pressure, impaired respiratory status, and bowel perforation. The goals should be to protect the infant from hypothermia, replace fluids, prevent infection, and look for other associated anomalies.

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

Answer: a. Risk for Infection related to incomplete immunization series Feedback: The child will be at risk for infection from childhood communicable diseases. None of the other nursing diagnoses relate to the mother's religious beliefs.

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

Answer: a. Screen family members for strep throat. Feedback: Rationale: The child with APIGN should have a diet low in protein with no added salt. Family members should be checked for strep throat, and the child should be monitored for any neurological changes.

The nurse is monitoring a 6-year-old admitted to the emergency department with sixth disease. For which medical emergency does the nurse watch closely? a. Seizure activity b. Increased pain c. Excessive diarrhea d. Sore throat

Answer: a. Seizure activity Feedback: Febrile seizures are a complication of sixth disease and the nurse should watch the client closely. Pain, diarrhea, and sore throat are not symptoms or complications of sixth disease.

A 10-year-old child presents to the emergency department with decreased urinary output, lethargy, and confusion. The nurse suspects hypernatremia. About what condition is the nurse most concerned and how can the hypernatremia be treated? a. Seizures/hypotonic fluid b. Coma/hypertonic fluid c. Confusion/salt tablets d. Anuresis/tap water

Answer: a. Seizures/hypotonic fluid Feedback: Seizures can occur when hypernatremia occurs rapidly or is severe. Severe hypernatremia can be fatal. Hypernatremia is treated by intravenous administration of hypotonic fluid. A decreased level of consciousness manifested by confusion, lethargy, or coma can result from shrinking of the brain cells; anuresis may also occur, but the treatments associated with these conditions will be a hypotonic fluid.

The parent of a hospitalized infant expresses the desire to hold her infant, who has been hospitalized with a bacterial infection. What is the most appropriate action by the nurse? a. Show the mother how to hold the infant so that intravenous lines are not jeopardized. b. Tell the mother that the infant should rest. c. Inform the mother that holding the infant may cause the intravenous line to become dislodged. d. Ask the mother why she wants to hold the infant.

Answer: a. Show the mother how to hold the infant so that intravenous lines are not jeopardized. Feedback: Parent-infant attachment is critical to the infant's development; therefore, the nurse should assist the mother to hold the infant in a way that does not jeopardize intravenous lines or equipment. Giving the mother messages that imply that she should not hold her child increases parental anxiety and jeopardizes appropriate development for the infant. The nurse already should understand why the mother wants to hold the infant.

Which assessment finding would indicate early hypovolemic shock? a. Weak central pulses b. Tachycardia c. Pale, cold skin d. Decreased blood pressure

Answer: b. Tachycardia Feedback: Decreased blood pressure, weak central pulses, and pale, cold skin all are signs of late, profound shock. Tachycardia is a sign of early hypovolemic shock.

The healthcare nurse is responsible for selecting client education materials in the waiting area of a healthcare center. Which reading materials would be appropriate for the waiting area? (Select all that apply.) a. Signs and symptoms of the flu b. Administration of asthma medications to a child c. Nutrition fun facts from a government site d. Instructions on endotracheal insertion during an emergency e. How to recognize when to initiate care for a sickle cell crisis

Answer: a. Signs and symptoms of the flu; b. Administration of asthma medications to a child; c. Nutrition fun facts from a government site; e. How to recognize when to initiate care for a sickle cell crisis Feedback: The nurse in the office or healthcare center setting may be responsible for selecting client education materials for the waiting area and those specifically used to teach families about various conditions (e.g., signs and symptoms of the flu, asthma medication administration, nutrition facts, and care for sickle cell crisis). Instruction on endotracheal insertion is not appropriate for client education

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

Answer: a. Small pupils and shallow breathing Feedback: Clinical signs that indicate the development of respiratory depression include sleepiness, small pupils, and shallow breathing. Tachypnea, sweating, vomiting, anxiety, delirium, and hallucinations are not signs indicative of developing respiratory depression.

Which interventions will facilitate positive coping in a preschool-age child after a deadly explosion in the neighborhood where the child lives? (Select all that apply.) a. Spending time with the child b. Postponing planned family events c. Accepting delayed reactions in the child d. Initiating detailed discussion about the event e. Limiting the amount of television the child watches following the event

Answer: a. Spending time with the child; c. Accepting delayed reactions in the child; e. Limiting the amount of television the child watches following the event Feedback: The preschool-age child might have difficulty coping when a disaster or an act of war or terrorism has occurred. The amount of television the child watches should be limited, because repeated showing of the event by the media might cause a child this age to think that the event is occurring over and over again. The parents should take cues from the child regarding how much to discuss about the event. It is normal for delayed reactions to occur. The parents should spend time with the child and continue with planned events as much as possible. They should maintain the child and family's routine as much as possible.

Which tasks should the nurse perform rather than delegate to an assistant? (Select all that apply.) a. Suctioning a 2-year-old with a tracheostomy b. Changing the diaper of the 3-month-old infant recovering from RSV c. Walking with a 2-year-old who has an IV receiving antibiotics for pneumonia d. Relieving the nurse who is watching a 2-year-old with croup, because he now sounds quiet e. Taking the temperature of an 8-month-old infant with bronchiolitis whose respirations are 68 and who is irritable

Answer: a. Suctioning a 2-year-old with a tracheostomy; d. Relieving the nurse who is watching a 2-year-old with croup, because he now sounds quiet; e. Taking the temperature of an 8-month-old infant with bronchiolitis whose respirations are 68 and who is irritable Feedback: Respirations of 68 are high for an 8-month-old infant. The nurse needs to assess for retractions and wheezing. A 2-year-old who becomes quiet following respiratory distress could be experiencing decompensation and requires an evaluation. Suctioning is a sterile procedure that only the nurse should perform.

A 4-year-old child with croup is brought to the emergency department. The child is anxious and crying and has a high-pitched stridor, retractions, and a barky cough. After administration of cool mist therapy, which assessment finding would indicate significant improvement in the child's respiratory status? a. The child is less anxious. b. The respiratory rate is decreased. c. Wheezing is less loud. d. The child drinks 8 ounces of fluid.

Answer: a. The child is less anxious. Feedback: All responses indicate conditions that are beneficial to the child. Respiratory distress and hypoxia cause anxiety as this vital life function is threatened. When anxiety improves, the nurse knows that the respiratory status must be improving as well, even if signs and symptoms continue.

The single mother of a 10-year-old tells the clinic nurse that lately, her daughter has been withdrawn and waking up in the middle of the night crying. Which event does the nurse suspect after speaking with the child and her mother? (Select all that apply.) a. The child started a new school last week. b. The mother is recently divorced. c. The mother has a new boyfriend. d. The child is popular in school e. Mother and father share visitation.

Answer: a. The child started a new school last week; b. The mother is recently divorced; c. The mother has a new boyfriend; e. Mother and father share visitation. Feedback: Family challenges and stress influence how children respond to situations. These challenges may affect the physical and mental health of the child. Children with divorced-, separated-, or single-parent households may believe that they are at fault for one or the other parent leaving; feel abandoned or fear abandonment; and fear new experiences or changes in routine. Popularity in school is not a cause for negative stressful events.

A 3-year-old is hospitalized with a fractured femur. Which assessment represents a protective factor that will facilitate the child's adaptation to the hospitalization? a. The child's parents take turns staying with him so that he is never alone. b. The parents state that they do not have insurance and will have to pay for the hospitalization. c. The child's sister must remain at the hospital because there is no one to take care of her at home. d. The parents state that the child's immunization status is not current.

Answer: a. The child's parents take turns staying with him so that he is never alone. Feedback: Having someone remain with the child at all times is a protective factor. The other examples all represent risk factors.

Which behavior by a client's parent is the best indicator that he understands how to administer medication to his child at home following surgery? a. The parent gives the medication to the child using appropriate technique. b. The parent describes to the nurse how he will give the medication. c. The parent signs the written discharge instruction, verifying understanding of the instructions. d. The parents state that he understands how to administer the medication.

Answer: a. The parent gives the medication to the child using appropriate technique. Feedback: Although all of the answers indicate some degree of understanding, the best way to determine understanding is to actually have the parent demonstrate by administering the medication as the nurse observes technique.

An 8-year-old child is diagnosed with viral pneumonia and sent home from the clinic without an antibiotic prescription. The symptoms worsen, and the child returns to the clinic a week later with signs of a higher fever, listlessness, and a harsh, productive cough. The child's mother states, "I knew a prescription for antibiotics was needed." Which response by the nurse is the most appropriate? a. "It is better to wait to make sure so we don't use antibiotics unnecessarily. This approach also saves healthcare dollars." b. "Antibiotics are not effective for viral pneumonia. Bacteria can grow later in the course of the illness, requiring the need for antibiotics at that time." c. "You do not want to expose your child to medication unnecessarily. Now it is necessary, because it is bacterial pneumonia." d. "Sometimes we just do not know. I'm glad you came back in."

Answer: b. "Antibiotics are not effective for viral pneumonia. Bacteria can grow later in the course of the illness, requiring the need for antibiotics at that time." Feedback: The nurse responds with the most informative, accurate response. The decision not to use antibiotics for viral pneumonia was based on sound rationale about the etiology of the illness, not cost.

A mother of a premature infant asks the nurse about the baby's need for supplemental iron. What is the nurse's best response? a. "All infants require iron supplements." b. "Because iron stores are developed during the third trimester of pregnancy, premature infants require supplemental iron." c. "The small body size of the preterm infant calls for supplemental iron to promote growth." d. "Preterm infants have decreased ability to synthesize iron."

Answer: b. "Because iron stores are developed during the third trimester of pregnancy, premature infants require supplemental iron." Feedback: Neonatal iron stores are decreased in the premature infant. The body size and ability to synthesize iron are not factors that indicate supplemental iron. Not all infants require iron.

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

Answer: b. "Chemotherapy decreases immune system function, increasing the risk of acquiring an infection." Feedback: Chemotherapeutic agents decrease the immunity of the child. Proper use of the mask will decrease the chance of acquiring an infection. Cancer is not spread; a mask cannot help contain moisture; and unsightly mouth sores are not a medical reason to wear a mask.

Which statement by the parent of an uncircumcised male infant would indicate the need for further teaching? a. "Frequent diaper changes are important." b. "I should forcibly retract the foreskin once a day." c. "Once the foreskin is retractable, it should be returned to its normal position after cleaning." d. "Harsh soaps should be avoided."

Answer: b. "I should forcibly retract the foreskin once a day." Feedback: The parent should never force the foreskin to retract, due to the fact that it may cause paraphimosis, which is where the foreskin cannot be returned to its normal position. Harsh soaps should be avoided. Frequent diaper changes are important to prevent irritation, and once the foreskin is retractable in early childhood, always return it to its normal position after cleaning.

The nurse concludes that a parent of an otherwise healthy child with varicella (chickenpox) has an accurate understanding of the disease. Which statement by the parents is appropriate following education about the disease process? a. "I will take my child to our primary healthcare provider to request antibiotics." b. "I will send my child back to school when all the lesions are dry and crusted over." c. "I will take my child to our primary healthcare provider to request acyclovir." d. "I will give my child acetaminophen 120 mg three times a day for the duration of the illness."

Answer: b. "I will send my child back to school when all the lesions are dry and crusted over." Feedback: Varicella is no longer contagious when all the lesions are dry. Acetaminophen should be used when the child has a fever, not three times per day, every day, during the illness. Antibiotics are not effective against viruses. Acyclovir is an antiviral but is recommended for immunocompromised children, not healthy children and adolescents.

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

Answer: b. "Infants maintain their temperature by losing heat through their heads." Feedback: Incorrect answers indicate the parents understand the lesson taught, and do not require further education. A correct answer indicates the parents do not understand the lesson, and require further education. Losing heat through their heads will have minimal affect on fluid loss in infants. A parent who makes this comment will require further education.

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

Answer: b. "Think about your favorite place to go in the summer." Feedback: Imagery involves a cognitive process in which the individual is encouraged to think about something positive, such as a favorite place. Taking slow, deep breaths is a breathing technique for pain control. Counting is a distraction technique. Touch is a type of cutaneous stimulation.

The nurse is caring for a child with sickle cell anemia. The parents ask the nurse what they can do to enhance their child's health. What recommendation by the nurse is the most appropriate? a. No immunizations, because the child is immunocompromised b. Additional immunizations, because of the child is at greater risk for infection c. Refer the child for genetic testing. d. Daily dietary supplemental folate and vitamin B12

Answer: b. Additional immunizations, because of the child is at greater risk for infection Feedback: All children with chronic conditions should receive additional immunizations because they are at greater risk for infection. Genetic testing of the child is not needed at this time and will not enhance the child's health; parents should be tested for sickle cell and sickle cell trait. Daily dietary supplements of folate and B12 are not necessary for sickle cell anemia.

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

Answer: b. Administer the prescribed dose of intravenous morphine. Feedback: The child is in severe pain and needs intravenous pain medication that will provide prompt relief. Although pain assessment is important, the nurse must rate the child's pain based on his actions and verbal statements instead of a FACES scale or numeric scale score. The child is not coping with the severe pain and therefore is unable to focus on scoring his pain. Explanations regarding pain rating scales are provided most effectively when the client is not in acute pain. Oral analgesics generally do not provide relief as effectively and promptly as intravenous medication does.

The nurse is assessing a child with tetralogy of Fallot. The nurse's assessment reveals hypoxemia as indicated by cyanosis, SaO2 of 84%, and bradycardia. What action should the nurse anticipate taking first? a. Preparing the family for imminent surgery b. Administering oxygen c. Notifying the physician d. IV placement

Answer: b. Administering oxygen Feedback: Surgery is not necessarily imminent in this case. IV placement and notification of the physician are important but not the first action.

The nurse is caring for a group of infants in the neonatal intensive care unit. Which infant would require preparation for immediate surgery due to risk of life-threatening respiratory distress? a. An infant with an umbilical hernia b. An infant with a diaphragmatic hernia c. An infant with a cleft palate d. An infant with gastroesophageal reflux

Answer: b. An infant with a diaphragmatic hernia Feedback: Gastroesophageal reflux, cleft palate, and umbilical hernia do not cause respiratory distress and are not considered surgical emergencies. A diaphragmatic hernia will cause the abdominal organs to extend into the chest, causing pressure on the thoracic cavity. Only 50% of afflicted infants survive.

Which nursing diagnosis is most important for a teenager diagnosed with SLE? a. Alterations in Nutrition b. Body Image, Disturbed c. Activity Intolerance, Risk for d. Infection, Risk for

Answer: b. Body Image, Disturbed Feedback: Adolescents with SLE may have an altered body image because of rash, alopecia, arthritic changes in the joints, and chronic disease. Alterations in nutrition, activity intolerance, and infection are important and should be addressed, but are not the priority for the teenager.

The parent of a 2-year-old brings the child to the emergency department because he is lethargic. Upon assessment, the nurse finds the child has the following vital signs: T 99°F, P 60, R 40, B/P 60/40. Which condition is imminent based on these findings? a. Endocarditis b. Cardiac arrest c. Cyanosis d. Congestive heart failure

Answer: b. Cardiac arrest Feedback: Bradycardia in children is a significant warning sign that cardiac arrest is imminent. Endocarditis is inflammation of the endocardium with symptoms of fever, fatigue, weakness, joint and muscle aches, loss of appetite, weight loss, and diaphoresis. Cyanosis is a decrease of oxygen in the blood, resulting in discoloration of the skin (purple, blue, mottled). Congestive heart failure symptoms include tachypnea, tachycardia, pallor or cyanosis, nasal flaring, grunting, retractions, cough, and crackles.

A nurse is evaluating a child with a cardiac defect. What should the nurse include as part of the activity and behavior assessment? (Select all that apply.) a. Growth patterns b. Change in activity c. Dusky color d. Exercise intolerance e. Irritability

Answer: b. Change in activity; d. Exercise intolerance; e. Irritability Feedback: Many assessments need to be completed for a child with a cardiac defect. Activity and behavior can be grossly affected by a variety of conditions. Color and growth are not part of the activity/behavior assessment.

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

Answer: b. Chicken fingers and milkshakes Feedback: Children with severe combined immunodeficiency should be given a diet high in protein and calories. Chicken fingers and milkshakes have both high calories and protein.

A school-age child is being seen in the oncology clinic for possible Hodgkin disease (HD). During the course of the nursing assessment, which findings would be expected? (Select all that apply.) a. Poor appetite b. Complaints of night sweats c. Fever d. Painless cervical nodes e. Painful cervical nodes

Answer: b. Complaints of night sweats; d. Painless cervical nodes Feedback: Painless cervical nodes are a hallmark sign of HD. In addition, night sweats are also characteristic. Fever, poor appetite, and painful cervical nodes are more characteristic of infection.

In obtaining a nursing history on an 18-month-old with diarrhea, which questions might help to identify the cause of the problem? (Select all that apply.) a. Has the child taken diphenhydramine in the past week? b. Do any other family members have diarrhea? c. Has the child been on antibiotics recently? d. Does the child have any food sensitivities? e. Has the child traveled recently?

Answer: b. Do any other family members have diarrhea?; c. Has the child been on antibiotics recently?; d. Does the child have any food sensitivities?; e. Has the child traveled recently? Feedback: A complete history of the child with diarrhea is important to finding the cause. Questions should cover recent travel, medication use, exposures, and foods eaten. Diphenhydramine is an antihistamine that does not cause diarrhea. Similar symptoms in other family members suggest infectious etiology.

A child was just diagnosed with Wilms' tumor. In planning teaching interventions, what key point should the nurse emphasize to the parents? a. Appropriate protective equipment should be worn for contact sports. b. Do not put pressure on the abdomen. c. Encourage the child to remain active. d. Frequent visits from friends and family will improve morale.

Answer: b. Do not put pressure on the abdomen. Feedback: Palpation of Wilms' tumor can cause rupture and spread of cancerous cells. Frequent visitation might allow the child to be exposed to more infections, and activity and sports are discouraged because of the risk of rupture of the encapsulated tumor.

The pediatric nurse in the primary care setting assesses a child who is complaining of ear pain. The mother reports that the child recently had an ear infection. She explains to the nurse that she gave the child amoxicillin for 3 days, but stopped it when the child appeared well. The most appropriate nursing diagnosis for the mother is: a. Noncompliance related to medication administration. b. Knowledge Deficit: Medication Administration related to lack of comprehension of previous instruction. c. Coping Deficit related to care of acutely ill child. d. Altered Family Processes related to ill child.

Answer: b. Knowledge Deficit: Medication Administration related to lack of comprehension of previous instruction. Feedback: The mother's actions indicate that she does not understand that the child needed the full dose of medication to completely treat the infection. Knowledge Deficit would be the most appropriate nursing diagnosis. Noncompliance is not the best answer, since the mother did give the medicine for 3 days, and does not specifically indicate that she understood instructions to administer the medication for a longer time period. There are no data to indicate a coping deficit or alteration in family processes.

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

Answer: b. Moon face Feedback: Side effects of corticosteroids include moon face, increased hair growth, increased appetite, and mood swings. Impaired balance is not associated with corticosteroids.

The nurse is providing teaching to the mother of a 10-month-old regarding the administration of iron to her baby. Teaching would be considered effective if the mother administered the iron supplement with which substance? a. Formula b. Orange juice c. Milk d. Water

Answer: b. Orange juice Feedback: The vitamin C in orange juice facilitates the absorption of iron. Milk, water, and formula do not have the vitamin C needed for iron absorption.

A child is diagnosed with lupus. Which nursing diagnosis is highest in priority? a. Impaired Gas Exchange b. Pain (chronic) c. Decreased Cardiac Output d. Alterations in Nutrition

Answer: b. Pain (chronic) Feedback: Although nutrition, gas exchange, and cardiac output all might be indicated for lupus, the first diagnosis seen would be related to pain.

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

Answer: b. Pneumococcal; c. Hib; d. MMR; e. Influenza Feedback: Children with SCA have an increased risk of infection and should be immunized accordingly. All children should receive MMR and IPV unless contraindicated. Synagist is an immunization given to decrease the risk of RSV. There is no indication that this child is at an increased risk for RSV.

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

Answer: b. Points to where the hurt is; d. Strikes out physically when painful procedures are performed. Feedback: The preschooler can point to where the pain is and can describe to some degree the type and intensity of the pain. A child this age will resist painful procedures by physically striking out. Holding the body very still to avoid pain and trying to be brave are characteristic of school-age children. Detailed description of pain is characteristic of adolescents.

A child with tetralogy of Fallot is monitored closely for dehydration to prevent complications from which physiological alteration? a. Fluid volume deficits b. Polycythemia c. Electrolyte imbalances d. Fever

Answer: b. Polycythemia Feedback: Dehydration may result in polycythemia, which can increase a child's risk for thromboembolism. Fluid volume deficits, electrolyte imbalances, and fever, although important, are not the most potentially life-threatening options.

The nurse is caring for a child following a bone marrow transplant (BMT). What is the priority nursing diagnosis for this child? a. Alterations in Nutrition b. Risk of Infection c. Ineffective Coping d. Pain

Answer: b. Risk of Infection Feedback: Infection is the first concern in a child who has undergone a BMT. Immunosuppression presents a great risk for the child. Pain, nutrition alterations, and ineffective coping might be seen but are not the priorities.

The nurse assesses a 4-year-old who was adopted from Russia and has had no immunizations. The child does not appear ill but has a fine, pink, maculopapular rash that progressed from the face to the neck, chest, and back, then to the extremities within 3 days. Cervical and occipital lymph nodes are tender and enlarged. Which communicable disease would the nurse suspect? a. Scarlet fever b. Rubella (German measles) c. Meningococcus d. Hand, foot, and mouth disease

Answer: b. Rubella (German measles) Feedback: The child's pattern of rash eruption and lymphadenopathy is characteristic of rubella. The child with scarlet fever has a fine, red, sandpaper rash that spares the face and appears on the neck and trunk. The toes and fingers can peel, and a strawberry tongue is seen on day 4 or 5. Hand, foot, and mouth lesions are papulovesicular and last 7-10 days. The child with meningococcus is very ill and has a red-to-purple urticarial, maculopapular, or petechial rash that can progress to purpura.

An 8-year-old is admitted to the emergency department with an injury to the abdomen with single organ involvement. Which type of injury does the nurse suspect? a. High-velocity blunt trauma b. Sports-related trauma c. Penetrating trauma d. Bike-related trauma

Answer: b. Sports-related trauma Feedback: Sports-related abdominal trauma is often associated with a direct blow to the abdomen, and a single organ is usually injured. High-velocity blunt trauma usually involves multiple organs. Blunt trauma may not be apparent in penetrating traumas and would have to be assessed to determine what injury lies beneath the skin surface. Bike-related traumas can result in serious abdominal injuries.

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

Answer: b. Sucrose pacifier Feedback: Sucrose provides short-term, natural pain relief and is most appropriate for use in infants and neonates to decrease pain during the procedure. Imagery is not appropriate for an infant. Massage and swaddling are appropriate comfort measures following procedures and as adjuncts to pain medication. Swaddling might be appropriate as a means of restraint for specific procedures, but it does not relieve pain.

A nurse explains why a 4-year-old presenting with respiratory distress has retractions. Which statement by the parent indicates that the teaching was understood? a. "When distress occurs, children swallow air, leading to expansion of the rib cage and retractions." b. "Retractions occur in all children, because their ribs are soft and pliable. They are not related to respiratory distress." c. "Children breathe primarily with their diaphragm, but when distress occurs, the muscles between the rib cage work with extra effort to move air through narrow airways." d. "Children breathe primarily with the muscles between the ribs, so when distress occurs, the extra work of breathing causes retractions."

Answer: c. "Children breathe primarily with their diaphragm, but when distress occurs, the muscles between the rib cage work with extra effort to move air through narrow airways." Feedback: Up to the age of 6 years, children breathe primarily with their diaphragm. The intercostal muscles assist by increasing the chest diameter. When distress occurs, the intercostal muscles of the rib cage work with extra effort to move air through narrow airways. This causes retractions.

Which instruction should be provided to the parents of an infant with gastroesophageal reflux? a. "Feed every 4-5 hours to prevent overfeeding." b. "Place in a seated position for 10 minutes after feedings." c. "Elevate the head of the crib at all times." d. "Burp every 3-4 ounces with feeding."

Answer: c. "Elevate the head of the crib at all times." Feedback: Management of gastroesophageal reflux includes administering small, frequent feedings and burping every 1-2 ounces. Elevating the head of the bed and holding the infant upright for 30 minutes after feeding help minimize the reflux. Putting the infant in a seated position can increase the pressure on the abdomen, causing reflux to increase.

A newborn infant has a high red blood cell (RBC) count obtained by a heelstick. The mom asks the nurse why the heelstick must be repeated. What is the nurse's best response? a. "The primary healthcare provider ordered two samples." b. "Two samples are required in all situations." c. "Falsely elevated RBCs might be seen in newborns." d. "Hospital policy requires a second sample when results are abnormal."

Answer: c. "Falsely elevated RBCs might be seen in newborns." Feedback: Falsely elevated RBCs might be seen after birth secondary to the infant's high level of erythropoietin, placental transfusion at birth, or low fluid volume intake. Once the infant is breathing room air, hemoglobin production slows. Another sample may be required before a definitive diagnosis can be made. Two samples are not required in all situations, only when there is a questionable result. Hospital policy and primary healthcare provider's order are not addressed.

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

Answer: c. "We live in a single-level home, so we'd have no trouble getting out of the house in case of a fire." Feedback: Having a good family fire escape plan involves knowing how to get out of the house safely, establishing a meeting site outside the house, keeping smoke detectors operative, and knowing how to move through the house safely and protect everyone from smoke inhalation. Living in a one-story house does not guarantee safe escape from a burning building, especially for a small child.

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

Answer: c. "You are here so we can help you feel better, not because of anything you might have done." Feedback: Preschoolers do not fully understand cause and effect and what causes illness. They also frequently view illness as punishment. The nurse needs to be clear about why the child is in the hospital without giving any physiological information that the child cannot understand. The nurse should not discount the statement by saying "Don't be silly." It also does not show the child that whatever behavior made her feel like she was bad has no relationship to her hospitalization. Children of this age may feel two unrelated events have a cause-and-effect relationship. Open-ended statements focus the child on behavior she thinks is bad instead of assuring her that her behavior is unrelated to the reason for hospitalization. Calling the mom to get her input about the child's behavior is not related to the hospitalization and does not focus on helping the child to understand why she is hospitalized.

A 4-year-old has been hospitalized for several days, and his parents have decided to return to work during the day and then spend the evening and night with him. They have informed the nurse that they will return around 5:30 or 6:00 p.m. During lunch, the child asks the nurse when his parents will return. What is the most appropriate response by the nurse? a. "I do not know when your parents are going to return." b. "Your parents will return when they get off work." c. "Your parents will return around suppertime." d. "Your parents will return between 5:30 and 6:00 p.m."

Answer: c. "Your parents will return around suppertime." Feedback: Preschoolers need to know when their parents will return as much as that is possible. Relating the response to an activity that the child will understand is appropriate. Being as specific as possible will help as well. The child cannot relate a time frame to "when they get off work." This child also will not understand 5:30 to 6:00 p.m. due to limited understanding of time concepts but will understand "suppertime." Giving the child no information will only increase anxiety. In a situation where the nurse does not know, phoning the parents might be beneficial.

A school nurse initiates an asthma action plan after checking a student's peak expiratory flow averages after three readings. Which peak expiratory flow average indicates that no action be taken? a. 35% b. 65% c. 85% d. 40%

Answer: c. 85% Feedback: A reading of 80% to 100% of peak expiratory flow is green, or best. A reading of 50% to 80% is yellow, or a warning. In order to prevent the symptoms from increasing, action must be taken. Less than 50% is red, or a warning. This emergency requires medical care.

In which child does the nurse anticipate a potential respiratory arrest following an assessment? a. A 5-month-old infant with RSV who is sleeping and has a respiratory rate of 24 b. A 2-year-old with epiglottitis who was intubated in the emergency department c. A 6-year-old with asthma who was previously wheezing and now has decreased breath sounds d. A 4-year-old, status post-tension pneumothorax from a motor vehicle accident with a chest tube in place, who complains of pain

Answer: c. A 6-year-old with asthma who was previously wheezing and now has decreased breath sounds Feedback: All of the children are acutely ill. A child with asthma who was wheezing and now has decreased breath sounds is acutely ill. This child's ability to move air is decreasing and is approaching respiratory arrest. Intubation protects the airway from closing in epiglottitis and a chest tube is the treatment for tension pneumothorax in a different room; therefore, these children are stable. The infant with RSV is sleeping with a normal respiratory rate, so there is no immediate danger here.

Which comments by the parents of a 7-year-old child with asthma indicate comprehension of instructions regarding medication use for control of the illness? a. The medications are too complicated for a 7-year-old to understand. b. If a spacer is used, a whistling sound indicates that the medication is being inhaled correctly. c. A spacer used on an inhaler helps trap the medication so it is inhaled more readily. d. Dry powder inhalers are for adult use only.

Answer: c. A spacer used on an inhaler helps trap the medication so it is inhaled more readily. Feedback: A 7-year-old is at an age when medication administration responsibility ought to be initiated. The spacer whistle is significant, although its significance varies with each type of spacer. Children may use dry powder inhalers when they are old enough to have a rapid inhalation.

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

Answer: c. Administer a dose of prescribed pain medication to the child. Feedback: The male client might be trying to be brave in front of the nurse. He also might be concerned about the consequences of stating that he has pain (i.e., IM injection). Unrelieved pain delays healing. The nurse should expect this child to have pain, because he has recently had surgery. Prompt administration of pain medication is the most appropriate initial action by the nurse. She should reassess the child within 30 minutes of administering pain medication. Although asking the mother to report further complaints of pain is an appropriate action, it is not the most appropriate initial action. The nurse should not confront the child about his pain rating.

Which intervention would the nurse include in the care of an infant following surgical repair of a cleft lip? a. Let the infant touch the suture lines as a means of self-comforting. b. Position the infant in the supine position for feedings to avoid aspiration. c. Administer pain medications as ordered. d. Use a special feeding device with shorter nipples.

Answer: c. Administer pain medications as ordered. Feedback: Special feeding devices with long nipples usually are used, and the infant is fed in the sitting position to avoid aspiration. Some soft restraints may be used to prevent the infant from touching the suture line.

The nurse in the primary care setting receives a call from a parent who reports that her 2-week-old infant is very fussy and is not feeding well. The nurse should: a. Advise the parent to hang up and dial 911. b. Instruct the parent to call back in 4 hours to update the nurse on the infant's condition. c. Arrange for the infant to be seen in the office promptly. d. Reassure the parent that this is normal behavior for the infant.

Answer: c. Arrange for the infant to be seen in the office promptly. Feedback: The nurse in the primary care setting must recognize that the infant might have a serious infection. While it is not an emergency at this point, the infant needs to be seen promptly.

A 2-month-old infant is hospitalized for surgical repair of a cleft lip and palate. What is the priority nursing intervention for this infant? a. Teach the parents to provide a safe home environment. b. Provide information about the recommended immunization schedule. c. Assess the parents for parental-infant bonding. d. Refer the family for enteral nutrition equipment.

Answer: c. Assess the parents for parental-infant bonding. Feedback: Parental bonding might be impaired in an infant with a facial defect. Teaching about safety and about recommended immunization schedules is done during well-child care visits; these are not priority nursing interventions at this time. Enteral nutrition equipment is not required for this infant.

The community health nurse has performed an assessment of an economically depressed neighborhood and recognizes that the area's children are exposed to several hazards. What should the nurse plan to do first? a. Plan a program that teaches parents about child safety. b. Refer children in the neighborhood for drug screening. c. Assess young children in the neighborhood for symptoms of lead poisoning. d. Ask the city council to provide a safe place for children to play.

Answer: c. Assess young children in the neighborhood for symptoms of lead poisoning. Feedback: Planning programs that teach about child safety and asking for a safe area for children to play are very important; however, the nurse's priority is to assess children for symptoms of lead poisoning first. Increased lead levels can lead to neurological damage. It is not appropriate to refer all children in the neighborhood for drug screening. The nurse must assess children first and then refer based on her findings.

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

Answer: c. Check the child's temperature. Feedback: The child's temperature will help the nurse decide whether the child has a mild or severe illness. Postponing the immunization might result in a missed opportunity if the parent does not keep the appointment. Missing school is not a contraindication for immunizations. The nurse should ask about previous reactions to immunizations, but this is not related to withholding the immunization because the child is not feeling well.

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

Answer: c. Obtain a prescription for EMLA or Ela-max from the primary healthcare provider and instruct the parents how and when to apply the medication. Feedback: EMLA and Ela-max are topical anesthetics that are appropriate to use to prevent or decrease pain associated with minor medical procedures. Parents can be taught how and when to apply the medication. Venipuncture is a painful procedure. Although therapeutic play can be a useful method to teach the child briefly about the procedure and to help relieve anxiety following the procedure, it will not actually decrease the discomfort that a child this age will experience from a needlestick.

While weighing a 12-month-old in the clinic, the nurse notes six nickel-sized bruises on the child's buttocks. The bruises range in color from purple to greenish-yellow. The nurse also notes a looped cord mark on the child's thigh. What is the priority action for the nurse to take in this situation? a. Inform the parents that she thinks the child has been abused. b. Document the assessment findings in detail. c. Report suspected child abuse to the appropriate authority. d. Do nothing, because these findings are normal for a child who is learning to walk.

Answer: c. Report suspected child abuse to the appropriate authority. Feedback: The multiple bruising on the buttocks and the looped cord mark are symptoms highly suspicious of physical abuse. In addition, bruises in different stages of healing might also be indicative of nonaccidental trauma. If the parents are informed of the nurse's suspicion, they might leave before further evaluation can be performed. Although detailed charting of the findings is essential and required, it is most imperative that suspected child abuse be reported to the appropriate authority in order to protect the child from further injury. A child who is learning to walk might have multiple bruises on the front of the legs but should not have them on his buttocks, nor should he have looped cord marks.

Nursing assessment of a school-age child reveals inflamed joints, rash on the trunk, and aimless movements of the extremities. The nurse recognizes these findings as characteristic of which cardiac disorder? a. Valvular insufficiency b. Infective endocarditis c. Rheumatic fever d. Kawasaki disease

Answer: c. Rheumatic fever Feedback: The manifestations noted are only signs of rheumatic fever.

A mother confides to the nurse that she gets so frustrated at times that she is afraid that she will hurt her child, who is challenged mentally and physically. Which nursing diagnosis is the most appropriate in this situation? a. Compromised Family Coping related to caregiver burnout b. Caregiver Role Strain related to child's chronic condition c. Risk for Impaired Parenting related to feelings of anxiety d. Fatigue related to excessive role demands in caring for child

Answer: c. Risk for Impaired Parenting related to feelings of anxiety Feedback: The mother states that she fears she will harm her child because she is frustrated, which is subjective data. She has not actually harmed the child; thus, she is at risk for harming the child. There are no subjective or objective data to support the other nursing diagnoses.

A child with cerebral palsy might be at high risk for neglect and abuse. Which nursing diagnoses address this risk? (Select all that apply.) a. Caregiver Role Strain related to continuous responsibilities for caring for child b. Ineffective Family Coping related to inadequate financial resources c. Risk of Parental Anxiety related to concerns of child's future d. Increased Parental Stress related to inadequate social support e. Risk of Impaired Parenting related to child's care requirements

Answer: c. Risk of Parental Anxiety related to concerns of child's future; e. Risk of Impaired Parenting related to child's care requirements Feedback: "Risk of/for" nursing diagnoses are those that might happen given the client's condition, medical diagnosis, and family circumstances. The other answers are actual nursing diagnoses that must be supported by objective or subjective data from a specific family situation.

11.The nurse is providing care for an 8-year-old hospitalized with a hernia. Which intervention is appropriate? a. Give the child a coloring book to help decrease anxiety. b. Explain the procedure to the child just before it is performed. c. Teach a stress-reduction technique. d. Allow the parent to be present for the procedure.

Answer: c. Teach a stress-reduction technique. Feedback: Prior to a hernia-repair procedure, the nurse should teach stress-reduction techniques such as deep breathing and visualization to the school-aged child. Coloring books before a procedure are good for preschoolers. The nurse should give explanations just before procedure to toddlers, since their concept of time is limited. Parents should be allowed the option of being present for procedures with infants.

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

Answer: c. The child reports a pain level of 0 on a 0-to-10 scale. Feedback: The child's pain rating is the best indicator of whether the delivery method for pain medication is effective. The absence of respiratory depression does not indicate that the child has pain relief. Pressing the button on a regular basis indicates that the child knows how to use the device but does not indicate how much pain the child has. Although napping might indicate some pain relief, it also might serve as a coping measure. In addition, if pain is well controlled, the child might be able to sleep for longer intervals.