Chapter 29: Health Promotion for the Infant, Child, and Adolescent, Ch 29: Health Promotion for the Infant, Child, and Adolescent, Ch 31: Care of the Child with a Physical Disorder, Ch 09: Life Span Development, Ch 30: Basic Pediatric Nursing Care, D...

The nurse is caring for a 5-year-old child who has been placed in traction after a fracture of the femur. Which is the most appropriate activity for this child?

A puzzle Rationale: In the preschooler, play is simple and imaginative, and it includes activities such as dressing up, paints, crayons, and simple board and card games. Puzzles are also appropriate and aid with fine motor development. Blocks are most appropriate for the toddler. A music video is most appropriate for the adolescent. Large picture books are most appropriate for the infant.

The parents of a 16 yo tell the nurse that they are concerned because the child sleeps until noon every weekend. Which is the most appropriate nursing response?

"Adolescents love to sleep late in the morning."

The parents of a 16-year-old child tell the nurse that they are concerned because the child sleeps until noon every weekend. Which is the most appropriate nursing response?

"Adolescents love to sleep late in the morning." Rationale: The sleep patterns of the adolescent vary some according to individual needs. However, in general, adolescents love to sleep late in the morning, but they should be encouraged to be responsible for waking themselves, particularly in time to get ready for school.

The nursing instructor asks a nursing student to describe the formal operations stage of Piaget's cognitive developmental theory. The appropriate response by the nursing student is which?

"The child has the ability to think abstractly."

The mother of a 4 yo who was recently hospitalized brings the child to the clinic for a follow-up visit. The mother tells the nurse that the child has begun to wet the bed & that it started when the child was brought home from the hospital. The mother is concerned & asks the nurse what to do. Which nursing response is appropriate?

"This is a normal occurrence following hospitalization."

794. A client is prescribed an eyedrop and an eye ointment for the right eye. How should the nurse best administer the medications? 1. Administer the eyedrop first, followed by the eye ointment. 2. Administer the eye ointment first, followed by the eyedrop. 3. Administer the eyedrop, wait 15 minutes, and administer the eye ointment. 4. Administer the eye ointment, wait 15 minutes, and administer the eyedrop.

1 When an eyedrop and an eye ointment are scheduled to be administered at the same time, the eyedrop is administered first. The instillation of two medications is separated by 3 to 5 minutes.

761. Bethanechol chloride is prescribed for a client with urinary retention. Which disorder would be a contraindication to the administration of this medication? 1. Gastric atony 2. Urinary strictures 3. Neurogenic atony 4. Gastroesophageal reflux

2 Bethanechol chloride (Urecholine) can be hazardous to clients with urinary tract obstruction or weakness of the bladder wall. The medication has the ability to contract the bladder and thereby increase pressure within the urinary tract. Elevation of pressure within the urinary tract could rupture the bladder in clients with these conditions.

The nurse prepares to take a BP on a school-age child. Where should the nurse place the blood pressure cuff to obtain an accurate measurement?

2/3 the distance between the antecubital fossa & the shoulder

The nurse is reinforcing instructions to a 16 yo male adolescent regarding dietary patterns. The nurse instructs the adolescent about the recommended amount of daily calories. How many calories a day does the nurse recommend as the approximate daily caloric allowance for a male adolescent?

2200

452. The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which should the nurse most likely expect to note? 1. Hematuria 2. Proteinuria 3. Bacteriuria 4. Glucosuria

3 Epispadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. The urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic facilitates entry of bacteria into the urine. Options 1, 2, and 4 are not characteristically noted in this condition.

793. The nurse is providing instructions to a client who will be self-administering eyedrops. To minimize systemic absorption of the eyedrops, the nurse should instruct the client to take which action? 1. Eat before instilling the drops. 2. Swallow several times after instilling the drops. 3. Blink vigorously to encourage tearing after instilling the drops. 4. Occlude the nasolacrimal duct with a finger after instilling the drops.

4 Applying pressure on the nasolacrimal duct prevents systemic absorption of the medication. Options 1, 2, and 3 will not prevent systemic absorption.

20. A 58-year-old male is concerned about some hearing loss he is experiencing. The nurse recognizes that this might be due to a sensory change of this age group known as: a. presbycusis. b. otitis externa. c. presbyopia. d. otitis media.

ANS: A Presbycusis is a normal age-related loss of hearing. REF: Page 206 TOP: Middle age

34. The nurse explains that for stability of the IV insertion site in an infant younger than 9 months of age, the insertion site is the: a. radial vein. b. scalp vein. c. femoral vein. d. brachial vein.

ANS: B A superficial scalp vein is the injection site for administering IV medication to infants younger than 9 months of age. REF: Page 975 TOP: IV medication

25. After feeding, the nurse should position the infant on the: a. stomach. b. right side. c. left side. d. back.

ANS: B After feeding, the infant is positioned on the right side to direct the food into the stomach. REF: Page 966 TOP: Feeding

48. The nurse instructs parents about the signs of otitis media, which include: a. earache, wheezing, vomiting. b. coughing, rhinorrhea, headache. c. fever, irritability, pulling on ear. d. wheezing, cough, drainage in ear canal.

ANS: C Clinical manifestations of otitis media include fever, irritability, and pulling on the ear. REF: Page 1058 TOP: Otitis media

45. A nurse assessing a 2-month-old infant expects the infant to: a. crawl on the floor. b. creep on the floor. c. sit up steadily without support. d. hold its head up while in the prone position.

ANS: D At 2 months the infant is able to hold the head up while in the prone position. Infants may crawl at 7 months and creep at about 9 months. By the end of the seventh month infants can sit up steadily without support. REF: Page 190 TOP: Growth and development

13. The nurse compresses the nailbed of a child who has just received an arm cast to assess: a. loss of sensation. b. impending edema. c. perception of pain. d. peripheral circulation.

ANS: D The blanch test is done by pressing down on the free edge of the nail and comparing the return of blood flow to assess for peripheral circulation. REF: Page 951 TOP: Circulation

31. The stage of family development that begins when the couple acknowledges to themselves and others that they are considering marriage is known as the: a. expectant stage. b. parenthood stage. c. establishment stage. d. engagement/commitment stage.

ANS: D The engagement/commitment stage begins when the couple acknowledges to themselves and others that they are considering marriage. At this time, opposition or support will be evident from friends and parents. Wedding plans must be arranged. Housing, work, and furnishings are some of the items discussed and explored. REF: Page 185 TOP: Family development

15. The cognitive developmental level of the adolescent according to Piaget is the: a. concrete operational stage. b. sensorimotor stage. c. preoperational stage. d. formal operational stage.

ANS: D The formal operational stage is the cognitive developmental level of adolescence. REF: Page 202 TOP: Cognitive development

2. The nurse discovers during the intake assessment of a 5-year-old child that he lives with his biological parents and siblings. The nurse categorizes this family type as a(n): a. extended family. b. blended family. c. social family. d. nuclear family.

ANS: D The nuclear family is considered the traditional family pattern. REF: Page 183 TOP: Family

20. The parents ask about preparation of their toddler for hospital admission. The nurse suggests the child be told: a. a week prior. b. 2 weeks prior. c. the day of admission. d. only two or three days before.

ANS: D The nurse should suggest the toddler be told only days before. REF: Page 959 TOP: Hospitalization

A nurse is evaluating the developmental level of a 2-year-old child. Which of the following does the nurse expect to observe in this child?

Answer: Holds a cup in one hand Rationale: By age 2 years, the child can hold a cup in one hand and use a spoon well.

A young adult college student begins to throw objects, shout insults, & stamp his feet after an instructor returned his work, noting it was substandard. Using Erikson's theory of personality development, which developmental stage has this individual unsuccessfully mastered?

Autonomy vs. shame & doubt

The nurse in the pediatric unit is admitting a 2 yo. The nurse plans care, knowing that the child is in which stage of Erikson's psychosocial stage of development?

Autonomy vs. shame & doubt

According to Kohlberg's theory of moral development, at the pre-conventional level, moral development is thought to be motivated by which factor?

Punishment & reward

The parent of a 3-year-old tells the nurse that the child is constantly rebelling and having temper tantrums. Which instruction should the nurse reinforce to the parent?

Set limits on the child's behavior. Rationale: According to Erikson, the child focuses on independence between the ages of 1 and 3 years. Gaining independence often means that the child has to rebel against the parents' wishes. Saying things like "no" and "mine" and having temper tantrums are common during this period of development. Being consistent and setting limits on the child's behavior are necessary elements. Punishing the child every time the child says "no" is likely to produce a negative response.

When reinforcing appropriate developmental skills interventions for a 1 yo who was born 2 mos premature, the nurse should plan to encourage the parents to support the child to achieve which developmentally appropriate goal?

Sit independently

The nurse assigned to care for an older adult client places an extra blanket in the client's room. The nurse understands that the older adult is less able to regulate hot and cold body changes because of alterations in the activity of which gland?

Sweat glands Rationale: Functions of the skin include protection, sensory reception, homeostasis, and temperature regulation. The skin helps regulate the body temperature in two ways, by dilation and constriction of blood vessels and by the activity of the sweat glands. As aging progresses, alterations in sweat gland activity make the glands less effective in temperature regulation, so the aging person is less able to regulate hot and cold body changes. The parotid glands are responsible for the drainage of saliva, which plays an important role in digestion. The pineal gland is a major site of melatonin biosynthesis. The thymus gland plays an immunological role throughout life.

The parents of a 2 yo arrive at the hospital to visit their child. The child is in the play room & ignores the parents during the visit. The nurse tells the parents that this behavior in a 2 yo indicates which?

The child is exhibiting a normal pattern

Birth

Hepatitis B

Kohlberg's theory

Kohlberg's theory states that individuals move through the six stages of development in a sequential fashion but that not everyone reaches stages 5 or 6 as part of their development of personal moralit

Which data would indicate a potential complication associated with age-related changes in the musculoskeletal system?

Overall sclerotic lesions Rationale: Sclerotic lesions occur as bone resorption increases and results in replacement of original bone with fibrous material. This condition occurs in Paget's disease, an age-related disorder.

A pediatric nurse is caring for a hospitalized toddler. The nurse determines that which play activity would be appropriate for the toddler?

Playing with a push-pull toy

Progesterone

Progesterone stimulates the secretions of the endometrial glands, causing endometrial vessels to become highly dilated and tortuous in preparation for possible embryo implantation.

The parents of an 8 yo tell the nurse that they are concerned about the child because the child seems to be more attentive to friends than anyone else. Which is the appropriate nursing response?

"At this age, the child is developing his or her own personality."

During a well-child checkup for a 4 mo old, the nurse reinforces instructing the mother how to introduce solid foods into her child's diet. Which statement indicates the mother needs further teaching?

"I will start giving home-prepared orange juice when my child is 3 mos old."

Which statement by a nursing student about Kohlberg's theory of moral development indicates the need for further teaching about the theory?

"Individuals move through all six stages in a sequential fashion." Rationale: Kohlberg's theory states that individuals move through the six stages of development in a sequential fashion but that not everyone reaches stages 5 or 6 as part of their development of personal morality. Options 2, 3, and 4 are correct statements regarding Kohlberg's theory.

The mother of a toddler tells the nurse that she has a difficult time getting the child to go to bed at night. The nurse should suggest which to the mother?

"Inform the child of bedtime a few minutes before it is time for bed."

The parent of a 4 yo expresses concern because her hospitalized child has started sucking his thumb. The mother states that this behavior began 2 days after hospital admission. Which is the appropriate nursing response?

"It is best to ignore the behavior."

The nurse is reinforcing instructions to the mother of a 2yo regarding dental care. Which statement by the mother indicates the need for further teaching?

"Proper dental care is not necessary for toddlers until their permanent teeth erupt."

When the nurse is collecting data from the older adult, which of the following findings would be considered normal physiological changes? Select all that apply.

- Decline in visual acuity - Increased susceptibility to urinary tract infections - Increased incidence of awakening after sleep onset

Which are components of Kohlberg's theory of moral development? Select all that apply.

- Moral development progresses in relation to cognitive development. - A person's ability to make moral judgments develops over a period of time. - The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. - In stage 2 (instrumental relativist orientation), the child conforms to rules to obtain rewards or to have favors returned.

Which interventions are appropriate for the care of an infant? Select all that apply.

- Provide swaddling - Hang mobiles with black-&-white contrast designs. - Caress the infant while bathing or during diaper changes.

767. The nurse is reviewing the laboratory results for a client receiving tacrolimus. Which laboratory result would indicate to the nurse that the client is experiencing an adverse effect of the medication? 1. Blood glucose of 200 mg/dL 2. Potassium level of 3.8 mEq/L 3. Platelet count of 300,000 cells/mm3 4. White blood cell count of 6000 cells/mm3

1 A blood glucose level of 200 mg/dL is significantly elevated above the normal range of 70 to 110 mg/dL and suggests an adverse effect. Other adverse effects include neurotoxicity evidenced by headache, tremor, and insomnia; gastrointestinal effects such as diarrhea, nausea, and vomiting; hypertension; and hyperkalemia.

15 months

15-18 mon = DTAP 12-15 mon = HIB, Pneumo, MMR, varicella 6-18 mon = IPV, HepB

In. polio (IPV)

1st dose = 2 months 2nd dose = 4 months 3rd dose = 6 - 18 months 4th dose = 4 - 6 years Contraindications - ABX allergy (neomycin, streptomycin, polymixinb) - Reaction to prior dose

Pneumo (PCV)

1st dose = 2 months 2nd dose = 4 months 3rd dose = 6 months 4th dose = 12 - 15 months Contraindications - Reaction to prior dose

DTAP

1st dose = 2 months 2nd dose = 4 months 3rd dose = 6 months 4th dose = 15 - 18 months 5th dose = 4-6 years Contraindications - Reaction to prior dose - Reaction to thimerosal (anti-fungus)

HIB: Haemophilus influenzae type B

1st dose = 2 months 2nd dose = 4 months 3rd or 4th dose = 12 - 15 months Contraindications - Reaction to prior dose

Hepatitis B vaccine

1st dose = birth 2nd dose = 1-2 months 3rd dose = 6 -18 months Contraindications - Yeast allergy - Previous rxn to prior dose

Hepatitis A

1st dose can be given at 12 months 2nd dose 6 - 18 months after first dose Contraindications - Any severe allergies including latex

419. After a tonsillectomy, the nurse reviews the health care provider's (HCP's) postoperative prescriptions. Which prescription should the nurse question? 1. Monitor for bleeding. 2. Suction every 2 hours. 3. Give no milk or milk products. 4. Give clear, cool liquids when awake and alert.

2 A tonsillectomy is the surgical removal of the tonsils. After tonsillectomy, suction equipment should be available, but suctioning is not performed unless there is an airway obstruction because of the risk of trauma to the surgical site. Monitoring for bleeding is an important nursing intervention after any type of surgery. Milk and milk products are avoided initially because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding. Clear, cool liquids are encouraged.

417. The nurse is reviewing the laboratory results for a child scheduled for tonsillectomy. The nurse determines that which laboratory value is most significant to review? 1. Creatinine level 2. Prothrombin time 3. Sedimentation rate 4. Blood urea nitrogen level

2 A tonsillectomy is the surgical removal of the tonsils. Because the tonsillar area is so vascular, postoperative bleeding is a concern. Prothrombin time, partial thromboplastin time, platelet count, hemoglobin and hematocrit, white blood cell count, and urinalysis are performed preoperatively. The prothrombin time results would identify a potential for bleeding. Creatinine level, sedimentation rate, and blood urea nitrogen would not determine the potential for bleeding.

418. The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position? 1. Supine 2. Side-lying 3. High Fowler's 4. Trendelenburg's

2 A tonsillectomy is the surgical removal of the tonsils. The child should be placed in a prone or side-lying position after the surgical procedure to facilitate drainage. Options 1, 3, and 4 would not achieve this goal.

414. After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial action? 1. Maintain NPO status. 2. Turn the child to the side. 3. Administer the prescribed antiemetic. 4. Notify the health care provider (HCP).

2 After tonsillectomy, if bleeding occurs, the nurse immediately turns the child to the side to prevent aspiration and then notifies the health care provider. NPO status would be maintained, and an antiemetic may be prescribed; however, the initial nursing action would be to turn the child to the side.

752. The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication? 1. Infection 2. Hyperglycemia 3. Hypophosphatemia 4. Disequilibrium syndrome

2 An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis.

415. The mother of a 6-year-old child arrives at a clinic because the child has been experiencing scratchy, red, and swollen eyes. The nurse notes a discharge from the eyes and sends a culture to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. On the basis of this diagnosis, the nurse determines that which requires further investigation? 1. Possible trauma 2. Possible sexual abuse 3. Presence of an allergy 4. Presence of a respiratory infection

2 Conjunctivitis is an inflammation of the conjunctiva. A diagnosis of chlamydial conjunctivitis in a child who is not sexually active should signal the health care provider to assess the child for possible sexual abuse. Trauma, allergy, and infection can cause conjunctivitis, but the causative organism is not likely to be Chlamydia.

798. In preparation for cataract surgery, the nurse is to administer cyclopentolate eyedrops. The nurse understands that which characterizes the medication action? 1. Produces miosis of the operative eye 2. Dilates the pupil of the operative eye 3. Constricts the pupil of the operative eye 4. Provides lubrication to the operative eye

2 Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication. Cyclopentolate is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis.

795. Which medication, if prescribed for the client with glaucoma, should the nurse question? 1. Betaxolol 2. Atropine sulfate 3. Pilocarpine hydrochloride 4. Pilocarpine

2 Options 1, 3, and 4 are miotic agents used to treat glaucoma. The correct option is a mydriatic and cycloplegic (also anticholinergic) medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye.

A LPN is assisting a high school nurse in conducting a session with female adolescents regarding the menstrual cycle. The LPN tells the adolescents that the normal duration of the menstrual cycle is about how many days?

28 days

The nurse is preparing to auscultate a client's abdomen for bowel sounds. The nurse listens for bowel sounds in which abdominal quadrant first? Refer to figure.

3 Rationale: When auscultating the abdomen, the nurse begins in the right lower quadrant (RLQ), in the ileocecal valve area, because bowel sounds are always present here normally. The nurse then proceeds to the other quadrants 1, 2, and 4.

765. The nurse is providing dietary instructions to a client who has been prescribed cyclosporine. Which food item should the nurse instruct the client to exclude from the diet? 1. Red meats 2. Orange juice 3. Grapefruit juice 4. Green leafy vegetables

3 A compound present in grapefruit juice inhibits metabolism of cyclosporine. As a result, consumption of grapefruit juice can raise cyclosporine levels by 50% to 100%, thereby greatly increasing the risk of toxicity.

749. A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 100.2° F. Which nursing action is most appropriate? 1. Encourage fluids. 2. Notify the health care provider. 3. Continue to monitor vital signs. 4. Monitor the site of the shunt for infection.

3 The client may have an elevated temperature following dialysis because the dialysis machine warms the blood slightly. Therefore it is not necessary to notify the health care provider. If the temperature is elevated excessively and remains elevated, sepsis would be suspected and a blood sample would be obtained as prescribed for culture and sensitivity determinations. Encouraging fluids is an unsafe action for a client with chronic kidney disease. Since an elevated temperature is expected following dialysis, monitoring the site for infection is unnecessary.

The nurse is caring for a 5 yo who has been placed in traction after a fracture of the femur. Which is the most appropriate activity for this child?

A puzzle

When caring for a 3 yo, the nurse should provide which toy for the child?

A wagon

18. The nurse selects which time as the best to administer the pancreatic enzyme replacement? a. Before meals and snacks b. Before bedtime c. Early in the morning d. After meals and snacks

ANS: A Pancreatic enzymes are administered before meals and snacks. REF: Page 1012 TOP: Cystic fibrosis

58. A child who uses senses and motor abilities to understand the world is displaying characteristics consistent with Piaget's: a. sensorimotor stage of cognitive development. b. preoperational stage of cognitive development. c. formal operational stage of cognitive development. d. concrete operational stage of cognitive development.

ANS: A Piaget's sensorimotor stage of cognitive development uses senses and motor abilities to understand the world; this period begins with reflexes and coordinates sensorimotor skills. REF: Page 188, Box 9-6 TOP: Piaget

19. A 53-year-old woman complains of night sweats and mood swings. The nurse recognizes that these symptoms most likely relate to: a. menopause. b. weight problems. c. dietary problems. d. thyroid problems.

ANS: A Signs and symptoms of menopause may include sweats and mood swings. REF: Page 207 TOP: Menopause

24. The school nurse collaborates with the physical education instructor to increase the amount of physical activity during the school day because of which major benefits of physical activity? (Select all that apply.) a. Reduced death rates as adults. b. Reduced risk of cardiovascular disease. c. Reduced risk of hypertension. d. Reduced risk of diabetes. e. Increased self-esteem.

ANS: A, B, C, D, E All options are benefits of regular physical activity. REF: Page 927 TOP: Benefits of physical exercise

64. Separation anxiety includes which stage(s)? (Select all that apply.) a. Detachment b. Protest c. Anger d. Despair e. Withdrawal

ANS: A, B, D The phases of separation anxiety are protest, despair, and detachment. REF: Page 191 TOP: Separation anxiety

28. The family pattern in which the male usually assumes the dominant role and functions in the work role, controls the finances, and makes most decisions is known as the: a. autocratic family pattern. b. patriarchal family pattern. c. matriarchal family pattern. d. democratic family pattern.

ANS: B In the patriarchal family pattern the male usually assumes the dominant role. The male member functions in the work role, is responsible for control of finances, and makes most decisions. REF: Page 184

35. Following a lumbar puncture of a 2-year-old, the nurse: a. keeps the child flat for several hours. b. allows the child to play at will. c. holds the child in a flexed position for 5 minutes. d. stands the child upright immediately.

ANS: B Children younger than 3 years of age are usually not affected by post-lumbar headache. These children are allowed to play at will following a lumbar puncture. REF: Page 970 TOP: Lumbar puncture

16. The nurse performing a physical assessment on a 25-year-old understands that during this time the patient is most likely experiencing: a. a gradual decline in physical capabilities. b. optimal level of functioning. c. slight diminishing of visual acuity. d. minimal hearing loss.

ANS: B During early adult years, the body is at an optimal level of functioning. REF: Page 204 TOP: Early adulthood

63. According to Erikson, an infant who was abandoned by his or her primary caregiver is at risk for developing a sense of: a. guilt. b. mistrust. c. isolation. d. confusion.

ANS: B During infancy a child's developmental task is basic trust versus mistrust. REF: Page 187, Table 9-2 TOP: Erikson

13. The mother of an 11-year-old asks about the benefits of her child joining a soccer team. At this age, the child will benefit because athletics provide an opportunity for the development of: a. role identification. b. competition. c. parallel play. d. cooperation.

ANS: B During school years, children become involved in competitive sports that support their drive for industry. REF: Page 200 TOP: Development

44. The mother brings the child to the nurse because of exposure to varicella. The nurse explains that early signs of the disease are: a. high fever over 101° F. b. general malaise. c. increased appetite. d. crusty sores.

ANS: B Early signs of varicella will develop during the prodromal period and are mainly low- grade fever, malaise, and anorexia. Lesions do not appear until later. REF: Page 1059, Table 31-7 TOP: Skin disorders

40. A nurse is caring for a neonate who is 22 inches in height. The nurse explains to the neonate's mother that by 1 year, the infant's expected height will be: a. 29 inches. b. 33 inches. c. 44 inches. d. 56 inches.

ANS: B Height increases by about 1 inch per month for the first 6 months. By 12 months of age the infant's birth length has increased about 50%. REF: Page 189 TOP: Growth and development

12. The nurse teaches the parents of a child with acute epiglottitis that the child could suddenly suffer: a. increased carbon dioxide levels. b. airway obstruction. c. inability to swallow. d. bronchial collapse.

ANS: B Immediate treatment of acute epiglottitis includes an artificial airway. REF: Page 1009 TOP: Epiglottis

17. Erikson identifies intimacy as a developmental task of adulthood. If this task is not accomplished, the outcome will be: a. inferiority. b. isolation. c. mistrust. d. guilt.

ANS: B Intimacy versus isolation is a developmental task of adulthood. REF: Page 205 TOP: Erikson

2. Lillian Wald, a social reformer at the turn of the 20th century, founded the: a. National Commission on Children. b. Henry Street Settlement. c. White House Conference. d. U.S. Children's Bureau.

ANS: B Lillian Wald, regarded as the founder of public health, founded Henry Street Settlement, which provided nursing services and social assistance. REF: Page 942 TOP: Lillian Wald

15. The school nurse recognizes that lack of physical activity and increased consumption of fast food by children are causative factors contributing to the problem of: a. nutritional disorders. b. weight gain. c. type I diabetes. d. dental caries.

ANS: B Many factors have contributed to the excess weight carried by children, including lack of physical activity and increased consumption of fast food. REF: Pages 927-928 TOP: Obesity

6. The parents of a child diagnosed with sickle cell anemia ask what to do to avoid a sickle cell crisis. The nurse explains that the medical management of sickle cell crisis includes: a. information for the parents including home care. b. providing adequate hydration and pain management. c. pain management and administration of iron supplements. d. adequate oxygenation and factor VIII.

ANS: B Medical management of sickle cell crisis includes palliative analgesics, hydration, and oxygen. REF: Page 994 TOP: Blood disorders

12. A 5-year-old who has an imaginary friend with whom he converses frequently is displaying characteristics consistent with Piaget's: a. operational stage. b. preoperational stage. c. formal operations stage. d. concrete operations stage.

ANS: B Piaget's preoperational stage describes the preschooler as imaginative and egocentric, believing in magical thinking. REF: Page 194 TOP: Development

7. When a mother asks the nurse about introducing solid foods into the child's diet, the nurse's best advice is to introduce: a. meat first. b. one solid food at a time several days apart. c. solid foods by mixing two or three foods together. d. solid foods by adding strained food to the infant's bottle.

ANS: B The best advice is to introduce one solid at a time allowing several days between. REF: Page 191 TOP: Nutrition

29. When suctioning to remove secretions from an artificial airway, the nurse should limit the suction time to: a. 1 minute. b. 5 seconds. c. 10 seconds. d. 15 seconds.

ANS: B The nurse should limit suctioning to no more than 5 seconds. REF: Page 972 TOP: Tracheal suction

43. A nurse understands that the average apical rate for a 2-month-old is approximately: a. 100 beats per minute. b. 110 beats per minute. c. 120 beats per minute. d. 130 beats per minute.

ANS: C At 2 months, the average apical rate is about 120 beats per minute. REF: Page 189 TOP: Growth and development

11. A pediatric nurse reminds parents of their responsibility in reducing the number of accidents involving children by consistently practicing: a. child awareness. b. good manners. c. anticipatory guidance. d. strict discipline.

ANS: C Anticipatory guidance has been the most widely used approach to educating parents in accident prevention. REF: Page 936 TOP: Injury prevention

14. A 14-year-old male patient has undergone a leg amputation. The nurse makes the focus of the nursing care plan to support the patient's: a. nutritional status. b. academic progress. c. body image. d. socialization needs.

ANS: C Body image and role identity are the major developmental tasks of the adolescent. REF: Page 202 TOP: Adolescent Step: Planning

3. The nurse instructs the family of a newborn 7-lb. baby that the anticipated weight at 1 year of age would be: a. 14 lbs. b. 17 lbs. c. 21 lbs. d. 25 lbs.

ANS: C By 1 year, birth weight is expected to triple. REF: Page 189 TOP: Growth

41. A nurse understands that the typical height for a 12-month-old is: a. 20 inches. b. 25 inches. c. 30 inches. d. 35 inches.

ANS: C By 12 months of age the infant's birth length has increased about 50%; the typical length is 30 inches. REF: Page 189 TOP: Growth and development

39. A nurse is caring for a neonate who weighs 7 pounds 3 ounces at birth. The nurse explains to the neonate's mother that by 1 year, the infant's expected weight will be: a. 10 pounds 3 ounces. b. 14 pounds 6 ounces. c. 21 pounds 9 ounces. d. 28 pounds 12 ounces.

ANS: C By the time the baby is 1 year of age, the birth weight has tripled. REF: Page 189 TOP: Growth and development

48. A nurse instructing the mother of a young infant about how to introduce solid foods into the infant's diet should instruct the mother to begin with: a. meats. b. fruits. c. cereals. d. vegetables.

ANS: C Cereals should be introduced first, followed by fruits and vegetables, and last meats. REF: Page 191 TOP: Diet

1. The nurse stresses that regular physical activity has been identified as a leading health indicator. Regular physical activity has which positive effect on children? a. Improves social skills b. Reduces fluid retention c. Increases bone and muscle strength d. Increases attention span

ANS: C In children, regular physical activity increases bone and muscle strength. PTS: 1 DIF: Cognitive Level: Application REF: Page 920 OBJ: 2 TOP: Physical activity KEY: Nursing Process Step: Implementation

29. The family pattern in which the female assumes primary dominance in areas of child care and homemaking as well as financial decision making is known as the: a. autocratic family pattern. b. patriarchal family pattern. c. matriarchal family pattern. d. democratic family pattern.

ANS: C In the matriarchal family pattern the female assumes primary dominance in areas of child care and homemaking, as well as financial decision making. REF: Page 184

21. When discussing long-term complications of a child with cleft lip and palate, the nurse tells the parents that one of the complications is: a. cognitive impairment. b. altered growth and development. c. faulty dentition. d. physical abilities.

ANS: C The older child with cleft lip and palate may experience psychologic difficulties because of the cosmetic appearance of the defect, problems with impaired speech, and faulty dentition. REF: Page 1016 TOP: Cleft lip and palate

31. The nurse recognizes that getting the hospitalized child to eat adequate amounts of food can be a challenge. One way to enhance nutrition is to: a. reward with sweets for eating meals. b. discourage participation in noneating activities. c. administer large amounts of nutritious fluids. d. leave nutritious finger foods out for the child to eat.

ANS: C Using nutritious liquids may satisfy the nutritional needs when a toddler is "too busy" to eat. Toddlers should not be left to eat unsupervised because of the danger of aspiration. REF: Page 966 TOP: Nutrition

11. Obtaining the respirations of an infant requires a modified approach from that of an adult because: a. infants breathe through their noses. b. infants have very rapid respirations. c. infants' respirations are thoracic in nature. d. infants' respiratory movements are abdominal.

ANS: D In children under 6 or 7 years of age, respiratory movements are abdominal. REF: Page 950 TOP: Vital signs

14. The nurse sets up a sample physical activities schedule to fit the FDA's Dietary Guidelines for Americans that recommends that children get at least how many minutes of physical activity per day? a. 15 b. 30 c. 45 d. 60

ANS: D The Dietary Guidelines for Americans recommend that children get at least 60 minutes of physical activity per day. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 921 OBJ: 2 TOP: Physical activity KEY: Nursing Process Step: Implementation

16. The nurse sets up a sample physical activities schedule to fit the FDA's Dietary Guidelines for Americans that recommends that children get at least how many minutes of physical activity per day? a. 15 b. 30 c. 45 d. 60

ANS: D The Dietary Guidelines for Americans recommend that children get at least 60 minutes of physical activity per day. REF: Page 929 TOP: Physical activity

10. When a toddler attempts to feed himself, the family should: a. encourage the child to use a fork. b. feed the child themselves using a fork. c. encourage large portions for easier handling. d. offer the child finger foods.

ANS: D Toddlers need to develop autonomy and do things for themselves in a trial-and-error method. REF: Page 194 TOP: Development

The nurse caring for an adolescent client recently diagnosed with bone cancer is monitoring the client for depression. To best recognize these symptoms in the adolescent, which characteristic should the nurse recall about adolescents?

Adolescents like to stay up late but rarely have insomnia

A mother of a 5 yo tells the nurse that the child scolds the floor or table if the child hurts herself on the object. According to Piaget's theory of cognitive development, which behavior is this known as?

Animism

When caring for a 3-year-old child, the nurse should provide which toy for this child?

Answer: A wagon Rationale: Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, trucks, and dolls are some appropriate toys.

A nurse is caring for a 6-month-old infant. Which of the following should the nurse expect to note in this infant?

Answer: Babbles using single consonants Rationale: Using single-consonant babbling occurs between 6 and 8 months. Between 8 and 9 months the infant begins to understand and obey simple commands such as "wave bye-bye." Simple words as "Mama" and the use of gestures to communicate begin between 9 and 12 months.

A nurse-midwife is conducting a session on the process of fertilization with a group of nursing students. The nurse-midwife asks a nursing student to identify the structure in which fertilization of an ovum takes place. The student answers correctly by identifying which location?

Answer: Fallopian tube Rationale: The fallopian tubes are a pathway for the ovum between the ovary and the uterus. Fertilization occurs in the fallopian tube.

A client who has been seen in the clinic has been diagnosed with endometriosis and asks the nurse to describe this condition. The nurse bases the response on which of the following?

Answer: It is the presence of tissue outside the uterus that resembles the endometrium. Rationale: Endometriosis is defined as the presence of tissue outside the uterus that resembles the endometrium in structure and function. The response of this tissue to the stimulation of estrogen and progesterone during the menstrual cycle is identical to that of the endometrium.

A nurse caring for an adolescent client recently diagnosed with bone cancer is monitoring the client for depression. To best recognize these symptoms in the adolescent, the nurse should recall that adolescents:

Answer: Like to stay up late but rarely have insomnia Rationale: The signs of depression include crying spells, insomnia, eating disorders, social isolation and withdrawal, serious acting-out behavior, feelings of hopelessness, unexplained physical symptoms, loss of interest in appearance, and giving away things or possessions.

A nursing instructor has taught a lecture on the reproductive cycle of the female and asks a nursing student to identify the anatomical structure that supports and protects the internal reproductive organs. The student correctly responds by identifying which structure?

Answer: Pelvis Rationale: The pelvis is a bony structure that supports and protects the lower abdominal and internal reproductive organs.

A nurse is caring for a 5-year-old child who has been placed in traction after a fracture of the femur. Which of the following is the most appropriate activity for this child?

Answer: A puzzle Rationale: In the preschooler, play is simple and imaginative, and it includes activities such as dressing up, paints, crayons, and simple board and card games.

The nurse should implement which activity to promote reminiscence among older clients?

Answer: Having storytelling hours Rationale: Clients who like to retell stories or to describe past events need to be provided with the opportunity to do so. This phenomenon is called life review or reminiscence.

A client with sickle cell anemia has vaso-occlusive pain. After noting that the client is of preschool age, the nurse plans to use which method to determine the adequacy of pain control?

Ask the client to point to faces (smiling to very sad) that best describe the pain.

Autonomy vs. shame and doubt

Autonomy vs. shame and doubt occurs during toddlerhood (early childhood, 18 months to 3 years).

The nurse is caring for a 6 mo old. Which developmental ability should the nurse expect to note in this infant?

Babbles using single consonants

The nurse employed in a well-baby clinic is collecting data on the language & communication developmental milestones of a 4 mo old. Based on the age of the infant, the nurse expects to note which highest level of developmental milestones?

Babbling sounds

The nursing student is preparing a conference on Freud's psychosexual stages of development, specifically the anal stage. Which appropriately relates to this stage?

Beginning of toilet training

Which car safety device should be used for a child who is 8 yo & is 4 feet tall?

Booster seat

Influenza

Can start giving annually after 6 months Contraindications - Pregnant - Egg allergy - GBS

Which describes Lawrence Kohlberg's first level of moral development?

Children determine the goodness or badness of an action in terms of the consequences.

According to Sigmund Freud's theory of personality development, which statement best describes the phallic stage?

Children recognize differences between males & females.

When the nurse is collecting data from the older adult, which findings should be considered normal physiological changes? Select all that apply.

Decline in visual acuity Increased susceptibility to urinary tract infections Increased incidence of awakening after sleep onset

An older client has been prescribed digoxin (Lanoxin). The nurse understands that which age-related change would place the client at risk for digoxin toxicity?

Decreased lean body mass and glomerular filtration rate Rationale: The older client is at risk for medication toxicity because of decreased lean body mass and an age-associated decreased glomerular filtration rate.

6 months

Dtap, HIB, IPV (6-18 mon), HepB (6-18 mon), Pneumo, Rota, influenza

2 months

Dtap, HIB, IPV, HepB (1-2 mon), Pneumo, Rota

4 months

Dtap, HIB, IPV, Pneumo, Rota

4-6 years

Dtap, IPV, MMR, varicella

initiative vs. guilt

Erikson's psychosocial stage of initiative vs. guilt occurs in late childhood (3 to 6 years). PRE-SCHOOL AGE

While collecting data related to the cardiac system on a client diagnosed with an incompetent heart valve, the nurse auscultates a murmur. Which best describes the sound of a heart murmur?

Gentle, blowing or swooshing noise Rationale: A heart murmur is an abnormal heart sound and is described as a gentle, blowing, swooshing sound. Lubb-dubb sounds are normal and represent the S1 (first heart sound) and S2 (second heart sound), respectively. A pericardial friction rub is described as a scratchy, leathery heart sound. A click is described as an abrupt, high-pitched snapping sound.

A 4 yo is reluctant to take deep breaths following abdominal surgery. Which measure would be effective to encourage deep breathing?

Have the child pretend to be a big bad wolf blowing the little pig's house down.

The nurse should implement which activity to promote reminiscence among older clients?

Having storytelling hours Rationale: Clients who like to retell stories or to describe past events need to be provided with the opportunity to do so. This phenomenon is called life review or reminiscence. In a sense, it is a way for the older client to relive and restructure life experiences, and it is a part of achieving ego identity.

12 months

HepA (given in 2 doses 6 months apart) 12-15 mon = HIB, Pneumo, MMR, varicella 6-18 mon = IPV, HepB

Industry vs. inferiority

Industry vs. inferiority occurs during SCHOOL-AGE years (6 to 12 years).

According to Erik Erikson's psychosocial developmental theory, the nurse should anticipate a 5 yoto be in which stage?

Initiative vs. guilt

The nurse is preparing to perform an abdominal examination. The initial step should be which?

Inspection Rationale: The appropriate technique for abdominal examination is inspection, auscultation, percussion, and palpation. Auscultation is performed after inspection and before percussion and palpation to ensure that the motility of the bowel and bowel sounds are not altered. The sequence of maneuvers is inspect, auscultate, percuss, and palpate.

The nurse is caring for an older client who is terminally ill. Which signs indicate to the nurse that death may be imminent?

Irregular, noisy breathing and cold, clammy skin Rationale: The clinical signs of impending or approaching death include inability to swallow; pitting edema; decreased gastrointestinal and urinary tract activity; bowel and bladder incontinence; loss of motion, sensation, and reflexes; cold or clammy skin; cyanosis; lowered blood pressure; noisy or irregular respiration; and Cheyne-Stokes respirations.

Mittelschmerz

Mittelschmerz (middle pain) refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation.

Which toy is age-appropriate for a 1 mo old?

Nursery mobile

According to Kohlberg's theory of moral development, at the preconventional level, moral development is thought to be motivated by which factor?

Punishment and reward Rationale: In the preconventional level, morals are thought to be motivated by punishment and reward. If the child is obedient and not punished, then he or she is being moral. The child sees actions as either good or bad. If the child's actions are good, then the child is praised. If the child's actions are bad, then the child is punished.

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On data collection of the client, the nurse expects to note which finding?

Rhythmic respirations with periods of apnea Rationale: Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular, rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.

Which developmental stage is Jean Piaget's 1st stage of cognitive development?

Sensorimotor

The parent of a 3 yo tells the nurse that the child is constantly rebelling & having temper tantrums. Which instruction should the nurse reinforce to the parent?

Set limits on the child's behavior

A nurse is reviewing the health record of a client who is suspected of having mittelschmerz. Which of the following should the nurse expect to note documented in the client's record?

Sharp pain located on the right side of the pelvis

The nurse is caring for a hospitalized 5 yo. The nurse should recognize that which is normal for this child in this developmental stage?

The child demonstrates egocentrism

The nurse is collecting data regarding the motor development of a 24 mo old. Based on the age of the child, the nurse expects to note which highest level of developmental milestone?

The child uses a doorknob to open a door

Function of the ovaries

The functions of the ovaries include sex hormone production and maturation of an ovum during each reproductive cycle.

The nurse is employed in a NB nursery. The nurse is aware that medication toxicity is more likely to occur in the neonate than in an adult because of which physiologic difference?

The liver is immature

Trust vs. mistrust characterizes

Trust vs. mistrust characterizes the stage of infancy

The nurse is providing an education class to healthy older adults. Which exercise will best promote health maintenance?

Walking three to five times a week for 30 minutes Rationale: Exercise and activity are essential for health promotion and maintenance in the older adult and for achieving an optimal level of functioning. Approximately half of the physical deterioration of the older client is caused by disuse rather than by the aging process or disease. One of the best exercises for an older adult is walking, with the goal of progressing to 30-minute sessions three to five times each week. Swimming and dancing are also beneficial.

The nurse provides instructions to a parent of a toddler experiencing physiological anorexia. The nurse determines the need for further teaching if the parent makes which statement?

"I should feed my child if she will not eat."

The nurse has reinforced information to the mother of a toddler regarding toilet training. Which statement by the mother would indicate a need for further teaching?

"I should have my child sit on the potty until my child urinates."

The nursing instructor asks a nursing student to describe the formal operations stage of Piaget's cognitive developmental theory. The appropriate response by the nursing student is which?

"The child has the ability to think abstractly." Rationale: In the formal operations stage, the child has the ability to think abstractly and solve problems.

A nursing student is assigned to care for a hospitalized 2yo. The nursing instructor reviews the plan of care with the student & asks the student to identify the expected behavior of the child in regard to separation anxiety. Which statement by the student indicates an understanding of separation anxiety that can occur in a 2yo?

"The child may ignore the parents when they visit."

The parents of a 4 yo tell the nurse that they are concerned because the child has been masturbating. Which is the appropriate response by the nurse?

"This is a normal behavior at this age."

The parents of a 4-year-old child tell the nurse that they are concerned because the child has been masturbating. Which is the appropriate response by the nurse?

"This is a normal behavior at this age." Rationale: According to Freud's psychosexual stages of development, the child is in the phallic stage between the ages of 3 and 6 years. At this time, the child devotes much energy to examining his or her genitalia, masturbating, and expressing interest in sexual concerns.

The mother of a 2 yo asks the nurse if it is all right to give the child a bottle at naptime. Which response by the nurse is appropriate?

"You may give the child a bottle if necessary, but if you do, it should contain water."

A mother of a 3 yo is concerned because the child is still insisting on a bottle at nap time & at bedtime. The nurse should make which suggestion to the mother?

"Allow the bottle if it contains water."

The parents of an 8-year-old child tell the nurse that they are concerned about the child because the child seems to be more attentive to friends than anyone else. Which is the appropriate nursing response?

"At this age, the child is developing his or her own personality." Rationale: According to Erikson, at ages 7 to 12 years, the child begins to move toward receiving support from peers and friends and away from that of parents. The child also begins to develop special interests that reflect his or her own developing personality instead of those of the parents. Therefore, the other options identify incorrect responses.

During a well-child visit a mother states she is frustrated with her 2 yo. Whenever she asks him if he wants something to eat, he says, "No," but then he starts to cry when she does not give him the food. Which statement by the nurse would indicate an understanding of psychosocial concepts related to growth & development of the toddler?

"Your toddler is asserting his independence as he is progressing through the stage of autonomy versus shame & doubt."

The nurse is checking a dark-skinned client for the presence of petechiae. Which body area is best for the nurse to check in this client?

Oral mucosa Rationale: In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa. Cyanosis is best noted on the palms of the hands and soles of the feet. Jaundice would best be noted in the sclera of the eye.

The nurse is performing a safety assessment in the home of a mother with 2 children. The ages of the children are 1 & 3 yrs. Which observation noted during the assessment would present the greatest hazard to the children?

Toys with small loose parts in the playroom

A mother of a 5-year-old child tells the nurse that the child scolds the floor or table if the child hurts herself on the object. According to Piaget's theory of cognitive development, this behavior is identified as:

Answer: Animism Rationale: Animism means that all inanimate objects are given living meaning. Object permanence, the realization that something out of sight still exists, occurs in the later stages of the sensorimotor stage of development.

Upon palpation of the fontanel of a 3-month-old newborn, the nurse notes that the anterior fontanel has not closed and is soft and flat. Which action should the nurse take?

Document the findings. Rationale: The anterior fontanel is diamond shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. The posterior fontanel closes by 2 to 3 months of age. Therefore, because the findings are normal, the nurse should document the findings.

The nurse is assessing the pain in a 3 yo after an appendectomy. Which pain scale should the nurse use?

FACES pain rating scale

The nurse is evaluating the developmental level of a 2 yo. Which should the nurse expect to observe in this child?

Holds a cup in one hand

According to Erik Erikson's psychosocial developmental theory, the nurse should anticipate an adolescent to be in which stage?

Identity vs. role confusion

A nurse has provided information to the mother of a toddler regarding toilet training. Which statement by the mother would indicate a need for further instructions?

"I should have my child sit on the potty until my child urinates." Rationale: The mother should wait until the child is 24 to 30 months old because this makes the task of toilet training considerably easier. Toddlers of this age are less negative and usually are more willing to control their sphincters to please their parents.

Which statement by a nursing student about Kohlberg's theory of moral development indicates the need for further teaching about the theory?

"Individuals move through all 6 stages in a sequential fashion."

The parent of a 4-year-old child expresses concern because her hospitalized child has started sucking his thumb. The mother states that this behavior began 2 days after hospital admission. Which is the appropriate nursing response?

"It is best to ignore the behavior." Rationale: In the hospitalized preschooler, it is best to accept regression if it occurs, because it is most often caused by the stress of the hospitalization. Parents may be overly concerned about regression and should be told that their child may continue the behavior at home.

An older client confides to the visiting nurse the fear of falling while going to the bathroom at night. Which statement indicates an understanding of the visual changes affecting the older client?

"Keep a red light on in the bathroom at night." Rationale: Because it takes longer to adapt to changes from dark to light and vice versa, older people are at greater risk for falls and injuries. Any place where there is a sudden change from dark to light or from light to dark can be dangerous. Getting up during the night is hazardous for an older client. Eyes adapt to the dark by using the rod receptors, which are sensitive to short blue-green wavelengths. Red wavelengths are longer and are perceived by the cones. Thus, a red light in the bathroom at night allows for adequate vision to function in the dark without the need for adaptation.

A nurse provides information to the mother of a toddler regarding toilet-training. The nurse should tell the mother which of the following? Select all that apply.

- "The child should not be forced to sit on the potty for long periods." - "The ability of the child to remove clothing is a sign of physical readiness." - "Waiting until the child is 24 to 30 months old makes the task considerably easier." - "At the age of 24 to 30 months old, the toddler is usually less negative and more willing to control their sphincters to please their parents." Rationale: Waiting until the child is 24 to 30 months old makes the task considerably easier because toddlers of this age are less negative and usually more willing to control their sphincters to please their parents.

The nurse provides information to the mother of a toddler regarding toilet-training. The nurse should tell the mother what information? Select all that apply.

- "The child should not be forced to sit on the potty for long periods." - "The ability of the child to remove clothing is a sign of physical readiness." - "Waiting until the child is 24-30 mos old makes the task considerably easier." - "At the age of 24-30 mos old, the toddler is usually less negative & more willing to control their sphincters to please their parents."

Which of the following are components of Kohlberg's theory of moral development? Select all that apply.

- Moral development progresses in relation to cognitive development. - A person's ability to make moral judgments develops over a period of time. -The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. -In stage 2 (instrumental relativist orientation), the child conforms to rules to obtain rewards or to have favors returned.

Select the interventions that are appropriate for the care of an infant

- Provide swaddling. - Hang mobiles with black-and-white contrast designs. - Caress the infant while bathing or during diaper changes.

421. Antibiotics are prescribed for a child with otitis media who underwent a myringotomy with insertion of tympanostomy tubes. The nurse provides discharge instructions to the parents regarding the administration of the antibiotics. Which statement, if made by the parents, indicates understanding of the instructions provided? 1. "Administer the antibiotics until they are gone." 2. "Administer the antibiotics if the child has a fever." 3. "Administer the antibiotics until the child feels better." 4. "Begin to taper the antibiotics after 3 days of a full course."

1 A myringotomy is the insertion of tympanoplasty tubes into the middle ear to promote drainage of purulent middle ear fluid, equalize pressure, and keep the ear aerated. The nurse must instruct parents regarding the administration of antibiotics. Antibiotics need to be taken as prescribed, and the full course needs to be completed. Options 2, 3, and 4 are incorrect. Antibiotics are not tapered, but are administered for the full course of therapy.

420. The nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which finding indicates the child is bleeding? 1. Frequent swallowing 2. A decreased pulse rate 3. Complaints of discomfort 4. An elevation in blood pressure

1 A tonsillectomy is the surgical removal of the tonsils. Frequent swallowing, restlessness, a fast and thready pulse, and vomiting bright red blood are signs of bleeding. An elevated blood pressure and complaints of discomfort are not indications of bleeding.

753. A week after kidney transplantation, a client develops a temperature of 101° F, the blood pressure is elevated, and the kidney is tender. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse suspects which complication? 1. Acute rejection 2. Kidney infection 3. Chronic rejection 4. Kidney obstruction

1 Acute rejection most often occurs in the first 2 weeks after transplantation. Clinical manifestations include fever, malaise, elevated white blood cell count, acute hypertension, graft tenderness, and manifestations of deteriorating renal function. Chronic rejection occurs gradually over a period of months to years. Although kidney infection or obstruction can occur, the symptoms presented in the question do not relate specifically to these disorders.

792. The nurse prepares a client for an ear irrigation as prescribed by the health care provider. Which action should the nurse take when performing the procedure? 1. Warm the irrigating solution to 98.6° F. 2. Position the client with the affected side up following the irrigation. 3. Direct a slow steady stream of irrigation solution toward the eardrum. 4. Assist the client to turn his or her head so that the ear to be irrigated is facing upward.

1 Before ear irrigation, the nurse should inspect the tympanic membrane to ensure that it is intact. The irrigating solution should be warmed to 98.6 ° F because a solution temperature that is not close to the client's body temperature will cause ear injury, nausea, and vertigo. The affected side should be down following the irrigation to assist in drainage of the fluid. When irrigating, a direct and slow steady stream of irrigation solution is directed toward the wall of the canal, not toward the eardrum. The client is positioned sitting, facing forward with the head in a natural position; if the ear is faced upward, the nurse would not be able to visualize the canal.

770. A client with a urinary tract infection is receiving ciprofloxacin by the intravenous (IV) route. The nurse appropriately administers the medication by performing which action? 1. Infusing slowly over 60 minutes. 2. Infusing in a light-protective bag. 3. Infusing only through a central line. 4. Infusing rapidly as a direct intravenous push medication.

1 Ciprofloxacin (Cipro) is prescribed for treatment of mild, moderate, severe, and complicated infections of the urinary tract, lower respiratory tract, and skin and skin structure. A single dose is administered slowly over 60 minutes to minimize discomfort and vein irritation. Other solutions infusing at the same site need to be temporarily discontinued while the ciprofloxacin is infusing.

769. A client with chronic kidney disease is receiving epoetin alfa. Which laboratory result would indicate a therapeutic effect of the medication? 1. Hematocrit of 32% 2. Platelet count of 400,000 cells/mm3 3. Blood urea nitrogen level of 15 mg/dL 4. White blood cell count of 6000 cells/mm3

1 Epoetin alfa is used to reverse anemia associated with chronic kidney disease. Therapeutic effect is seen when the hematocrit is between 30% and 33%. Options 2, 3, and 4 are not associated with the action of this medication.

446. The nurse is planning care for a child with hemolytic-uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to implement which measure? 1. Restrict fluids as prescribed. 2. Care for the arteriovenous fistula. 3. Encourage foods high in potassium. 4. Administer analgesics as prescribed.

1 Hemolytic-uremic syndrome is thought to be associated with bacterial toxins, chemicals, and viruses that result in acute kidney injury in children. Clinical manifestations of the disease include acquired hemolytic anemia, thrombocytopenia, renal injury, and central nervous system symptoms. A child with hemolytic-uremic syndrome undergoing peritoneal dialysis because of anuria would be on fluid restriction. Pain is not associated with hemolytic-uremic syndrome, and potassium would be restricted, not encouraged, if the child is anuric. Peritoneal dialysis does not require an arteriovenous fistula (only hemodialysis).

781. A woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the emergency department, frantic and screaming for help. The nurse should instruct the woman to take which immediate action? 1. Irrigate the eyes with water. 2. Come to the emergency department. 3. Call the health care provider (HCP). 4. Irrigate the eyes with diluted hydrogen peroxide.

1 In this type of accident, the client is instructed to irrigate the eyes immediately with running water for at least 20 minutes, or until the emergency medical service personnel arrive. In the emergency department, the cleansing agent of choice is usually normal saline. Calling the HCP and going to the emergency department delays necessary intervention. Hydrogen peroxide is never placed in the eyes.

748. The nurse is reviewing a client's record and notes that the health care provider has documented that the client has a renal function disorder. On review of the laboratory results, the nurse most likely would expect to note which finding? 1. Elevated creatinine level 2. Decreased hemoglobin level 3. Decreased red blood cell count 4. Decreased white blood cell count

1 Measuring the creatinine level is a frequently used laboratory test to determine renal function. The creatinine level increases when at least 50% of renal function is lost. A decreased hemoglobin level and red blood cell count may be noted if bleeding from the urinary tract occurs or if erythropoietic function by the kidney is impaired. An increased white blood cell count is most likely to be noted in renal disease.

771. During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action? 1. Call the health care provider (HCP). 2. Reassure the client that this is normal. 3. Turn the client onto his or her operative side. 4. Administer the prescribed pain medication and antiemetic.

1 Severe pain or pain accompanied by nausea following a cataract extraction is an indicator of increased intraocular pressure and should be reported to the HCP immediately. Options 2, 3, and 4 are inappropriate actions.

766. Tacrolimus is prescribed for a client. Which disorder, if noted in the client's record, would indicate that the medication needs to be administered with caution? 1. Pancreatitis 2. Ulcerative colitis 3. Diabetes insipidus 4. Coronary artery disease

1 Tacrolimus (Prograf) is used with caution in immunosuppressed clients and in clients with renal, hepatic, or pancreatic function impairment. Tacrolimus is contraindicated in clients with hypersensitivity to this medication or hypersensitivity to cyclosporine.

741. The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent? 1. Palpation of a thrill over the fistula 2. Presence of a radial pulse in the left wrist 3. Absence of a bruit on auscultation of the fistula 4. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand

1 The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. The presence of a thrill and bruit indicate patency of the fistula. Although the presence of a radial pulse in the left wrist and capillary refill shorter than 3 seconds in the nail beds of the fingers on the left hand are normal findings, they do not assess fistula patency.

740. A client is admitted to the emergency department following a fall from a horse and the health care provider (HCP) prescribes insertion of a Foley catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action? 1. Notify the HCP. 2. Use a small-sized catheter. 3. Administer pain medication before inserting the catheter. 4. Use extra povidone-iodine solution in cleansing the meatus.

1 The presence of blood at the urinary meatus may indicate urethral trauma or disruption. The nurse notifies the HCP, knowing that the client should not be catheterized until the cause of the bleeding is determined by diagnostic testing. Therefore options 2, 3, and 4 are incorrect.

778. The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention should be initiated immediately? 1. Apply ice to the affected eye. 2. Irrigate the eye with cool water. 3. Notify the health care provider (HCP). 4. Accompany the client to the emergency department.

1 Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by an HCP and receive a thorough eye examination to rule out the presence of other eye injuries.

787. The clinic nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? 1. The right eye is tested, followed by the left eye, and then both eyes are tested. 2. Both eyes are assessed together, followed by an assessment of the right eye and then the left eye. 3. The client is asked to stand at a distance of 40 feet from the chart and is asked to read the largest line on the chart. 4. The client is asked to stand at a distance of 40 feet from the chart and to read the line that can be read 200 feet away by an individual with unimpaired vision.

1 Visual acuity is assessed in one eye at a time, and then in both eyes together, with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together. Visual acuity is measured with or without corrective lenses and the client stands at a distance of 20 feet from the chart.

453. The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment findings should the nurse expect to observe? Select all that apply. 1. Pallor 2. Edema 3. Anorexia 4. Proteinuria 5. Weight loss 6. Decreased serum lipids

1, 2, 3, 4 Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor. The child gains weight.

791. The nurse is preparing to administer eyedrops. Which interventions should the nurse take to administer the drops? Select all that apply. 1. Wash hands. 2. Put gloves on. 3. Place the drop in the conjunctival sac. 4. Pull the lower lid down against the cheek bone. 5. Instruct the client to squeeze the eyes shut after instilling the eyedrop. 6. Instruct the client to tilt the head forward, open the eyes, and look down.

1, 2, 3, 4 To administer eye medications, the nurse should wash hands and put gloves on. The client is instructed to tilt the head backward, open the eyes, and look up. The nurse pulls the lower lid down against the cheekbone and holds the bottle like a pencil with the tip downward. Holding the bottle, the nurse gently rests the wrist of the hand on the client's cheek and squeezes the bottle gently to allow the drop to fall into the conjunctival sac. The client is instructed to close the eyes gently and not to squeeze the eyes shut to prevent the loss of medication.

746. The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply. 1. Check the level of the drainage bag. 2. Reposition the client to his or her side. 3. Contact the health care provider (HCP). 4. Place the client in good body alignment. 5. Check the peritoneal dialysis system for kinks. 6. Increase the flow rate of the peritoneal dialysis solution.

1, 2, 4, 5 If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. The connecting tubing and peritoneal dialysis system are also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the HCP. Increasing the flow rate is an inappropriate action and is not associated with the amount of outflow solution.

782. The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. 1. Avoid activities that require bending over. 2. Contact the surgeon if eye scratchiness occurs. 3. Place an eye shield on the surgical eye at bedtime. 4. Episodes of sudden severe pain in the eye are expected. 5. Contact the surgeon if a decrease in visual acuity occurs. 6. Take acetaminophen (Tylenol) for minor eye discomfort.

1, 3, 5, 6 Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and usually is relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse also would instruct the client to notify the surgeon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure, such as bending over.

423. A child has been diagnosed with acute otitis media of the right ear. Which interventions should the nurse include in the plan of care? Select all that apply. 1. Provide a soft diet. 2. Position the child on the left side. 3. Administer an antihistamine twice daily. 4. Irrigate the right ear with normal saline every 8 hours. 5. Administer ibuprofen (Motrin IB) for fever every 4 hours as prescribed and as needed. 6. Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy.

1, 5, 6 Acute otitis media is an inflammatory disorder caused by an infection of the middle ear. The child often has fever, pain, loss of appetite, and possible ear drainage. The child also is irritable and lethargic and may roll the head or pull on or rub the affected ear. Otoscopic examination may reveal a red, opaque, bulging, and immobile tympanic membrane. Hearing loss may be noted particularly in chronic otitis media. The child's fever should be treated with ibuprofen (Motrin IB). The child is positioned on his or her affected side to facilitate drainage. A soft diet is recommended during the acute stage to avoid pain that can occur with chewing. Antibiotics are prescribed to treat the bacterial infection and should be administered for the full prescribed course. The ear should not be irrigated with normal saline because it can exacerbate the inflammation further. Antihistamines are not usually recommended as a part of therapy.

MMR

1st dose = 12 - 15 months 2nd dose = 4 - 6 years Contraindications - ABX allergy (neomycin) - Pregnancy - HIV/AIDS - immunocompromised individuals

Varicella

1st dose = 12 - 15 months 2nd dose = 4 - 6 years Contraindications - Gelatin allergy - ABX allergy (neomycin) - Pregnant women - immunocompromised, corticosteroid therapy

Rotavirus

1st dose = 2 months 2nd dose = 4 months Contraindications Reaction to prior dose SCID: severe combined immunodeficiency Immunosuppressive Tx

777. A client arrives in the emergency department following an automobile crash. The client's forehead hit the steering wheel and a hyphema is diagnosed. The nurse should place the client in which position? 1. Flat in bed 2. A semi-Fowler's position 3. Lateral on the affected side 4. Lateral on the unaffected side

2 A hyphema is the presence of blood in the anterior chamber. Hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as a penetrating injury from a BB or pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea.

797. A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication would the nurse identify as the cause of the client's complaint? 1. Doxycycline 2. Acetylsalicylic acid 3. Atropine sulfate 4. Diltiazem hydrochloride

2 Aspirin is contraindicated for gastrointestinal bleeding and is potentially ototoxic. The client should be advised to notify the prescribing health care provider so the medication can be discontinued and/or a substitute that is less toxic to the ear can be taken instead. Options 1, 3, and 4 do not have effects that are potentially associated with hearing difficulties.

739. A client is admitted to the emergency department following a motor vehicle accident. The client was wearing a lap seat belt when the accident occurred and now the client has hematuria and lower abdominal pain. To assess further whether the pain is caused by bladder trauma, the nurse should ask the client if the pain is referred to which area? 1. Hip 2. Shoulder 3. Umbilicus 4. Costovertebral angle

2 Bladder trauma or injury is characterized by lower abdominal pain that may radiate to one of the shoulders due to phrenic nerve irritation. Bladder injury pain does not radiate to the umbilicus, costovertebral angle, or hip.

758. The nurse is providing discharge instructions to a client receiving sulfamethoxazole. Which instruction should be included in the list? 1. Restrict fluid intake. 2. Maintain a high fluid intake. 3. If the urine turns dark brown, call the health care provider (HCP) immediately. 4. Decrease the dosage when symptoms are improving to prevent an allergic response.

2 Each dose of sulfamethoxazole should be administered with a full glass of water, and the client should maintain a high fluid intake. The medication is more soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Some forms of sulfamethoxazole cause urine to turn dark brown or red. This does not indicate the need to notify the HCP.

444. The nurse reviews the record of a child who is suspected to have glomerulonephritis and expects to note which finding that is associated with this diagnosis? 1. Hypotension 2. Brown-colored urine 3. Low urinary specific gravity 4. Low blood urea nitrogen level

2 Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Gross hematuria, resulting in dark, smoky, cola-colored or brown-colored urine, is a classic symptom of glomerulonephritis. Hypertension is also common. Blood urea nitrogen levels may be elevated. A moderately elevated to high urinary specific gravity is associated with glomerulonephritis.

790. Betaxolol hydrochloride eyedrops have been prescribed for a client with glaucoma. Which nursing action is most appropriate related to monitoring for side/adverse effects of this medication? 1. Monitoring temperature 2. Monitoring blood pressure 3. Assessing peripheral pulses 4. Assessing blood glucose level

2 Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are side/adverse effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. Options 1, 3, and 4 are not specifically associated with this medication.

737. A client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious and the nurse suspects air embolism. What is the priority nursing action? 1. Monitor vital signs every 15 minutes for the next hour. 2. Discontinue dialysis and notify the health care provider (HCP). 3. Continue dialysis at a slower rate after checking the lines for air. 4. Bolus the client with 500 mL of normal saline to break up the air embolus.

2 If the client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, notify the HCP, and administer oxygen as needed. Options 1, 3, and 4 are incorrect.

779. A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action? 1. Apply an eye patch. 2. Perform visual acuity tests. 3. Irrigate the eye with sterile saline. 4. Remove the piece of wood using a sterile eye clamp.

2 If the eye injury is the result of a penetrating object, the object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea.

450. The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse should plan which intervention? 1. Cover the bladder with petroleum jelly gauze. 2. Cover the bladder with a nonadhering plastic wrap. 3. Apply sterile distilled water dressings over the bladder mucosa. 4. Keep the bladder tissue dry by covering it with dry sterile gauze.

2 In bladder exstrophy, the bladder is exposed and external to the body. In this disorder, one must take care to protect the exposed bladder tissue from drying, while allowing the drainage of urine. This is accomplished best by covering the bladder with a nonadhering plastic wrap. The use of petroleum jelly gauze should be avoided because this type of dressing can dry out, adhere to the mucosa, and damage the delicate tissue when removed. Dry sterile dressings and dressings soaked in solutions (that can dry out) also damage the mucosa when removed.

445. The nurse performing an admission assessment on a 2-year-old child who has been diagnosed with nephrotic syndrome notes that which most common characteristic is associated with this syndrome? 1. Hypertension 2. Generalized edema 3. Increased urinary output 4. Frank, bright red blood in the urine

2 Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, hyperlipemia, and edema. Other manifestations include weight gain; periorbital and facial edema that is most prominent in the morning; leg, ankle, labial, or scrotal edema; decreased urine output and urine that is dark and frothy; abdominal swelling; and blood pressure that is normal or slightly decreased.

422. The day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which observation made by the nurse indicates the presence of this condition? 1. The child has difficulty hearing. 2. The child consistently tilts the head to see. 3. The child does not respond when spoken to. 4. The child consistently turns the head to hear.

2 Strabismus is a condition in which the eyes are not aligned because of lack of coordination of the extraocular muscles. The nurse may suspect strabismus in a child when the child complains of frequent headaches, squints, or tilts the head to see. Other manifestations include crossed eyes, closing one eye to see, diplopia, photophobia, loss of binocular vision, or impairment of depth perception. Options 1, 3, and 4 are not indicative of this condition.

736. A client with acute kidney injury has a serum potassium level of 6.0 mEq/L. The nurse should plan which action as a priority? 1. Check the sodium level. 2. Place the client on a cardiac monitor. 3. Encourage increased vegetables in the diet. 4. Allow an extra 500 mL of fluid intake to dilute the electrolyte concentration.

2 The client with hyperkalemia is at risk of developing cardiac dysrhythmias and cardiac arrest. Because of this, the client should be placed on a cardiac monitor. Fluid intake is not increased because it contributes to fluid overload and would not affect the serum potassium level significantly. Vegetables are a natural source of potassium in the diet, and their use would not be increased. The nurse also may assess the sodium level because sodium is another electrolyte commonly measured with the potassium level. However, this is not a priority action of the nurse.

786. A client with Ménière's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? 1. Increase sodium in the diet. 2. Avoid sudden head movements. 3. Lie still and watch the television. 4. Increase fluid intake to 3000 mL a day.

2 The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Lying still and watching television will not control vertigo.

775. A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear? 1. Pruritus 2. Tinnitus 3. Hearing loss 4. Burning in the ear

2 Tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client's thinking process and attention span. Options 1, 3, and 4 are not associated specifically with disorders of the inner ear.

783. Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the test results documented in the client's chart, knowing that which is the range for normal intraocular pressure? 1. 2 to 7 mm Hg 2. 10 to 21 mm Hg 3. 22 to 30 mm Hg 4. 31 to 35 mm Hg

2 Tonometry is a method of measuring intraocular fluid pressure, using a calibrated instrument that indents or flattens the corneal apex. Pressures between 10 and 21 mm Hg are considered within the normal range.

738. A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of which condition? 1. Pyelonephritis 2. Glomerulonephritis 3. Trauma to the bladder or abdomen 4. Renal cancer in the client's family

3 Bladder trauma or injury should be considered or suspected in the client with low abdominal pain and hematuria. Glomerulonephritis and pyelonephritis would be accompanied by fever and are thus not applicable to the client described in this question. Renal cancer would not cause pain that is felt in the low abdomen; rather, the pain would be in the flank area.

762. The nurse, who is administering bethanechol chloride, is monitoring for cholinergic overdose associated with the medication. The nurse should check the client for which sign of overdose? 1. Dry skin 2. Dry mouth 3. Bradycardia 4. Signs of dehydration

3 Cholinergic overdose of bethanechol chloride produces manifestations of excessive muscarinic stimulation such as salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension. Treatment includes supportive measures and the administration of atropine sulfate subcutaneously or intravenously.

416. The nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. Which, if stated by the mother, indicates a need for further teaching? 1. "I need to wash my hands frequently." 2. "I need to clean the eye as prescribed." 3. "It is okay to share towels and washcloths." 4. "I need to give the eye drops as prescribed."

3 Conjunctivitis is an inflammation of the conjunctiva. Bacterial conjunctivitis is highly contagious, and the nurse should teach infection control measures. These include good hand-washing and not sharing towels and washcloths. Options 1, 2, and 4 are correct treatment measures.

780. The nurse is caring for a client following enucleation and notes the presence of bright red drainage on the dressing. Which nursing action is most appropriate? 1. Document the finding. 2. Continue to monitor the drainage. 3. Notify the health care provider (HCP). 4. Mark the drainage on the dressing and monitor for any increase in bleeding.

3 If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the HCP, because this indicates hemorrhage. Options 1, 2, and 4 are inappropriate.

796. A miotic medication has been prescribed for the client with glaucoma and the client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client? 1. "The medication will help dilate the eye to prevent pressure from occurring." 2. "The medication will relax the muscles of the eyes and prevent blurred vision." 3. "The medication causes the pupil to constrict and will lower the pressure in the eye." 4. "The medication will help block the responses that are sent to the muscles in the eye."

3 Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork. Options 1, 2, and 4 are incorrect.

768. The nurse receives a call from a client concerned about eliminating brown-colored urine after taking nitrofurantoin for a urinary tract infection. The nurse should make which appropriate response? 1. "Discontinue taking the medication and make an appointment for a urine culture." 2. "Decrease your medication to half the dose because your urine is too concentrated." 3. "Continue taking the medication because the urine is discolored from the medication." 4. "Take magnesium hydroxide (Maalox) with your medication to lighten the urine color."

3 Nitrofurantoin (Furadantin) imparts a harmless brown color to the urine and the medication should not be discontinued until the prescribed dose is completed. Magnesium hydroxide (Maalox) will not affect urine color. In addition, antacids should be avoided because they interfere with medication effectiveness.

789. The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? 1. Speak loudly. 2. Speak frequently. 3. Speak at a normal volume. 4. Speak directly into the impaired ear.

3 Speaking in a normal tone to the client with impaired hearing and not shouting are important. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear.

772. The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? 1. Avoid overuse of the eyes. 2. Decrease the amount of salt in the diet. 3. Eye medications will need to be administered for life. 4. Decrease fluid intake to control the intraocular pressure.

3 The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life. Options 1, 2, and 4 are not accurate instructions.

743. The nurse is assessing a client with epididymitis. The nurse anticipates which findings on physical examination? 1. Fever, diarrhea, groin pain, and ecchymosis 2. Nausea, vomiting, scrotal edema, and ecchymosis 3. Fever, nausea, vomiting, and painful scrotal edema 4. Diarrhea, groin pain, testicular torsion, and scrotal edema

3 Typical signs and symptoms of epididymitis include scrotal pain and edema, which often are accompanied by fever, nausea and vomiting, and chills. Epididymitis most often is caused by infection, although sometimes it can be caused by trauma. Epididymitis needs to be distinguished correctly from testicular torsion.

During a routine well-child checkup for a 2½ yo, the nurse plans to teach the mother proper nutrition & weight gain expectations for her child. The nurse reviews the chart & finds that the toddler's birth weight was 7 pounds 15 ounces. The nurse expects that the child should weigh approximately how much at this time?

31 pounds 12 ounces

773. The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign/symptom is associated with this eye disorder? 1. Total loss of vision 2. Pain in the affected eye 3. A yellow discoloration of the sclera 4. A sense of a curtain falling across the field of vision

4 A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options 1 and 3 are not characteristics of this disorder. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal.

776. The nurse is performing an assessment on a client with a suspected diagnosis of cataract. What is the chief clinical manifestation that the nurse expects to note in the early stages of cataract formation? 1. Diplopia 2. Eye pain 3. Floating spots 4. Blurred vision

4 A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception. Options 1, 2, and 3 are not characteristics of a cataract.

784. The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? 1. Cranial nerve I, olfactory 2. Cranial nerve IV, trochlear 3. Cranial nerve III, oculomotor 4. Cranial nerve VII, facial nerve

4 An acoustic neuroma (or vestibular schwannoma) is a unilateral benign tumor that occurs where the vestibulocochlear or acoustic nerve (cranial nerve VIII) enters the internal auditory canal. It is important that an early diagnosis be made because the tumor can compress the trigeminal and facial nerves and arteries within the internal auditory canal. Treatment for acoustic neuroma is surgical removal via a craniotomy. Assessment of the trigeminal and facial nerves is important. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve. Acoustic neuromas rarely recur following surgical removal.

759. Trimethoprim-sulfamethoxazole is prescribed for a client. The nurse should instruct the client to report which symptom if it develops during the course of this medication therapy? 1. Nausea 2. Diarrhea 3. Headache 4. Sore throat

4 Clients taking trimethoprim (TMP)-sulfamethoxazole (SMZ) should be informed about early signs/symptoms of blood disorders that can occur from this medication. These include sore throat, fever, and pallor, and the client should be instructed to notify the health care provider (HCP) if these occur. The other options do not require HCP notification.

448. The nurse provided discharge instructions to the parents of a 2-year-old child who had an orchiopexy to correct cryptorchidism. Which statement by the parents indicate that further teaching is necessary? 1. "I'll check his temperature." 2. "I'll give him medication so he'll be comfortable." 3. "I'll check his voiding to be sure there's no problem." 4. "I'll let him decide when to return to his play activities."

4 Cryptorchidism is a condition in which one or both testes fail to descend through the inguinal canal into the scrotal sac. Surgical correction may be necessary. All vigorous activities should be restricted for 2 weeks after surgery to promote healing and prevent injury. This prevents dislodging of the suture, which is internal. Normally, 2-year-olds want to be active; allowing the child to decide when to return to his play activities may prevent healing and cause injury. The parents should be taught to monitor the temperature, provide analgesics as needed, and monitor the urine output.

745. The nurse is collecting data from a client who has a history of benign prostatic hyperplasia. To determine whether the client currently is experiencing this condition, the nurse should ask the client about the presence of which early symptom? 1. Nocturia 2. Urinary retention 3. Urge incontinence 4. Decreased force in the stream of urine

4 Decreased force in the stream of urine is an early symptom of benign prostatic hyperplasia. The stream later becomes weak and dribbling. The client then may develop hematuria, frequency, urgency, urge incontinence, and nocturia. If untreated, complete obstruction and urinary retention can occur.

755. The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations? 1. Hypertension, tachycardia, and fever 2. Hypotension, bradycardia, and hypothermia 3. Restlessness, irritability, and generalized weakness 4. Headache, deteriorating level of consciousness, and twitching

4 Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing increased intracranial pressure and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates.

750. The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the most appropriate nursing action? 1. Monitor the client. 2. Elevate the head of the bed. 3. Medicate the client for nausea. 4. Notify the health care provider (HCP).

4 Disequilibrium syndrome may be caused by the rapid decreases in the blood urea nitrogen level during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs/symptoms of disequilibrium syndrome and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The HCP must be notified.

754. A client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. Which assessment finding indicates the need to notify the health care provider (HCP)? 1. Red bloody urine 2. Pain related to bladder spasms 3. Urinary output of 200 mL higher than intake 4. Blood pressure, 100/50 mm Hg; pulse, 130 beats/minute

4 Frank bleeding (arterial or venous) may occur during the first day after surgery. Some hematuria is usual for several days after surgery. A urinary output of 200 mL more than intake is adequate. Bladder spasms are expected to occur following surgery. A rapid pulse with a low blood pressure is a potential sign of excessive blood loss. The HCP should be notified.

451. The nurse understands that which information collected during the assessment of a child recently diagnosed with glomerulonephritis is most often associated with the diagnosis? 1. Child fell off a bike onto the handlebars 2. Nausea and vomiting for the last 24 hours 3. Urticaria and itching for 1 week before diagnosis 4. Streptococcal throat infection 2 weeks before diagnosis

4 Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Group A β-hemolytic streptococcal infection is a cause of glomerulonephritis. Often, a child becomes ill with streptococcal infection of the upper respiratory tract and then develops symptoms of acute poststreptococcal glomerulonephritis after an interval of 1 to 2 weeks. The assessment data in options 1, 2, and 3 are unrelated to a diagnosis of glomerulonephritis.

449. The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan? 1. "Caution should be used when straddling the infant on a hip." 2. "Vital signs should be taken daily to check for bladder infection." 3. "Catheterization will be necessary when the infant does not void." 4. "Circumcision has been delayed to save tissue for surgical repair."

4 Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. The infant should not be circumcised because the dorsal foreskin tissue will be used for surgical repair of the hypospadias. Options 1, 2, and 3 are unrelated to this disorder.

756. A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which medication? 1. Diuretics 2. Antibiotics 3. Antitussives 4. Decongestants

4 In the client with benign prostatic hyperplasia, episodes of urinary retention can be triggered by certain medications, such as decongestants, anticholinergics, and antidepressants. The client should be questioned about the use of these medications if the client has urinary retention. Retention also can be precipitated by other factors, such as alcoholic beverages, infection, bed rest, and becoming chilled.

764. Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication? 1. Normal hemoglobin level 2. Decreased creatinine level 3. Decreased white blood cell count 4. Elevated blood urea nitrogen level

4 Nephrotoxicity can occur from the use of cyclosporine (Sandimmune). Nephrotoxicity is evaluated by monitoring for elevated blood urea nitrogen and serum creatinine levels. Cyclosporine does not depress the bone marrow.

757. Nitrofurantoin is prescribed for a client with a urinary tract infection. The client contacts the nurse and reports a cough, chills, fever, and difficulty breathing. The nurse should make which interpretation about the client's complaints? 1. The client may have contracted the flu. 2. The client is experiencing anaphylaxis. 3. The client is experiencing expected effects of the medication. 4. The client is experiencing a pulmonary reaction requiring cessation of the medication.

4 Nitrofurantoin can induce two kinds of pulmonary reactions: acute and subacute. Acute reactions, which are most common, manifest with dyspnea, chest pain, chills, fever, cough, and alveolar infiltrates. These symptoms resolve 2 to 4 days after discontinuing the medication. Acute pulmonary responses are thought to be hypersensitivity reactions. Subacute reactions are rare and occur during prolonged treatment. Symptoms (e.g., dyspnea, cough, malaise) usually regress over weeks to months following nitrofurantoin withdrawal. However, in some clients, permanent lung damage may occur. The remaining options are incorrect interpretations.

774. The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe? 1. A pink-colored tympanic membrane 2. A pearly colored tympanic membrane 3. A transparent and clear tympanic membrane 4. A red, dull, thick, and immobile tympanic membrane

4 Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane, with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head.

751. A client newly diagnosed with chronic kidney disease has just been started on peritoneal dialysis. During the infusion of the dialysate, the client complains of abdominal pain. Which action by the nurse is most appropriate? 1. Stop the dialysis. 2. Slow the infusion. 3. Decrease the amount to be infused. 4. Explain that the pain will subside after the first few exchanges.

4 Pain during the inflow of dialysate is common during the first few exchanges because of peritoneal irritation; however, the pain usually disappears after 1 to 2 weeks of treatment. The infusion amount should not be decreased, and the infusion should not be slowed or stopped.

785. The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. The nurse understands that which describes this condition? 1. Tinnitus that occurs with aging 2. Nystagmus that occurs with aging 3. A conductive hearing loss that occurs with aging 4. A sensorineural hearing loss that occurs with aging

4 Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. Options 1, 2, and 3 are incorrect.

447. A 7-year-old child is seen in a clinic, and the primary health care provider documents a diagnosis of primary nocturnal enuresis. The nurse should provide which information to the parents? 1. Primary nocturnal enuresis does not respond to treatment. 2. Primary nocturnal enuresis is caused by a psychiatric problem. 3. Primary nocturnal enuresis requires surgical intervention to improve the problem. 4. Most children outgrow the bed-wetting problem without therapeutic intervention.

4 Primary nocturnal enuresis occurs in a child who has never been dry at night for extended periods. The condition is common in children, and most children eventually outgrow bed-wetting without therapeutic intervention. The child is unable to sense a full bladder and does not awaken to void. The child may have delayed maturation of the central nervous system. The condition is not caused by a psychiatric problem.

747. A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess the client for which manifestations of this complication? 1. Warmth, redness, and pain in the left hand 2. Aching pain, pallor, and edema of the left arm 3. Edema and reddish discoloration of the left arm 4. Pallor, diminished pulse, and pain in the left hand

4 Steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and a diminished pulse distal to the fistula. The client also complains of pain distal to the fistula, caused by tissue ischemia. Warmth and redness probably would characterize a problem with infection. The manifestations described in options 2 and 3 are incorrect.

744. A client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for which characteristic of this disorder? 1. Soft and swollen prostate gland 2. Reddened, swollen, and boggy prostate gland 3. Tender and edematous prostate gland with ecchymosis 4. Tender, indurated prostate gland that is warm to the touch

4 The client with bacterial prostatitis has a swollen and tender prostate gland that is also warm to the touch, firm, and indurated. Systemic symptoms include fever with chills, perineal and low back pain, and signs of urinary tract infection, which often accompany the disorder.

760. Phenazopyridine is prescribed for a client for symptomatic relief of pain resulting from a lower urinary tract infection. The nurse should provide the client with which information regarding this medication? 1. Take the medication at bedtime. 2. Take the medication before meals. 3. Discontinue the medication if a headache occurs. 4. A reddish orange discoloration of the urine may occur.

4 The nurse should instruct the client that a reddish-orange discoloration of urine may occur. The nurse also should instruct the client that this discoloration can stain fabric. The medication should be taken after meals to reduce the possibility of gastrointestinal upset. A headache is an occasional side effect of the medication and does not warrant discontinuation of the medication.

763. Oxybutynin chloride is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication? 1. Pallor 2. Drowsiness 3. Bradycardia 4. Restlessness

4 Toxicity (overdosage) of oxybutynin produces central nervous system excitation, such as nervousness, restlessness, hallucinations, and irritability. Other signs of toxicity include hypotension or hypertension, confusion, tachycardia, flushed or red face, and signs of respiratory depression. Drowsiness is a frequent side effect of the medication but does not indicate overdosage.

742. A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder? 1. Hematuria and pyuria 2. Dysuria and proteinuria 3. Hematuria and urgency 4. Dysuria and penile discharge

4 Urethritis in the male client often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear to mucopurulent discharge. Because this disorder often coexists with gonorrhea, diagnostic tests are done for both and include culture and rapid assays.

788. A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. How should the nurse interpret this finding? 1. The client is legally blind. 2. The client's vision is normal. 3. The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet. 4. The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet.

4 Vision that is 20/20 is normal—that is, the client is able to read from 20 feet what a person with normal vision can read from 20 feet. A client with a visual acuity of 20/60 can only read at a distance of 20 feet what a person with normal vision can read at 60 feet.

40. The pediatric nurse, along with the primary caregiver(s), has a special duty to the child and the family.

ANS: teach The pediatric nurse is in a position to assess, instruct, and support children and their families about developmental progress, nutrition, and possible undiagnosed anomalies. REF: Page 943 TOP: Teaching

66. Any substance such as a drug, alcohol, or virus that interferes with fetal development is called a(n) .

ANS: teratogen A teratogen is any substance that interferes with fetal development, such as a drug, alcohol, or a virus. REF: Page 182 TOP: Teratogen

52. The nurse reassures the anxious mother of a child with pyloric stenosis who is to have surgery that the surgical procedure, called a , is quickly done and the child recovers almost immediately.

ANS: pyloromyotomy When the muscle is cut, the obstruction is immediately relieved and the child who is hungry will begin to eat and keep food down. REF: Pages 1022-1023 TOP: Pyloromyotomy

22. The nurse recognizes that preventive programs in schools must be stepped up in order to prevent violence, especially .

ANS: shootings Premeditated intentional shootings are occurring more frequently among adolescents. PTS: 1 DIF: Cognitive Level: Application REF: Page 923 OBJ: 10 TOP: Shootings KEY: Nursing Process Step: Implementation

A 6 yo is hospitalized with a fracture of the femur & is placed in traction. In meeting the psychosocial needs of the child, the nurse most appropriately selects which play activity for the child?

A board game

The nurse is caring for an older client who is reminiscing about past life experiences in a positive manner. The nurse plans care with the understanding that this behavior indicates which?

A normal psychosocial response According to Erikson, the later years of life are from 65 years of age until death. The adult reminisces about past life experiences, often viewing them in a positive way. The adult needs to feel good about his or her accomplishments, see successes in his or her life, and feel that he or she has made a contribution to society.

The nurse notes documentation that a client has conductive hearing loss. The nurse understands that which is a cause of this type of hearing loss?

A physical obstruction to the transmission of sound waves Rationale: A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in the 8th cranial nerve, or a defect of the sensory fibers that lead to the cerebral cortex.

The nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. The nurse understands that this indicates which finding?

A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed Rationale: In the Romberg test, the client is asked to stand with the feet together and the arms at the sides and to close the eyes and hold the position. Normally the client can maintain posture and balance. A positive Romberg is a vestibular neurological sign that is found when a client elicits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A positive gaze nystagmus evaluation results in an involuntary rhythmic, rapid, twitching of the eyeballs. A positive Babinski test results with dorsiflexion of the ankle and great toe with fanning of the other toes. If this occurs in anyone older than 2 years, it indicates the presence of central nervous system disease. A lack of normal sense of position coupled with an inability to return extended fingers to a point of reference is a finding in a past pointing test.

When caring for a 3-year-old child, the nurse should provide which toy for the child?

A wagon Rationale: Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, trucks, and dolls are some appropriate toys. A puzzle with large pieces only may be appropriate. A farm set and a golf set may contain items that the child could swallow.

69. Growth and development that proceeds from the head toward the feet is known as .

ANS: cephalocaudal Cephalocaudal is defined as growth and development that proceeds from the head toward the feet. REF: Page 182 TOP: Development

65. The process that refers to gradual change and differentiation is .

ANS: development Development is the process of gradual change and differentiation. REF: Page 182 TOP: Development

22. The nurse recognizes that preventive programs in schools must be stepped up to attempt to prevent violence, especially .

ANS: shootings Premeditated intentional shootings are occurring more frequently among adolescents. REF: Page 930 TOP: Shootings

21. The public health nurse offered as a motivation the report from Healthy People 2010 that found that drug use among remains below the all-time high reported in 1979.

ANS: adolescents Adolescents have been found to be using fewer illicit drugs than in 1979. REF: Page 929 TOP: Drug use in adolescents

51. When the mother of a child with gastroesophageal reflux calls the clinic nurse to report that her baby is vomiting small amounts of blood, the nurse explains that the esophagus has been irritated by .

ANS: gastric acid Gastric acid that has repeatedly come in contact with the esophageal mucosa will erode the mucosa, and bleeding will result. REF: Page 1021 TOP: Gastroesophageal reflux (GER)

53. The nurse anticipates that the cerebrospinal fluid (CSF) taken from a child with bacterial meningitis would have a low level.

ANS: glucose The glucose level in the CSF of a child with bacterial meningitis is low because the bacteria in the fluid have digested the glucose. REF: Page 1041 TOP: Cerebrospinal fluid (CSF)

41. The nurse recognizes that % of hospitalized children have special needs.

ANS: 35 thirty-five Children with special needs comprise 35% of the pediatric hospitalization admissions. REF: Page 944 TOP: Special needs children

67. The nurse instructs a group of parents that a rapidly growing 15-year-old boy may require as many as calories a day.

ANS: 3600 three thousand six hundred thirty-six hundred Rapidly growing adolescent boys may require as many as 3600 calories daily. REF: Page 203 TOP: Adolescent nutrition

21. A nurse emphasizes a study that focused on the amount of time children spend using various media, such as TV, video games, and computers and stated that by cutting this time by %, it would have a significant impact on increasing physical activity.

ANS: 50 fifty If sedentary time were cut in half, this would have a significant effect on the increase in physical activity. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 920 OBJ: 2 TOP: Sedentary lifestyle KEY: Nursing Process Step: Implementation

20. The nurse emphasizes a study that focused on the amount of time children spend in front of the TV that stated cutting TV watching by % would have a significant impact on increasing physical activity.

ANS: 50 fifty If sedentary time were cut in half, this would have a significant effect on the increase in physical activity. REF: Page 928 TOP: Sedentary lifestyle

42. The nurse is aware that visual acuity evaluation in a child is best assessed after the age of years.

ANS: 6 six A child's refraction does not reach 20/20 until about the age of 6. REF: Page 952 TOP: Visual acuity

70. Growth and development that moves from the center toward the outside is known as .

ANS: proximodistal Proximodistal refers to growth and development that moves from the center toward the outside. REF: Page 182 TOP: Development

50. A nurse instructing a group of parents about injury prevention should inform the group that the leading cause of injury and death of infants and young children is: a. accidents. b. child abuse. c. drug abuse. d. adolescent parents.

ANS: A Accidents are the leading cause of injury and death of infants and young children. REF: Page 192 TOP: Prevention

54. The theory of aging that suggests the older person who is more active socially is more likely to adjust well to aging is the: a. activity theory. b. autoimmunity theory. c. wear-and-tear theory. d. disengagement theory.

ANS: A According to the activity theory, the older person who is more active socially is more likely to adjust well to aging. REF: Page 211 TOP: Theories of aging

16. The nurse educates the family of a newly admitted child with cystic fibrosis that the therapy will be centered on: a. chest physiotherapy. b. mucus-drying agents. c. prevention of diarrhea. d. insulin therapy.

ANS: A Chest physiotherapy and aerosol medications are the center of treatment for cystic fibrosis. REF: Page 1012 TOP: Cystic fibrosis

26. The family pattern in which the relationships are unequal and the parents attempt to control the children with strict, rigid rules and expectations is known as the: a. autocratic family pattern. b. patriarchal family pattern. c. matriarchal family pattern. d. democratic family pattern.

ANS: A In the autocratic family pattern the relationships are unequal. The parents attempt to control the children with strict, rigid rules and expectations. This family pattern is least open to outside influence. REF: Page 184

27. The family pattern that is least open to outside influence is known as the: a. autocratic family pattern. b. patriarchal family pattern. c. matriarchal family pattern. d. democratic family pattern.

ANS: A In the autocratic family pattern the relationships are unequal. The parents attempt to control the children with strict, rigid rules and expectations. This family pattern is least open to outside influence. REF: Page 184

59. A child who has just begun to demonstrate object permanence is in which of Piaget's stages of cognitive development? a. Sensorimotor b. Preoperational thought c. Formal operational thought d. Concrete operational thought

ANS: A Piaget's sensorimotor stage of cognitive development uses senses and motor abilities to understand the world; this period begins with reflexes and coordinates sensorimotor skills. While in this stage, a child learns that an object still exists when it is out of sight (object permanence). REF: Page 188, Box 9-6 TOP: Piaget

57. A nurse instructing a group of parents about safety rules for infants and young children should instruct the parents to: a. remove plants from the child's reach. b. provide the infant with a pillow at night. c. use a plastic covering on the infant's mattress. d. keep the crib sides up and set the mattress at the highest setting.

ANS: A Safety rules for infants and young children include keeping the crib sides up and the mattress set at the lowest setting, never using plastic bags or coverings on mattresses or near infant's playthings, avoiding the use of pillows with small infants, and removing plants from the child's reach. REF: Page 193, Safety Alert! TOP: Safety

55. Which theory of aging suggests that previously developed coping abilities and the ability to maintain previous roles and activities are critical to adjustment to old age? a. Continuity theory b. Autoimmunity theory c. Wear-and-tear theory d. Disengagement theory

ANS: A Supporters of the continuity theory suggest that the critical factors in adjustment to old age are previously developed coping abilities and the ability to maintain previous roles and activities. REF: Page 211 TOP: Theories of aging

The nurse is providing instructions to a new parent regarding the psychosocial development of the infant. Using Erikson's psychosocial development theory, which instruction should the nurse reinforce to the parents?

Allow the infant to signal a need

33. The stage of family development that begins when conception occurs and continues through the pregnancy is known as the: a. expectant stage. b. parenthood stage. c. establishment stage. d. engagement/commitment stage.

ANS: A The expectant stage begins when conception occurs and continues through the pregnancy. REF: Page 185 TOP: Family development

6. Which children must be secured in the back seat in a rear-facing safety seat? a. Children weighing up to 20 lb b. Children weighing between 20 and 30 lb c. Children weighing between 30 and 40 lb d. Children weighing more than 40 lb

ANS: A The law states that a child from birth to 20 lb must be situated in a rear-facing safety seat that is secured in the back seat when riding in an automobile. PTS: 1 DIF: Cognitive Level: Application REF: Page 923 OBJ: 7 TOP: Injury KEY: Nursing Process Step: Implementation

8. The nurse teaches a group of parents about a law that states that a rear-facing safety seat secured in the back seat is required for any child who weighs: a. up to 20 pounds. b. between 20 and 30 pounds. c. between 30 and 40 pounds. d. more than 40 pounds.

ANS: A The law states that a child from birth to 20 pounds while sitting in a car should be situated in a rear-facing safety seat that is secured in the back seat. REF: Page 930 TOP: Injury

38. When the nurse is inserting a feeding tube in an 8-month-old, the most efficient safety reminder device (SRD) the nurse would use is a(n): a. mummy. b. clove hitch. c. jacket device. d. elbow device.

ANS: A The mummy restraint controls the arms and the body of the infant. REF: Page 967 TOP: Safety reminder devices (SRDs) Step: Planning

5. As a child begins to develop language skills, the nurse anticipates that the number of words in a sentence: a. corresponds to the chronological age of the child. b. increases with each month of age. c. matches the number of words they know. d. depends on hollow phrases.

ANS: A The number of words in a sentence corresponds to chronological age. REF: Page 189 TOP: Language

31. The nurse explains to the parents of a child with developmental hip dysplasia that the application of a Pavlik harness will hold the child's femurs in: a. abduction. b. adduction. c. flexion. d. extension.

ANS: A The use of the Pavlik harness maintains abduction for 4 to 6 months. REF: Page 1035 TOP: Pavlik

16. When the mother of a 3-year-old expresses concern about her daughter's slowed growth rate, the nurse's most informative response would be: a. "Three-year-olds have finished a growth spurt and now their coordination can catch up." b. "Children's growth is hereditary. She may be of small stature like you." c. "The growth of a 3-year-old is associated with their nutrition. How is she eating?" d. "Your daughter is healthy and happy. Don't worry about her growth right now."

ANS: A Three-year-olds slow down in their growth in a natural cycle. REF: Page 946 TOP: Growth

50. When assessing the laboratory values of a child with nephrosis, the nurse anticipates which result(s)? (Select all that apply.) a. High levels of protein in the urine b. High serum lipid levels c. Low serum protein levels d. Low hemoglobin e. High white blood cell count

ANS: A, B, C A patient with nephrotic syndrome presents with high levels of serum lipids, low serum protein, and albumin in urine that is dark and frothy with a high specific gravity. The hemoglobin and WBC are usually normal. REF: Pages 1026-1027 TOP: Nephrosis

18. The school nurse collaborates with the physical education instructor to increase the amount of physical activity during the school day. What are major benefits of physical activity? (Select all that apply.) a. Reduced death rates as adults b. Reduced risk of cardiovascular disease c. Reduced risk of hypertension d. Reduced risk of diabetes e. Reduced self-esteem

ANS: A, B, C, D Physical activity reduces death rates as adults, reduces the risk of cardiovascular disease, and reduces the risk of diabetes and hypertension. Physical activity increases self-esteem. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 920 OBJ: 2 TOP: Benefits of physical exercise KEY: Nursing Process Step: Implementation

43. The nurse clarifies that the family-centered care approach terminates which policies? (Select all that apply.) a. Rigid visiting hours b. Age restrictions on visitors c. Exclusion of family during procedures d. Discouraging family to stay overnight e. Restricting parents from reading the chart

ANS: A, B, C, D, E Family-centered care terminates all the restrictive policies of traditional hospitals. REF: Pages 944-945 TOP: Family-centered care

68. The nurse informs a group of college students that young adults will face which challenges in this particular time of life? (Select all that apply.) a. Starting a family b. Selecting housing c. Job security d. Relations with extended family e. Establishing intimacy

ANS: A, B, C, D, E All options are developmental tasks of the young adult of today. REF: Page 205 TOP: Young adult

23. The pediatric nurse stresses that health promotion activities must be ongoing for which reason(s)? (Select all that apply.) a. To identify health risks b. To encourage healthy behavior c. To prevent disease d. To improve nutrition e. To prevent accidents

ANS: A, B, C, D, E All options are goals of health promotion. REF: Page 926 TOP: Health promotion

17. What are reasons that a pediatric nurse should stress that health promotion activities must be ongoing? (Select all that apply.) a. To identify health risks b. To encourage healthy behavior c. To strengthen family bonds d. To improve nutrition e. To prevent accidents

ANS: A, B, D, E Health promotion activities must be ongoing to identify health risks, to encourage healthy behavior, to improve nutrition, and to prevent accidents. There is no link between health promotion activities and strengthening family bonds. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 919 OBJ: 1 TOP: Health promotion KEY: Nursing Process Step: Implementation

According to Erik Erikson's psychosocial developmental theory, the nurse would anticipate a 5-year-old child to be in the stage of:

Answer: Initiative vs. guilt Rationale: A 5-year-old child would be expected to be experiencing Erikson's psychosocial stage of initiative versus guilt (late childhood, 3 to 6 years)

39. The nurse welcomes the presence of the family in a pediatric unit because it reduces the stressors of hospitalization. Which are common stressors for the hospitalized child? (Select all that apply.) a. Separation b. Lack of love c. Fear of pain d. Unfamiliar food e. Loss of control

ANS: A, C, E Parents lend stability and comfort for the child and restore his or her sense of control. REF: Page 944 TOP: Parents on the pediatric unit

24. The nurse explains that gastroesophageal reflux (GER) usually begins within the first week of life in infants and is usually treated by: a. making the infant NPO. b. thickening the food with cereal. c. placing the infant in an upright position. d. feeding the infant in a car seat.

ANS: B GER is treated with small feedings thickened with cereal. REF: Page 1021 TOP: Nutrition

2. When caring for a child with coarctation of the aorta, the nurse assesses for the most common clinical manifestation, which is: a. clubbing of the digits. b. upper extremity hypertension. c. pedal edema and portal congestion. d. loud systolic ejection murmur.

ANS: B Coarctation of the aorta results in hypertension in the upper extremities. REF: Page 991 TOP: Heart defect

41. An infant has been diagnosed with cradle cap. The nurse recognizes that the intervention to treat the scaly patches on the scalp is to apply: a. alcohol. b. mineral oil. c. calamine. d. A&D ointment.

ANS: B Crusty patches can be removed with the application of mineral oil. REF: Page 1053 TOP: Skin disorders

42. An adolescent female asks the nurse about taking retinoic acid (Accutane). The nurse instructs that the medication: a. should be used only for 10 weeks. b. requires that sexually active females use contraception. c. lowers hemoglobin very quickly. d. has few side effects.

ANS: B Accutane has many side effects and can produce birth defects. Effective contraception is necessary during treatment and 1 month after the 20 weeks it is to be taken. REF: Page 1055 TOP: Acne

26. When a safety reminder device (SRD) is used to protect a child, a responsibility of the nurse is to: a. apply it loosely. b. remove it every 2 hours. c. place it over clothing. d. apply only one type.

ANS: B Any SRD should be removed every 2 hours. REF: Page 967 TOP: Safety

9. The nurse delays assessing the temperature in an infant because of the false elevation of temperature caused by the child: a. having a bowel movement. b. crying vigorously. c. having just eaten. d. having been in a cold room.

ANS: B Crying increases the temperature; eating and bowel movements do not. A cold room would lower the temperature. REF: Page 949 TOP: Vital signs

12. An 8-year-old child asks how a blood pressure is taken. The nurse should reply: a. "This small machine will measure your systolic and diastolic pressure." b. "The armband will hug your arm and tell me how well your blood is going through your arm." c. "The armband will cut off your circulation for a while and then we can hear when it comes back." d. "When you are ill we need to know if your blood is still moving in your body."

ANS: B Because children are upset by unfamiliar procedures, it is best to explain each step in simple terms. It is best not to mention anything that may increase anxiety. REF: Pages 957-958 TOP: Vital signs

6. The nurse appropriately teaches a young mother that breast milk or formula is the only food an infant needs until: a. 2-3 months. b. 4-6 months. c. 7-9 months. d. 10-12 months.

ANS: B Breast milk or formula is the only food needed for 4 to 6 months. REF: Page 191 TOP: Nutrition

4. The mother of a 5-month-old child is concerned because the child cannot sit by himself. The nurse explains that sitting alone is not expected until the baby is: a. 6 months. b. 7 months. c. 8 months. d. 9 months.

ANS: B By the end of the seventh month, the child can sit up without support. REF: Page 190 TOP: Development

42. A nurse understands that an average weight for a 12-month-old is: a. 18.5 pounds. b. 21.5 pounds. c. 28.5 pounds. d. 34.5 pounds.

ANS: B By the time the baby is 1 year of age, the birth weight has tripled (average weight is 21.5 pounds). REF: Page 189 TOP: Growth and development

30. The toddler is receiving oxygen in a mist tent. One of the disadvantages of the tent is that it requires the nurse to: a. remove the restless child. b. change wet bedding and clothing as needed. c. open the mist tent at least once an hour. d. keep all objects outside of the tent.

ANS: B Frequent linen and clothing changes may be necessary because of the heavy humidity in the tent. REF: Page 971 TOP: Mist tent

39. Which additional congenital malformation is expected in 80% of infants with a myelomeningocele? a. Cerebral palsy b. Hydrocephalus c. Meningitis d. Neuroblastoma

ANS: B Hydrocephalus is present in 80% of infants affected by a myelomeningocele. REF: Page 1047 TOP: Spina bifida

9. The nurse teaches parents that the severity of infant respiratory distress syndrome (RDS) is most influenced by: a. poor cough and gag reflex. b. the gestational age at birth. c. administering high concentrations of oxygen. d. the sex of the infant.

ANS: B RDS is caused by a deficiency of surfactant and occurs almost exclusively in preterm, low-birth-weight infants. REF: Page 1003 TOP: Respiratory distress syndrome (RDS)

3. Parents of a 6-month-old child who has just been diagnosed with iron deficiency anemia ask why it was not diagnosed earlier. The nurse's best response is: a. "Are you sure your child has iron deficiency anemia?" b. "This happens when the maternal stores of iron are depleted at about 6 months." c. "This anemia is caused by blood loss." d. "The child may not have had it for a long time."

ANS: B Iron deficiency anemia becomes apparent at about 6 months of age in a full-term infant, when maternal stores of iron are depleted. REF: Page 992 TOP: Anemia

47. The nurse instructs the parents of a child who has had a myringotomy to position the child: a. supine. b. on the affected side. c. on the unaffected side. d. in a Trendelenburg position.

ANS: B Lying on the affected side facilitates drainage following a myringotomy. REF: Page 1062 TOP: Myringotomy

13. The school nurse recognizes that lack of physical activity and increased consumption of fast food by children are causative factors contributing to which of the following problems? a. Nutritional disorders b. Weight gain c. Type I diabetes d. Dental caries

ANS: B Many factors have contributed to the excess weight carried by children, including lack of physical activity and increased consumption of fast food. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 920 OBJ: 1 TOP: Obesity KEY: Nursing Process Step: Assessment

18. Because of the Healthy People 2010 findings relative to adolescents' health needs, the public health nurse led the move to create a citywide program for: a. a juvenile diabetic seminar. b. a teenage suicide hotline. c. scoliosis screening. d. a teenage parenting course.

ANS: B Mental health issues include depression, suicide, eating disorders, and substance abuse. REF: Page 930 TOP: Mental health

29. When selecting nursing diagnoses for the 4-year-old child with nephrosis, the nurse places priority on risk for: a. impaired body image. b. skin impairment. c. nutritional deficit. d. injury.

ANS: B Nephrosis is a clinical state characterized by gross edema, which makes skin care a priority. REF: Page 1027 TOP: Genitourinary disorders

32. The pediatric nurse warns student nurses about medicating newborns and young children because these children are: a. less susceptible to medication effects than adults. b. more susceptible to medication effects than adults. c. equally susceptible to medication effects as adults. d. less susceptible to all medications.

ANS: B Newborns and young children are more susceptible to the toxic effects of some medications than adults. REF: Page 972 TOP: Medication

51. A nurse assessing a toddler should consider which finding abnormal? a. Lumbar lordosis b. Cyanotic nailbeds c. A protruding abdomen d. A convex lumbar curve

ANS: B Normal assessment findings in a toddler include lumbar lordosis (convex lumbar curve) and a protruding abdomen. Cyanotic nailbeds is an abnormal finding. REF: Page 192 TOP: Abnormal findings

38. The nurse is caring for a newborn with a myelomeningocele. Before surgery, the nursing interventions should include: a. leaving the lesion uncovered and placing the infant supine. b. covering the lesion with a sterile, saline-soaked gauze. c. applying lotion to the lesion to keep it moist. d. covering the lesion with a dry, sterile gauze.

ANS: B Nursing interventions for an infant with myelomeningocele include covering the lesion with a sterile, saline-soaked gauze. DIF: Cognitive Level: ApplicationREF: Page 1047, Box 31-10 OBJ: 13 TOP: Spina bifida

43. A new mother asks the clinic nurse if she must continue giving her baby nystatin for thrush since the white lesions on his tongue have disappeared. The nurse replies: a. "No. When the lesions have gone you may stop the nystatin." b. "Yes. You should continue it for the full 7 days." c. "No. Thrush is a self-limiting disorder and nystatin is given for comfort only." d. "Yes. The medication should be refilled for a second week of therapy."

ANS: B Nystatin should be given for the full 7 days even if the lesions are no longer present. REF: Page 1057 TOP: Skin disorders

25. The home health nurse assesses an older adult's respiratory function carefully because age-related changes in the respiratory system could result in increased: a. vital capacity. b. susceptibility to respiratory infections. c. expiratory capacity due to increased chest size. d. oxygen and carbon dioxide exchange.

ANS: B Older adults are more susceptible to respiratory infections. REF: Page 212, Table 9-4 TOP: Older adult

60. A child who has just begun to demonstrate egocentric thinking is in which of Piaget's stages of cognitive development? a. Sensorimotor b. Preoperational thought c. Formal operational thought d. Concrete operational thought

ANS: B Piaget's preoperational stage of cognitive development includes the development of egocentric thinking (understanding the world from only one perspective, that of the self). REF: Page 188, Box 9-6 TOP: Piaget

1. Dr. Abraham Jacobi focused attention on health problems in children and made a major stride toward their welfare by initiating: a. pediatric wards in hospitals. b. free inoculations against smallpox. c. milk stations in the city of New York. d. serving nutritious foods in orphanages.

ANS: C Dr. Abraham Jacobi, referred to as the father of pediatrics, initiated the establishment of milk stations in New York showing how to sanitize milk for children. REF: Page 942 TOP: Abraham Jacobi

1. The nurse uses a diagram to show that tetralogy of Fallot involves a combination of which four congenital defects? a. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy b. Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy c. Aortic stenosis, atrial septal defect, overriding aorta, right ventricular hypertrophy d. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy

ANS: B Tetralogy of Fallot involves a combination of four congenital defects: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. REF: Page 990 TOP: Heart defect

52. The theory of aging that suggests the body becomes less able to recognize or tolerate the "self" is the: a. free radical theory. b. autoimmunity theory. c. wear-and-tear theory. d. biologic programming theory.

ANS: B The autoimmunity theory holds that with aging the body becomes less able to recognize or tolerate the "self." As a result the immune system produces antibodies that act against the self. REF: Page 210 TOP: Theories of aging

23. The nurse reminds an older adult patient that the task for the older adult is to achieve ego integrity. Failure to achieve this task results in: a. failure. b. despair. c. reminiscing. d. accomplishment.

ANS: B The challenge of late adulthood is integrity versus despair. REF: Page 211 TOP: Older adult

10. A 2-year-old child with laryngotracheobronchitis (LTB) is fussy and restless in the oxygen tent. The oxygen level in the tent is 25%, and blood gases are normal. The nurse should: a. restrain the child in the tent and notify the physician. b. increase the oxygen concentration in the tent. c. take the child out of the tent and into the playroom. d. ask the mother for help in comforting the child.

ANS: B The child with LTB should be placed in the mist tent with 30% oxygen. Restlessness is caused by poor oxygenation. REF: Page 1009 TOP: Laryngotracheobronchitis (LTB)

Montgomery's tubercles

Answer: Montgomery's tubercles are sebaceous glands in the areola Rationale: hey are inactive and not obvious except during pregnancy and lactation, when they enlarge and secrete a substance that keeps the nipple soft. Within each breast are lobes of glandular tissue that secrete milk. Alveoli are small sacs that contain acinar cells to secrete milk.

8. The parents of a child with acute lymphoblastic leukemia ask about the best approach for maintaining remission of the disease. The nurse informs them that the most effective therapy would be: a. surgery to remove enlarged lymph nodes. b. long-term chemotherapy. c. nutritional supplements to enhance blood cell production. d. blood transfusions to replace ineffective red cells.

ANS: B The drug of choice is methotrexate, a chemotherapeutic agent, to produce remission. REF: Page 998 TOP: Blood disorders

26. When assessing a child admitted with intussusception, the nurse discovers the hallmark sign of intussusception, which is: a. mucus-like stools. b. currant jelly-like stools. c. tarry, black stools. d. green, soft stools.

ANS: B The hallmark sign of intussusception is currant jelly stools. REF: Page 1023 TOP: Gastrointestinal disorders

18. The nurse informs a group of young adults that the leading cause of death in their age group is: a. diabetes. b. accidents. c. hypertension. d. testicular cancer.

ANS: B The leading cause of death in young adults is accidents. REF: Page 200 TOP: Accidents

13. The mother of a child who has pneumonia is asking what could have been done to prevent the infection. The nurse teaches the mother that children older than 2 years: a. are still protected by antibodies from the mother. b. can be inoculated against pneumococcal pneumonia. c. may have nutritional deficits that make them vulnerable. d. are frequently sedentary, which makes them susceptible to infections.

ANS: B The new recommendations for inoculations include protection against pneumonia. REF: Page 1042 TOP: Pneumonia

34. The stage of family development that begins at the birth or adoption of the first child is known as the: a. expectant stage. b. parenthood stage. c. establishment stage. d. engagement/commitment stage.

ANS: B The parenthood stage begins at the birth or adoption of the first child. REF: Page 185 TOP: Family development

35. The stage of family development in which the transition to parenthood is seen as a major event is known as the: a. expectant stage. b. parenthood stage. c. establishment stage. d. engagement/commitment stage.

ANS: B The parenthood stage begins at the birth or adoption of the first child. The transition to parenthood is seen as a major event. REF: Page 185 TOP: Family development

28. When a child with respiratory difficulties is placed in a mist tent, the nurse explains that the purpose of the tent is to: a. provide a constant oxygen supply. b. liquefy respiratory secretions. c. provide moisture to the mucous membranes. d. improve the infant's hydration.

ANS: B The purpose of the mist tent is to liquefy respiratory secretions. REF: Page 971 TOP: Mist tent

37. The stage of family development that is considered to be the last stage of the life cycle is known as the: a. expectant stage. b. senescence stage. c. establishment stage. d. disengagement stage.

ANS: B The senescence stage is the last stage of the life cycle, which requires the individual to cope with a large range of changes. For the older adult the family unit continues to be a major source of satisfaction and pleasure. Most older adults prefer to live independently. REF: Page 185 TOP: Family development

5. The parents of a child who has been diagnosed with sickle cell anemia ask why their child experiences pain. The nurse explains that the child's pain is caused by: a. inflammation of the vessels. b. obstructed blood flow. c. overhydration. d. stress-related headaches.

ANS: B The signs and symptoms of sickle cell anemia include the sickle-shaped cells clumping and obstructing blood flow, which causes pain. REF: Page 993 TOP: Blood disorders

30. When caring for a 7-week-old infant with hypothyroidism, the nurse explains that the administration of oral thyroid replacement therapy is critical for this child to prevent: a. excessive growth. b. cognitive impairment. c. damage to the nervous system. d. damage to the urinary system.

ANS: B The treatment of choice for congenital and acquired hypothyroidism is oral thyroid hormone replacement therapy. Prompt treatment is especially critical in the infant with congenital hypothyroidism to avoid permanent cognitive impairment. REF: Page 1030 TOP: Hypothyroidism

18. When assessing a neonate, the pediatric nurse should alert the head nurse or physician about which assessment finding? a. Crossed eyes b. A tuft of hair on the sacrum c. Purposeless movement of the arms d. Blue tint to the soles of the feet

ANS: B The tuft of hair along the spine is an indicator for spina bifida occulta. All other options are normal in the newborn. REF: Page 951 TOP: Newborn assessment

33. A newborn has talipes and has been casted. The nurse explains that the casts must be changed: a. daily. b. weekly. c. bi-weekly. d. monthly.

ANS: B Treatment of talipes consists of manipulation and the application of a series of short leg casts. The foot is gently manipulated into a more normal position and then casted to maintain the correction. Casts are changed weekly to allow for further manipulation and to accommodate the rapidly growing infant. REF: Pages 1038-1039 TOP: Club foot

19. Following surgical repair of a cleft palate, when soft food is introduced, the nurse modifies the care plan to include feeding safety based on the knowledge that to avoid injury to the suture line, it is best to avoid the use of a: a. feeding dropper. b. spoon. c. syringe. d. cup.

ANS: B When feeding a child with a repaired cleft palate, the nurse should avoid utensils. REF: Page 1017 TOP: Cleft lip and palate Step: Planning

40. When speaking to young parents, the nurse states that lead poisoning is one of the most common preventable health problems affecting children. When lead levels exceed the amount that can be absorbed by the bones, it leads to: a. malnutrition. b. anemia. c. bone pain. d. diarrhea.

ANS: B When the amount of lead ingested exceeds the amount that can be absorbed by the bone, it leads to anemia. REF: Page 1049 TOP: Lead poisoning

19. Which are physical risks associated with excess weight? (Select all that apply.) a. Poor eyesight b. Heart disease c. Arthritis d. Stroke e. Appendicitis

ANS: B, C, D Heart disease, arthritis, and stroke are physical risks that are associated with excess weight. Poor eyesight and appendicitis are not associated with weight gain. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 920 OBJ: 10 TOP: Obesity KEY: Nursing Process Step: Implementation

20. Which of the following interventions should be included when teaching a healthy behaviors class for parents of adolescents? (Select all that apply.) a. Always monitor the child's telephone conversations b. Insist on seatbelt use at all times c. Encourage tanning bed use versus exposure to the sun d. Maintain recommended immunization schedule e. Encourage good dental care

ANS: B, D, E Adolescents should always wear seatbelts. Immunizations should be obtained according to the recommended schedule. Good dental care is important. Parents should give the child privacy in their telephone conversations. Tanning bed exposure is as detrimental to skin as exposure to the sun and both should be avoided. PTS: 1 DIF: Cognitive Level: Application REF: Page 921 OBJ: 10 TOP: Healthy behaviors KEY: Nursing Process Step: Implementation

6. Problems such as domestic violence, sexually transmitted infections (STIs), school failure, and motor vehicle accidents (MVAs) are attributed to: a. lack of supervision. b. psychological problems. c. substance abuse. d. physiological problems.

ANS: C Substance abuse is associated with many social problems such as domestic violence, STDs, school failure, and MVAs. REF: Page 929 TOP: Substance abuse

27. When a 2-year-old child is admitted with a diagnosis of Hirschsprung's disease, the nurse explains that the causative factor of this disease is: a. frequent evacuation of solids, liquid, and gases. b. excessive peristaltic movement. c. the absence of parasympathetic ganglion cells in a portion of the colon. d. one portion of the bowel telescoping into another.

ANS: C The causative factor in Hirschsprung's disease is the absence of parasympathetic ganglion cells in a portion of the colon. REF: Page 1024 TOP: Gastrointestinal disorders

6. The pediatric nurse who uses the developmental approach in her practice will focus on: a. stimulation of the child to reach expected norms. b. age-centered care plans. c. strengths of the child. d. characteristics for the particular age.

ANS: C A developmental approach emphasizes the child's abilities and considers individuality. REF: Page 946 TOP: Developmental approach

20. The nurse is assisting the parents of a child born with a cleft lip and palate to deal with the deformity. An appropriate nursing diagnosis for the parents is: a. parental role conflict. b. risk for delayed growth and development. c. risk for impaired attachment. d. anticipatory grieving.

ANS: C A goal is to promote bonding between parents and infant. REF: Page 1017 TOP: Cleft lip and palate

15. When interacting with the parents of a SIDS infant, one of the things the nurse attempts to assist with is: a. referring the parents to a psychologist. b. encouraging the parents to remain stoic. c. allaying feelings of guilt and blame. d. learning how the event could have been prevented.

ANS: C As parents try to cope, they have feelings of guilt and blame. REF: Page 1007 TOP: Sudden infant death syndrome (SIDS)

36. The nurse can minimize an unpleasant-tasting drug by: a. pouring the drug over ice. b. squirting the drug in the mouth with a syringe. c. administering the drug through a straw. d. enlisting the parent's assistance.

ANS: C Administering the drug through a straw will diminish an unpleasant taste. Having the child hold the nose is helpful, as bad taste is associated with the smell of the drug. REF: Page 974 TOP: Medication

9. What practice should be used by a pediatric nurse to remind parents of their responsibility in reducing the number of accidents involving children? a. Child awareness b. Good manners c. Anticipatory guidance d. Strict discipline

ANS: C Anticipatory guidance has been the most widely used approach to educating parents in accident prevention. PTS: 1 DIF: Cognitive Level: Application REF: Page 926 OBJ: 9 TOP: Injury prevention KEY: Nursing Process Step: Implementation

23. When attempting to provide information to the parents of a child undergoing surgery, the nurse notes that the parents appear confused and do not seem to remember what they are being told. This may be because of the: a. noisy environment. b. serious nature of surgery. c. increased level of parents' anxiety. d. developmental age of the child.

ANS: C Anxiety of the parents may result in confusion and forgetfulness. REF: Page 963 TOP: Hospitalization

27. Before performing a gavage feeding, the nurse should: a. hold the feeding tube under water to check for bubbling. b. check for gastric distention. c. aspirate stomach contents. d. ensure sterility of feeding equipment.

ANS: C Aspirating stomach contents to confirm tube placement is the most effective test. REF: Page 967 TOP: Tube feedings

49. A nurse instructing the mother of a young infant about how to introduce solid foods into the infant's diet should instruct the mother to: a. introduce fruits and vegetables first. b. mix foods to allow the infant variety. c. introduce only one new food at a time. d. introduce new foods at 24-hour intervals.

ANS: C Cereals should be introduced first, followed by fruits and vegetables, and last meats. Only one new food should be introduced at a time, followed by several days between new foods. Food should not be mixed to allow the infant to develop interest in different foods and tastes. REF: Page 191 TOP: Diet

2. What is the single most preventable cause of death and disease in the United States today? a. Drug use b. Alcohol addiction c. Cigarette smoking d. Malnutrition

ANS: C Cigarette smoking continues to be the single most preventable cause of death. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 921 OBJ: 1 TOP: Tobacco use KEY: Nursing Process Step: Assessment

4. The nurse informs a group of adolescents that the single most preventable cause of death and disease in the United States today is: a. drug use. b. alcohol addiction. c. cigarette smoking. d. malnutrition.

ANS: C Cigarette smoking continues to be the single most preventable cause of death. REF: Page 929 TOP: Tobacco use

24. When assessing the home for fall risks and increased safety for an 85-year-old, the home health nurse suggests that: a. bright lights be kept on at all times. b. sponge baths be taken rather than showers. c. excess furniture be removed. d. loose, comfortable shoes be worn.

ANS: C Clearing the home of excess furniture, scatter rugs, use of night lights, and wearing supportive shoes reduce the risk of falls in older adults. REF: Page 215, Safety Alert! TOP: Older adult

A pediatric nurse is caring for a hospitalized toddler. The nurse determines that the appropriate play activity for the toddler is which of the following?

Answer: Playing with a push-pull toy Rationale: The toddler has increased use of motor skills and enjoys manipulating small objects such as toy people, cars, and animals.

49. The nurse instructs the mother of a child with a ventricular septal defect that she can expect the child to become cyanotic when the child does what? a. Experiences an elevation in temperature b. Sleeps on the left side c. Cries vigorously d. Is held upright e. Eats

ANS: C Crying vigorously will increase the pressure in the right ventricle, which will allow unoxygenated blood to enter the circulating volume. REF: Page 990 TOP: Septal defects

28. The nurse caring for a 6-year-old child with acute glomerulonephritis anticipates that the most difficult part of the care will be implementing: a. forced fluids. b. increased feedings. c. bed rest. d. frequent position changes.

ANS: C During the acute phase of glomerulonephritis, bed rest is usually recommended. A diet of restricted fluid, sodium, potassium, and phosphate is initially required. REF: Page 1028 TOP: Genitourinary disorders

3. Smoking contributes to an increased risk of heart and lung disease in children by which methods? a. Air pollution b. Allergens in the environment c. Environmental smoke d. Lack of oxygen in the air

ANS: C Environmental smoke may result in an increased risk of heart and lung disease, particularly asthma and bronchitis in children. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 922 OBJ: 1 TOP: Tobacco use KEY: Nursing Process Step: Assessment

5. The school nurse develops a campaign to make parents aware of how smoking can contribute to an increased risk of heart and lung disease in children caused by: a. air pollution. b. allergens in the environment. c. environmental smoke. d. lack of oxygen in the air.

ANS: C Environmental smoke may result in an increased risk of heart and lung disease, particularly asthma and bronchitis in children. REF: Page 929 TOP: Tobacco use

4. The nurse recognizes that children who have congenital abnormalities, malignancies, gastrointestinal (GI) diseases, or central nervous system (CNS) anomalies are grouped into a special category called: a. very dependent children. b. children requiring special education. c. children with special needs. d. children requiring long-term care.

ANS: C The definition of children with special needs includes congenital abnormalities, malignancies, GI diseases, and CNS anomalies. REF: Page 944 TOP: Children

11. What is the leading cause of fatal injury in children younger than 1 year old? a. Burns b. Poisons c. Asphyxiation d. Motor vehicle accidents

ANS: C In children younger than 1 year, the leading cause of fatal injury is asphyxiation by aspiration of foreign material into the respiratory tract. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 928 OBJ: 6 TOP: Asphyxiation KEY: Nursing Process Step: Implementation

13. The home health nurse stresses to parents that the leading cause of fatal injury in children younger than 1 year of age is from: a. burns. b. poisons. c. asphyxiation. d. motor vehicle accidents.

ANS: C In children younger than 1 year, the leading cause of fatal injury is asphyxiation. REF: Page 938 TOP: Asphyxiation

1. The nurse stresses that regular physical activity has been identified as a leading health indicator. Regular physical activity has which positive effect on children? a. Improves social skills b. Reduces fluid retention c. Increases bone and muscle strength d. Increases attention span

ANS: C In children, regular physical activity increases bone and muscle strength. REF: Page 927 TOP: Physical activity

21. When the newly admitted 2-year-old who was potty-trained before admission begins to wet the bed, the mother is frightened. The nurse can allay anxiety by saying: a. "Don't be concerned. Accidents happen." b. "Let's put a diaper on your child until this gets better." c. "The stress of hospitalization makes children regress a little." d. "Your child will relearn 'potty-training' if you are patient."

ANS: C It is not unusual for children to regress when hospitalized. REF: Page 960 TOP: Hospitalization regression

35. When assessing a child for classical signs of meningeal irritation, the nurse records: a. positive Kernig's sign, diarrhea, and headache. b. negative Brudzinski's sign, positive Kernig's sign, and irritability. c. positive Brudzinski's and Kernig's signs and photophobia. d. negative Kernig's sign, vomiting, and fever.

ANS: C Manifestations of meningitis include photophobia and positive Kernig's and Brudzinski's signs. REF: Page 1041 TOP: Meningitis

10. To prevent accidental poisoning of a child, where should medications be placed in the home? a. In a dresser drawer b. In the medicine cabinet c. In a locked cupboard d. On a high shelf

ANS: C Medications should be kept in a locked cupboard. PTS: 1 DIF: Cognitive Level: Application REF: Page 928 OBJ: 5 TOP: Poisoning KEY: Nursing Process Step: Implementation

12. To prevent accidental poisoning of a child, parents are instructed by the home health nurse to place medicines: a. in a dresser drawer. b. in the medicine cabinet. c. in a locked cupboard. d. on a high shelf.

ANS: C Medications should be kept in a locked cupboard. REF: Page 937 TOP: Poisoning

8. The nurse explains that a baby's muscular development progresses in a pattern that is: a. regressive. b. erratic. c. cephalocaudal. d. unpredictable.

ANS: C Muscular development proceeds from head to foot (cephalocaudal). REF: Page 182 TOP: Growth

62. A child who is able to use a systematic, scientific problem-solving approach is in which of Piaget's stages of cognitive development? a. Sensorimotor b. Preoperational thought c. Formal operational thought d. Concrete operational thought

ANS: C Piaget's formal operational stage of cognitive development includes the ability to use a systematic, scientific problem-solving approach. REF: Page 188, Box 9-6 TOP: Piaget

15. What age group is experiencing the largest increase in drug use? a. 7- to 9-year-olds b. 10- to 12-year-olds c. 12- to 13-year-olds d. 15- to 17-year-olds

ANS: C Research shows an increase in children aged 12 to 13 years who are experimenting with drugs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 922 OBJ: 1 TOP: Substance abuse KEY: Nursing Process Step: Implementation

17. The school nurse focuses a drug awareness program on the age group that has the largest increase in drug use. That age group is: a. 7- to 9-year-olds. b. 10- to 12-year-olds. c. 12- to 13-year-olds. d. 15- to 17-year-olds.

ANS: C Research shows an increase in children aged 12 to 13 years who are experimenting with drugs. REF: Page 929 TOP: Substance abuse

The nursing student is preparing a conference on Freud's psychosexual stages of development, specifically the anal stage. Which appropriately relates to this stage?

Beginning of toilet training Rationale: Toilet training generally occurs during this period. According to Freud, the child gains pleasure from both the elimination and retention of feces.

56. A nurse instructing a group of parents about steps to reduce the incidence of sudden infant death syndrome should instruct the parents to: a. bottle-feed an infant at night. b. place infants on their stomach to sleep. c. keep an infant's room well ventilated. d. place soft bedding and pillows in an infant's crib.

ANS: C Steps to reduce the incidence of sudden infant death syndrome include placing infants on their back to sleep, avoiding exposure to cigarette smoke, avoiding using soft bedding or pillows, keeping rooms well ventilated, breastfeeding if possible, and maintaining regular medical checkups for infants. REF: Page 192, Safety Alert! TOP: Safety

4. Which factor is mostly associated with problems such as domestic violence, sexually transmitted infections (STIs), school failure, and motor vehicle accidents (MVAs)? a. Lack of supervision b. Psychological problems c. Substance abuse d. Physiological problems

ANS: C Substance abuse is associated with many social problems such as domestic violence, STIs, school failure, and MVAs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 922 OBJ: 1 TOP: Substance abuse KEY: Nursing Process Step: N/A

14. When conducting a class for parents about sudden infant death syndrome (SIDS), the nurse instructs the class that new information suggests not placing the infant in which position? a. Right side-lying b. Left side-lying c. Prone d. Supine

ANS: C The American Academy of Pediatrics recommends placing the infant supine or side- lying rather than prone as a defense against SIDS. REF: Page 1006 TOP: Sudden infant death syndrome (SIDS)

32. A teenage girl has been placed in a body cast for the treatment of scoliosis, the most common skeletal deformity of adolescence. When the family asks what they can do to be more supportive, the nurse suggests: a. enrolling her in a health club. b. taking her to the mall in a wheelchair. c. purchasing clothes to disguise the cast. d. spending a majority of their time with her.

ANS: C The adolescent is trying to fit in with peers and has concerns about body image. REF: Pages 1036-1038 TOP: Scoliosis

1. The nurse tells a mother that the blueprint for all inherited traits, such as height, is found in the: a. sperm. b. ovary. c. chromosomes. d. nucleus of the cell.

ANS: C The blueprint for all inherited traits is found in the chromosomes. REF: Page 182 TOP: Growth

36. The physician is treating a child with meningitis with a course of antibiotic therapy. The nurse assures the parents that the child will be out of isolation when: a. the course of antibiotics is complete. b. a negative CNS culture is obtained. c. the antibiotics have been initiated for 24 hours. d. the child has no symptoms of the disease.

ANS: C The child with bacterial meningitis is isolated until antibiotic therapy has been administered for at least 24 hours. REF: Page 1041 TOP: Meningitis

32. The stage of family development that extends from the wedding until the birth of the first child is known as the: a. expectant stage. b. parenthood stage. c. establishment stage. d. engagement/commitment stage.

ANS: C The establishment stage extends from the wedding until the birth of the first child. During this phase, one of the important tasks is the adjustment from the single independent to the married, interdependent state. The challenges facing the newly married couple include learning to live with another person, decision making, conflict resolution, and communication. REF: Page 185 TOP: Family development

11. In response to a mother's concern about the development of a food allergy in her 5-month-old, the nurse suggests delaying introduction of foods including: a. oat cereals. b. potatoes. c. citrus fruits. d. green vegetables.

ANS: C The general guideline for foods to avoid until the baby is 6 months old are egg whites, citrus fruits, and wheat flour. REF: Page 191 TOP: Allergy

14. When assessing jaundice in an African-American child with sickle cell anemia, the nurse should: a. examine the sclera. b. press the edge of the pinna. c. apply pressure to the gum. d. compare the color on the soles of the feet.

ANS: C The gums in individuals with dark complexions can be used to assess jaundice by pressing the gums about the teeth. REF: Page 951 TOP: Jaundice

38. The nurse recognizes that during the first 5 months of life, an infant is expected to gain approximately how many pounds per month? a. 0.5 b. 1 c. 1.5 d. 2

ANS: C The infant is expected to gain about 1.5 pounds per month until 5 months. REF: Page 189 TOP: Growth and development

17. When reviewing the pathophysiology of cystic fibrosis, the nurse recognizes that it is characterized by: a. multiple upper respiratory infections. b. an underproduction of exocrine glands. c. excessive, thick mucus. d. an overproduction of thin mucus.

ANS: C The pathophysiology of cystic fibrosis includes excessive, thick mucus. REF: Page 1011 TOP: Cystic fibrosis

33. The nurse preparing to administer an IM injection to a 2-year-old recognizes the preferred injection site for a child of this age is the: a. deltoid muscle. b. upper thigh. c. mid-thigh. d. gluteus.

ANS: C The primary site for an IM injection for a 2-year-old is the vastus lateralis. REF: Page 976, Box 30-10 TOP: IM medication

4. Therapeutic management of iron deficiency anemia includes administration of what? a. Multivitamins b. Calcium c. Ferrous sulfate d. Iodine

ANS: C Therapeutic management of iron deficiency anemia is iron supplementation. REF: Pages 992-993 TOP: Anemia

46. A child has developed a diaper rash, and the parents are using zinc oxide to treat it. The nurse is instructing the parents about removal of the ointment and suggests using: a. mild soap and water. b. a cotton ball. c. mineral oil. d. alcohol swabs.

ANS: C To completely remove ointment, especially zinc oxide, mineral oil should be used. DIF: Cognitive Level: ApplicationREF: Page 1052, Box 31-12 OBJ: 15 TOP: Diaper rash

3. When the pediatric nurse is attempting to establish a trusting relationship with a child, the most important and lasting thing to be done is to: a. convey respect. b. talk with the child. c. be honest. d. talk with family.

ANS: C To establish a trusting relationship, the most important thing is to be honest. REF: Page 943 TOP: Pediatric nurse

34. A child with Duchenne's muscular dystrophy rises from the floor by walking up the thighs with the hands. The nurse records this observation as: a. hand-assistance. b. leg crawling. c. Gowers' sign. d. Bright's sign.

ANS: C Using the hands to walk up the thighs is known as Gowers' sign. REF: Page 1039 TOP: Duchenne's muscular dystrophy (DMD)

22. The nurse measures intake and output for an infant with dehydration by: a. attaching a urine collecting bag. b. wringing out the diaper. c. weighing the diaper. d. inserting a catheter.

ANS: C Wet diapers can be weighed to assess the amount of output. REF: Page 1018 TOP: Dehydration

17. The nurse explains to the anxious parents that the administration of an opioid analgesic to their 3-year-old is: a. likely to cause significant respiratory depression. b. done with the knowledge that addiction may occur. c. effective as a pain control method. d. given only in cases of severe pain.

ANS: C When administered to children, opioid analgesics do not have any greater respiratory depression than when given to an adult, and the risk of addiction is virtually nonexistent in children. It is an effective type of analgesia. REF: Page 962 TOP: Opioid analgesia

5. The mother of a child with diabetes asks the nurse in charge of the family-centered pediatric unit if she might see her child's laboratory reports. The nurse should reply: a. "Although the actual reports are not shared, I can tell you her blood sugar is 200 mg." b. "I'll write them down for you and bring them to your room." c. "Come to the conference room where we can have privacy while you look at them." d. "I'll notify the physician that you wish to see the reports."

ANS: C With a family-centered care approach, hospitals welcome parents, and parents have access to information 24 hours a day. REF: Pages 944-945 TOP: Family-centered care

14. The home health nurse assesses the home for possible dangers because of her awareness that the second leading cause of accidental death in children 1 to 4 years of age is: a. falls. b. asphyxiation. c. poisons. d. burns.

ANS: D Burns are the second leading cause of accidental death in children 1 to 4 years of age. REF: Page 938 TOP: Burns

12. What is the third leading cause of accidental death in children 1 to 4 years of age? a. Falls b. Asphyxiation c. Poisons d. Burns

ANS: D Burns are the third leading cause of accidental death in children 1 to 4 years of age. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 928 OBJ: 9 TOP: Burns KEY: Nursing Process Step: Assessment

22. There are many theories of aging. The one that claims there is a hereditary basis for aging is: a. activity theory. b. physiological theory. c. disengagement theory. d. biological programming theory.

ANS: D Biological programming theory suggests a hereditary basis for aging. REF: Page 210 TOP: Aging

9. The pediatric nurse reminds the parents of a 2-year-old that by this age the child should be protected against how many vaccine-preventable childhood diseases? a. 4 b. 6 c. 8 d. 10

ANS: D Children who follow the immunization schedule are protected against 10 vaccine- preventable childhood diseases by age 2. REF: Page 931 TOP: Immunizations

11. The mother of a child with acute laryngotracheobronchitis (LTB) asks why her child must be kept NPO. The nurse explains that: a. the epinephrine given causes nausea and vomiting. b. the child is being hydrated with IV fluids. c. swollen respiratory passages make eating difficult. d. the child's rapid respirations pose a risk for aspiration.

ANS: D Rapid respirations predispose to aspiration. REF: Page 1009 TOP: Laryngotracheobronchitis (LTB)

37. The nurse caring for a 4-year-old child with cerebral palsy recognizes that the priority nursing interventions are designed to: a. assist with referral to specialized education. b. support the child with independent toileting. c. assist the child to develop effective communication. d. encourage the child to ambulate independently.

ANS: D A clinical manifestation of cerebral palsy is usually the need of support with communication, locomotion, and self-help. REF: Page 1045 TOP: Cerebral palsy Step: Planning

2. When speaking to a parents' group, the nurse cites a study that found that 11% of children between 6 and 19 were overweight or obese. The nurse explained the goal of Healthy People 2010 is to reduce this to: a. 10%. b. 8%. c. 7%. d. 5%.

ANS: D A goal of Healthy People 2010 is to reduce child obesity to 5%. REF: Page 927 TOP: Physical activity

53. The theory of aging that suggests there should be a natural withdrawal between the individual and society is the: a. free radical theory. b. autoimmunity theory. c. wear-and-tear theory. d. disengagement theory.

ANS: D According to supporters of the disengagement theory of aging, there should be a natural withdrawal, or disengagement, between the individual and society. REF: Page 211 TOP: Theories of aging

21. Prejudice against older adults is known as: a. socialism. b. sexism. c. racism. d. ageism.

ANS: D Ageism is a form of discrimination and prejudice against the older adult. REF: Page 208 TOP: Late adulthood

7. When using anticipatory guidance to prepare a 5-year-old for an IM injection, the nurse should state: a. "Ethan, I'm going to give you a shot." b. "Ethan, the doctor wants you to have some medicine, and it will hurt." c. "Ethan, some medicine can only be given with a needle." d. "Ethan, I am going to give you some medicine that will sting, but only for a little while."

ANS: D Anticipatory guidance is the psychological preparation of a patient for a stressful event by explaining what will happen and the probable outcome. REF: Page 947 TOP: Anticipatory guidance

5. Approximately half of all new HIV cases are among people under what age? a. 50 years b. 40 years c. 30 years d. 25 years

ANS: D Approximately half of all new HIV cases are among people younger than 25. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 923 OBJ: 1 TOP: Sexual behavior KEY: Nursing Process Step: Implementation

7. The college counselor stresses safe sex because he is aware that half of all new HIV cases are among people younger than: a. 50 years. b. 40 years. c. 30 years. d. 25 years.

ANS: D Approximately half of all new HIV cases are among people younger than 25. REF: Page 930 TOP: Sexual behavior

46. A nurse assessing a 4-month-old infant expects the infant to: a. crawl up the stairs. b. creep on the floor at least 30 feet. c. walk upright with a waddling gait. d. hold head at a 90-degree angle while prone.

ANS: D At 4 months the infant is able to hold the head up steadily to a 90-degree angle while in the prone position. Infants may crawl at 7 months and creep at about 9 months. Standing with support and walking occur at about 8 months to 15 months. REF: Page 190 TOP: Growth and development

44. A nurse recognizes that the average resting respiratory rate for a 12-month-old child is approximately: a. 15 breaths per minute. b. 20 breaths per minute. c. 25 breaths per minute. d. 30 breaths per minute.

ANS: D Average resting respiratory rate for the 12 month old is about 30 breaths per minute. REF: Page 189 TOP: Growth and development

24. The best time to bathe an infant is: a. at bedtime. b. early in the morning. c. after a feeding. d. before a feeding.

ANS: D Bathing is usually done before a feeding to reduce the possibility of vomiting, regurgitation, or aspiration. REF: Page 965 TOP: Feeding Step: Planning

9. The nurse counsels a young family that a child must have adequate physiological, neuromuscular, and psychological maturity to master toilet training, usually around the age of: a. 6-10 months. b. 10-14 months. c. 14-18 months. d. 18-24 months.

ANS: D Children reach psychological and physiological maturity for toilet training by 18 to 24 months. REF: Page 194 TOP: Toilet training

3. The school nurse designed a home program to increase physical activity in children while at home to reduce the time spent watching television. The average amount of time children spend in media-focused activities per day is estimated at: a. 2 hours. b. 4 hours. c. 5 hours. d. hours.

ANS: D Children spend an average of hours a day with various media. REF: Page 928 TOP: Physical activity

7. The pediatric nurse reminds the parents of a 2-year-old that by this age the child should be protected against how many vaccine-preventable childhood diseases? a. 4 b. 6 c. 8 d. 10

ANS: D Children who follow the immunization schedule are protected against 10 vaccine-preventable childhood diseases by age 2. PTS: 1 DIF: Cognitive Level: Application REF: Page 924 OBJ: 3 TOP: Immunizations KEY: Nursing Process Step: Implementation

22. When initiating a care plan for a child with special needs, the nurse recognizes the probability that the child will be: a. accustomed to the hospital milieu. b. unable to adapt to the hospital setting. c. withdrawn and uncooperative. d. hospitalized for a longer period of time.

ANS: D Children with special needs who are hospitalized are more vulnerable to the emotional and developmental consequences of hospitalization and will have longer and more traumatic hospital stays. REF: Page 960 TOP: Hospitalization of child with special needs

25. The nurse assessing an infant who has been diagnosed with hypertrophic pyloric stenosis anticipates: a. a history of diarrhea following each feeding. b. gastric pain evidenced by vigorous crying. c. poor appetite due to a poor sucking reflex. d. an olive-shaped mass at the midline.

ANS: D Examination of the abdomen may assist in the diagnosis and reveal key signs of hypertrophic pyloric stenosis. Visible peristaltic waves that move from left to right across the epigastric region may be evident, and palpation may reveal an olive-shaped mass in this area to the right of the midline. REF: Page 1022 TOP: Pyloric stenosis

7. When reviewing laboratory results for a child with hemophilia, the nurse anticipates finding an abnormal: a. prothrombin time. b. bleeding time. c. platelet count. d. partial thromboplastin time.

ANS: D Expected laboratory findings for a child with hemophilia include a prolonged partial thromboplastin time. REF: Page 995 TOP: Blood disorders

16. Because the water in the infant's residential area is not fluoridated, when should the nurse suggest that the infant receive supplemental fluoride? a. 2 months old b. 4 months old c. 5 months old d. 6 months old

ANS: D Fluoride supplementation should be initiated at 6 months of age if the water in the infant's residential area is not fluoridated. PTS: 1 DIF: Cognitive Level: Application REF: Page 926 OBJ: 4 TOP: Dental care KEY: Nursing Process Step: Implementation

19. Because the water in the infant's residential area is not fluoridated, the nurse suggests the infant receive supplemental fluoride when the infant is: a. 2 months old. b. 4 months old. c. 5 months old. d. 6 months old.

ANS: D Fluoride supplementation should be initiated at 6 months of age if the water in the infant's residential area is not fluoridated. REF: Page 936 TOP: Dental care

8. When measuring the head circumference of an infant, the nurse should place the tape measure: a. across the eyebrows and around the occipital lobe. b. over the zygomatic arches and around the parietal areas. c. around forehead and around the crown of the head. d. above the eyebrows and pinnas and around the occipital lobe.

ANS: D Head circumference is measured in children up to 36 months above the eyebrows and pinnas and around the occipital lobe. REF: Page 948 TOP: Head circumference

30. The family pattern in which the adult members function as equals is known as the: a. autocratic family pattern. b. patriarchal family pattern. c. matriarchal family pattern. d. democratic family pattern.

ANS: D In the democratic family pattern the adult members function as equals. Children are treated with respect and recognized as individuals. This style encourages joint decision making, and it recognizes and supports the uniqueness of each individual member. This family pattern favors negotiation, compromise, and growth. REF: Page 184

15. When discussing growth and development with the parents of a child, the nurse explains that nutrition is the single most important influence on: a. cognitive development. b. secondary sexual characteristics. c. production of blood cells. d. growth of bones and muscle.

ANS: D Nutrition is probably the single most important influence on growth. REF: Page 954 TOP: Nutrition Step: Planning

47. A nurse teaching the mother about infant oral hygiene instructs the mother to offer the infant sips of: a. cola. b. milk. c. juice. d. water.

ANS: D Oral hygiene for the young infant consists of offering sips of clear water and wiping and massaging infant's gums. REF: Page 189 TOP: Dentition

61. A child who has just begun to demonstrate the ability to understand and apply logical operations to help interpret specific experiences or perceptions is in which of Piaget's stages of cognitive development? a. Sensorimotor b. Preoperational thought c. Formal operational thought d. Concrete operational thought

ANS: D Piaget's concrete operational stage of cognitive development includes the ability to understand and apply logical operations or principles to help interpret specific experiences or perceptions. REF: Page 188, Box 9-6 TOP: Piaget

8. A major dental problem among very young children is bottle mouth caries. What is a preventative measure the nurse should suggest? a. Juice at bedtime b. Milk at bedtime c. A sugar-coated pacifier d. Water at bedtime

ANS: D Specific interventions can prevent bottle mouth caries, such as offering water in the bedtime bottle. PTS: 1 DIF: Cognitive Level: Application REF: Page 926 OBJ: 4 TOP: Dental health KEY: Nursing Process Step: Implementation

10. A major dental problem among very young children is bottle mouth caries. The nurse suggests a preventative measure of offering: a. juice at bedtime. b. milk at bedtime. c. a sugar-coated pacifier. d. water at bedtime.

ANS: D Specific interventions can prevent bottle mouth caries, such as offering water in the bedtime bottle. REF: Page 936 TOP: Dental health

37. The pediatric nurse recognizes the significant developmental impact that a disfiguring facial wound could have on a: a. 4-year-old. b. 6-year-old. c. 10-year-old. d. 14-year-old.

ANS: D The adolescent fears a change in body image associated with surgery. REF: Page 963, Table 30-8 TOP: Surgery

36. The stage of family development in which there is a period of family life when the grown children depart from home is known as the: a. expectant stage. b. senescence stage. c. establishment stage. d. disengagement stage.

ANS: D The disengagement stage of parenthood is the period of family life when the grown children depart from the home. REF: Page 185 TOP: Family development

10. To ensure accuracy of measurements, the nurse performs vital signs assessment in which order? a. Respiration, temperature, pulse b. Pulse, respiration, temperature c. Temperature, pulse, respiration d. Respiration, pulse, temperature

ANS: D The respiration is taken first on an infant before the child is disturbed, pulses are assessed next, and last the temperature is obtained. REF: Page 949 TOP: Vital signs

45. The mother of a child who has been diagnosed with varicella asks the nurse when the child can return to school. The nurse states that the child is no longer contagious: a. when the fever dissipates. b. after the incubation period. c. when the lesions have healed. d. when the lesions are crusted over.

ANS: D Varicella is no longer contagious when the lesions are dry. REF: Page 1059, Table 31-7 TOP: Skin disorders

19. When communicating with a 5-year-old child, the nurse should: a. use two-word sentences and colored pictures. b. rely on short three-word sentences. c. use descriptive words with hand gestures. d. speak in no more than six-word sentences.

ANS: D When conversing with children, the nurse should use sentences with the number of words being equal to their age plus 1. A 5-year-old can follow a six-word sentence. REF: Page 957 TOP: Development

23. A school-age child has been rehydrated following a bout of diarrhea. The nurse offers foods that are nonirritating to the bowel, including: a. apricots and peaches. b. chocolate milk. c. applesauce and milk. d. bananas and rice.

ANS: D When rehydration has been completed, the nurse should offer bananas and rice, which are nonirritating. REF: Page 1019 TOP: Nutrition

A 16 yois admitted to the hospital for acute appendicitis, & an appendectomy is performed. Which intervention is most appropriate to facilitate normal growth & development?

Allow the child to participate in activities with other individuals in the same age group when the condition permits.

A 16-year-old child is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which intervention is most appropriate to facilitate normal growth and development?

Allow the child to participate in activities with other individuals in the same age group when the condition permits. Rationale: Adolescents are not often sure they want their parents with them when they are hospitalized. Because of the importance of the peer group, separation from friends is a source of anxiety.

The nurse is providing information to unlicensed assistive personnel (UAP) regarding caring for the older adult. The nurse tells the UAPs that which situation portrays ageism?

Advising older adults to forgo aggressive treatment Rationale: Ageism is a form of prejudice in which older adults are stereotyped by characteristics found in only a few members of their group. Fundamental to ageism is the view that older people are different from "me" and will remain different from "me." Therefore, they are portrayed as not experiencing the same desires, needs, and concerns.

The nurse is reinforcing instructions for a client in how to perform a testicular self-examination (TSE). The nurse explains that which is the best time to perform this exam?

After a shower or bath Rationale: The nurse needs to teach the client how to perform a testicular self-examination (TSE). The nurse should instruct the client to select a day of the month and perform the exam on the same day each month. The nurse should also instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. This will provide ease in palpating, and the client will be better able to identify any abnormalities. The client would stand to perform the exam, but it would be difficult to perform the exam while voiding. Having a bowel movement is unrelated to performing the TSE.

The nurse is providing instructions to a new parent regarding the psychosocial development of the infant. Using Erikson's psychosocial development theory, which instruction should the nurse reinforce to the parents?

Allow the infant to signal a need. Rationale: According to Erikson, the caregiver should not try to anticipate the infant's needs at all times but rather allow the infant to signal his or her needs. If an infant is not allowed to signal a need, he or she will not learn how to control the environment. Erikson believed that a delayed or prolonged response to an infant's signal would inhibit the development of trust and lead to the mistrust of others.

The parent of a 16-year-old child tells the nurse that she is concerned because the child sleeps until noon every weekend and whenever there is a day off from school. Which of the following is the appropriate nursing response?

Answer: "Adolescents love to sleep late in the morning." Rationale: The sleep patterns of the adolescent vary according to individual needs. Adolescents love to sleep late in the morning, but they should be encouraged to be responsible for waking themselves, particularly in time to get ready for school.

The parent of an 8-year-old child tells the nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. The appropriate nursing response would be which of the following?

Answer: "At this age, the child is developing his or her own personality." Rationale:According to Erikson, from the ages of 7 to 12 years, the child begins to move toward receiving support from peers and friends and away from that of parents. The child also begins to develop special interests that reflect his or her own developing personality instead of those of the parents.

The nurse evaluates that the older client needs teaching on how to promote sleep when the client states which of the following?

Answer: "I drink hot chocolate before bedtime." Rationale: Many nonpharmacological sleep aids can be used to influence sleep. The client should avoid caffeinated beverages and stimulants (e.g., tea, cola, chocolate) and foods that contain tyrosine (e.g., cheddar cheese). The client should exercise regularly, because exercise promotes sleep by burning off tension that accumulates during the day

A nurse provides instructions to a parent of a toddler experiencing physiological anorexia. The nurse determines the need for further instructions if the parent makes which statement?

Answer: "I should feed my child if she will not eat." Rationale: Toddlers have the skills required to feed themselves. Children who can feed themselves should not be fed or force fed. To increase nutritious intake, juice intake is limited to 6 ounces per day, and milk intake to 16 to 24 ounces per day. In addition, the nurse instructs the mother to limit nutritious snacks to two per day and to give them only at the toddler's request.

During a well-child checkup for a 4-month-old the nurse teaches the mother how to introduce solid foods into her child's diet. The nurse determines that further teaching is required when the mother states:

Answer: "I will start giving home-prepared orange juice when my child is 3 months old." Rationale: Solids should be introduced over a period of time between the ages of 4 and 6 months. Failure to introduce solids by 6 months of age might prevent the child from accepting solids later. The pattern in which solids are introduced is not important as long as meats are introduced after cereals, fruits, and vegetables

A nurse has given a client instructions on how to do active range-of-motion exercises on her contracted right hand. The nurse determines that the client understands the rationale for this procedure when the client makes which of the following statements?

Answer: "I'm doing these exercises so I can begin to fasten my buttons and dress myself again." Rationale: client understands the purpose of the therapy and provides an incentive for the client to comply with the exercises

The mother of a toddler tells the nurse that she has a difficult time getting the child to go to bed at night. The nurse suggests which of the following to the mother?

Answer: "Inform the child of bedtime a few minutes before it is time for bed." Rationale: Most toddlers take an afternoon nap and until approximately age 2, some also require a morning nap. Toddlers often resist going to bed.

The parent of a 4-year-old child expresses concern because her hospitalized child has started sucking his thumb. The mother states that this behavior began 2 days after hospital admission. Which of the following is the appropriate nursing response?

Answer: "It is best to ignore the behavior." Rationale: In the hospitalized preschooler, it is best to accept regression if it occurs, because it is most often caused by the stress of the hospitalization. Parents may be overly concerned about regression and should be told that their child may continue the behavior at home

A nursing student is asked to describe the corpus of the uterus. Which response by the student indicates an understanding of the anatomy of the uterus?

Answer: "It is the uppermost part of the uterus." Rationale: The uterus has three divisions, the corpus, isthmus, and the cervix. The upper division is the corpus or the body of the uterus. The uppermost part of the uterine corpus, above the area where the fallopian tubes enter the uterus, is the fundus of the uterus.

An older client confides to the visiting nurse that they are afraid they will fall while going to the bathroom at night. Which suggestion, if made by the nurse, indicates an understanding of the visual changes affecting the older client?

Answer: "Keep a red light on in the bathroom at night." Rationale: Because it takes longer to adapt to changes from dark to light and vice versa, older people are at greater risk for falls and injuries. Any place where there is a sudden change from dark to light or from light to dark can be dangerous.

A nursing instructor asks a nursing student about the reason for the reduction of anesthetic medication dosage in the older person. The nursing student appropriately responds by stating:

Answer: "The increase of fatty tissue allows anesthetic agents, which have an affinity for fatty tissue, to concentrate in body fat." Rationale: An older person needs fewer anesthetic agents to produce anesthesia, and it takes longer for the older person to eliminate anesthetic agents. One reason for the reduction of dosage is that the percentage of fatty tissue increases as people age.

A nursing instructor asks a nursing student to describe Montgomery's tubercles of the breast. Which response by the student indicates an understanding of this anatomical structure?

Answer: "These are sebaceous glands that are located in the areola."

A parent of a 4-year-old child tells the nurse that she is concerned because the child has been masturbating. The appropriate response by the nurse is which of the following?

Answer: "This is a normal behavior at this age." Rationale: According to Freud's psychosexual stages of development, the child is in the phallic stage between the ages of 3 and 6 years. At this time, the child devotes much energy to examining his or her genitalia, masturbating, and expressing interest in sexual concerns.

The mother of a 4-year-old who was recently hospitalized brings the child to the clinic for a follow-up visit. The mother tells the nurse that the child has begun to wet the bed and that it started when the child was brought home from the hospital. The mother is concerned and asks the nurse what to do. The appropriate nursing response is which of the following?

Answer: "This is a normal occurrence following hospitalization." Rationale: Regression can occur in a preschooler and is most often caused by the stress of the hospitalization. It is best to accept the regression if it occurs. Parents may be overly concerned about regression and should be told that regression is normal following hospitalization.

The mother of a 2-year-old child asks the nurse if it is all right to give the child a bottle at naptime. The appropriate response by the nurse is which of the following?

Answer: "You may give the child a bottle if necessary, but if you do, it should contain water." Rationale: A child should never be allowed to fall asleep with a bottle because of the risk of bottle-mouth caries.

During a well-child visit a mother states she is frustrated with her 2-year-old child. Whenever she asks him if he wants something to eat, he says, "No," but then he starts to cry when she does not give him the food. Which of the following statements by the nurse would indicate an understanding of psychosocial concepts related to growth and development of the toddler?

Answer: "Your toddler is asserting his independence as he is progressing through the stage of autonomy versus shame and doubt." Rationale: According to Erikson, toddlers are acquiring a sense of autonomy while overcoming a sense of shame and doubt. They are attempting to relinquish their dependence and asserting independence, which will be present as negativism in their quest for independence. The word "no" is a very strong part of their vocabulary.

According to Sigmund Freud's theory of personality development, the phallic stage is best described as which of the following? PHALLIC STAGE

Answer: (PHALLIC STAGE)----Children recognize differences between males and females. Rationale: Freud's phallic stage of development includes the recognition of differences between the sexes

A nurse is providing instructions to a 16-year-old male adolescent regarding dietary patterns. The nurse instructs the adolescent that the recommended amount of daily calories is approximately:

Answer: 2200 Rationale: The recommended amount of daily calories for a male adolescent between the ages of 15 and 18 years is 2200.

A 6-year-old is hospitalized with a fracture of the femur and is placed in traction. In meeting the psychosocial needs of the child, the nurse most appropriately selects which of the following play activities for the child?

Answer: A board game Rationale: The school-age child becomes organized, with more direction in play activities. School-age children's interests include collections, drawing, construction, dolls, pets, guessing games, board games, riddles, hobbies, competitive games, and listening to the radio or television.

A 16-year-old adolescent is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which of the following interventions is most appropriate to facilitate normal growth and development?

Answer: Allow the child to participate in activities with other individuals in the same age group when the condition permits. Rationale: Adolescents often are not sure whether they want their parents with them when they are hospitalized. Because of the importance of the peer group, separation from friends is a source of anxiety.

A nurse is providing instructions to a new parent regarding the psychosocial development of the infant. Using Erikson's psychosocial development theory, the nurse would instruct the parent to:

Answer: Allow the infant to signal a need. Rationale: According to Erikson, the caregiver should not try to anticipate the infant's needs at all times, but rather must allow the infant to signal his or her needs. If an infant is not allowed to signal a need, he or she will not learn how to control the environment.

The nurse should plan which of the following to encourage autonomy in the client who is a resident in a long-term care facility?

Answer: Allowing him to choose his social activities Rationale: Autonomy is the personal freedom to direct one's own life as long as it does not impinge on the rights of others. An autonomous person is capable of rational thought.

In planning care for older clients in a long-term care facility, the nurse recalls that which of the following is accurate regarding sexuality and the older client?

Answer: Although responses may be slower, sexual ability is present in later years of life.

A client with sickle cell anemia has vaso-occlusive pain. After noting that the client is of preschool age, the nurse plans to use which of the following methods to determine the adequacy of pain control methods?

Answer: Ask the client to point to faces (smiling to very sad) that best describe the pain. Rationale: A client of preschool age has the cognitive ability to recognize happy and sad faces and to correlate them with the level of pain experienced. Using descriptive words to communicate varying intensities of pain may be too complicated for some preschoolers

A nurse is assessing a 36-month-old child during a wellness visit to the pediatrician. The child weighs 43 pounds and is 41 inches tall. After plotting the measurements on the standardized growth charts for a 36-month-old, what should the nurse do next?

Answer: Assess the parents' body shape and stature. Rationale: A strong correlation exists between parent and child with regard to traits such as height, weight, and rate of growth. Most physical characteristics, including shape and form of features, body build, and physical peculiarities are inherited and influence the way in which children grow and interact with their environment.

A nurse in the pediatric unit is admitting a 2-year-old child. The nurse plans care, knowing that the child is in which stage of Erikson's psychosocial stages of development?

Answer: Autonomy vs. shame and doubt Rationale: A 2-year-old child, a toddler, is in the autonomy vs. shame and doubt stage. In this stage, the toddler develops a sense of control over the self and bodily functions and exerts himself or herself.

A young adult college student begins to throw objects, shout insults, and stamp his feet after an instructor returned his work, noting it was substandard. Using Erikson's theory of personality development, which developmental stage has this individual unsuccessfully mastered?

Answer: Autonomy vs. shame and doubt Rationale: A widely accepted theory of personality development is that by Erik Erikson. Each of Erikson's eight stages has two components: the favorable and unfavorable aspects of the core conflict. No core conflict is ever totally mastered, and when individuals face new situations in life, they may revert to a previously mastered core conflict

A nurse is encouraging an older incontinent client's participation in recreational therapy. What nursing intervention would the nurse consider performing first?

Answer: Change the client's soiled disposable brief. Rationale: Basic physiological needs are a priority in administering nursing care.

Which of the following describes Lawrence Kohlberg's first level of moral development?

Answer: Children determine the goodness or badness of an action in terms of the consequences. Rationale: Kohlberg's first level of moral development is the preconventional stage in which children determine the goodness or badness of an action in terms of the consequences.

An older client is taking multiple medications for a variety of health problems. The nurse would monitor the results of which of the following most important laboratory tests when evaluating adverse effects of medication therapy in the older adult?

Answer: Creatinine Rationale: Creatinine should be most closely monitored because it relates to kidney function. Because many medications are excreted by the kidneys, that makes this the laboratory test of choice for ongoing monitoring.

A nurse is collecting data from an older adult client. Which of the following indicates a potential complication associated with the skin of this client?

Answer: Crusting Rationale: he normal physiological changes that occur in the skin of older adults include thinning of the skin, loss of elasticity, deepening of expression lines, and wrinkling. Crusting noted on the skin indicates a potential complication.

Upon palpation of the fontanel of a 3-month-old newborn, the nurse notes that the anterior fontanel has not closed and is soft and flat. Which of the following actions should the nurse take?

Answer: Document the findings. Rationale: The anterior fontanel is diamond shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age.

A nurse is assessing the pain in a 3-year-old child after an appendectomy. Which pain scale should the nurse use?

Answer: FACES pain rating scale Rationale: There is a pain-rating tool identified with children as young as a neonate. Because the child in this question is 3 years old, the recommended pain scale is the FACES pain scale, which can be used with children as young as 3 years of age.

A 4-year-old child is reluctant to take deep breaths following abdominal surgery. The effective measure to encourage deep breathing is to:

Answer: Have the child pretend he is the big, bad wolf blowing the little pig's house down. Rationale: The preschooler has a vivid imagination and loves to pretend. Engaging the child in therapeutic play appropriate to age is considered the most effective way to intervene.

A nurse prepares to discharge a client who is experiencing family-related stress. Which goal does the nurse include to help the client achieve her primary developmental task?

Answer: Help the client to resume her familial role. Rationale: The primary developmental task of middle adulthood is to realize generativity and to help guide children or the next generation through social situations in a productive manner. Thus the nurse helps the client reclaim her role in the family as mentor and facilitator to avert stagnation in society

A nurse is working with an older client and family about discharge following hospitalization. When initiating discussions with the group, the nurse understands that older persons would prefer to live:

Answer: Independently, but close to their children Rationale: Most older people prefer to maintain their independence while having the resource of children or family nearby to help in times of need.

A nursing instructor asks a nursing student about Kohlberg's theory of moral development. The instructor determines that the student needs to further research this theory if the student states that a component of the theory includes which of the following?

Answer: Individuals move through all six stages in a sequential fashion. Rationale: Kohlberg's theory states that individuals move through the six stages of development in a sequential fashion but that not everyone reaches stages 5 or 6 as part of their development of personal mortality.

A nurse is admitting a 10-month-old infant who is being hospitalized for a respiratory infection. The nurse develops a plan of care for the infant and includes which of the following?

Answer: Providing a consistent routine such as touching, rocking, and cuddling throughout the hospitalization Rationale: A 10-month-old is in the trust vs. mistrust stage of psychosocial development, according to Erikson. The infant is developing a sense of self, and the nurse should most appropriately provide a consistent routine for the child. Hospitalization may have an adverse effect, and the nurse should touch, rock, and cuddle the infant to promote a sense of trust and to provide sensory stimulation.

According to Kohlberg's theory of moral development, at the preconventional level, moral development is thought to be motivated by which of the following?

Answer: Punishment and reward Rationale: morals are thought to be motivated by punishment and reward. If the child is obedient and not punished, then he or she is being moral. The child sees actions as either good or bad. If the child's actions are good, then the child is praised. If the child's actions are bad, then the child is punished.

Which of the following developmental stages is Jean Piaget's first stage of cognitive development?

Answer: Sensorimotor Rationale: Jean Piaget's first stage of cognitive development is the sensorimotor stage (birth to 2 years). The preoperational stage is the second stage (2 to 7 years of age).

The parent of a 3-year-old tells the nurse that the child is constantly rebelling and having temper tantrums. Which instruction should the nurse provide to the parent?

Answer: Set limits on the child's behavior. Rationale: According to Erikson, the child focuses on independence between the ages of 1 and 3 years. Gaining independence often means that the child has to rebel against the parents' wishes

A nurse is collecting data from a female client who is suspected of having mittelschmerz. Which of the following should the nurse expect to note?

Answer: Sharp pain located on the right side of the pelvis Rationale: The pain is caused by growth of the dominant follicle within the ovary, or rupture of the follicle and subsequent spillage of follicular fluid and blood into the peritoneal space. The pain is fairly sharp and is felt on the right or left side of the pelvis. It generally lasts a few hours to 2 days, and slight vaginal bleeding may accompany the discomfort.

When reinforcing appropriate developmental skills interventions for a 1-year-old child who was born 2 months premature, the nurse would plan to encourage the parents to support the child to do which of the following?

Answer: Sit independently. Rationale: For premature infants, calculate the developmental age by deducting the time of prematurity from the age of the child until reaching the age of 2 years.

A nurse assigned to care for an older adult client places an extra blanket in the client's room. The nurse understands that the older adult is less able to regulate hot and cold body changes because of alterations in the activity of the:

Answer: Sweat glands Rationale: Functions of the skin include protection, sensory reception, homeostasis, and temperature regulation. The skin helps regulate the body temperature in two ways, by dilation and constriction of blood vessels and by the activity of the sweat glands.

A nurse is assisting in conducting a teaching session with a group of adolescents. The nurse tells the adolescents that the primary hormone that induces the growth of pubic and axillary hair at puberty is:

Answer: Testosterone Rationale: Testosterone is produced by the adrenal glands in the female and induces the growth of pubic and axillary hair at puberty.

The parents of a 2-year-old arrive at the hospital to visit the child. The child is in the play room and ignores the parents during the visit. The nurse tells the parents that this behavior in a 2-year-old child indicates which of the following?

Answer: That the child is exhibiting a normal pattern rationale: The toddler is particularly vulnerable to separation. A toddler often shows anger at being left by ignoring the parent or pretending to be more interested in play than in going home.

A nurse is caring for a hospitalized 5-year-old client. The nurse would recognize that which of the following is normal for this child in this developmental stage?

Answer: The child demonstrates egocentrism. Rationale: A 5-year-old child is in Jean Piaget's preoperational stage of egocentrism.

A nurse is performing a safety assessment in the home of a mother with two children. The ages of the children are 1 and 3 years. Which of the following, if noted during the assessment, would present the greatest hazard to the children?

Answer: Toys with small loose parts in the playroom Rationale: Toys with small loose parts would be the priority concern. Children at this age are likely to place the small toy parts in their mouths, which could lead to aspiration and choking.

A nurse prepares to take a blood pressure (BP) on a school-age child. To obtain an accurate measurement, the nurse places the blood pressure cuff so that it covers:

Answer: Two thirds the distance between the antecubital fossa and the shoulder Rationale: The size of the BP cuff is important. Cuffs that are too small will cause falsely elevated values and those that are too large will cause inaccurate low values. The cuff should cover two thirds the distance between the antecubital fossa and the shoulder.

The nurse is providing an education class to healthy older adults. Which exercise will best promote health maintenance?

Answer: Walking three to five times a week for 30 minutes Rationale: One of the best exercises for an older adult is walking, with the goal of progressing to 30-minute sessions three to five times each week. Swimming and dancing are also beneficial.

A nursing instructor asks a nursing student to describe the formal operations stage of Piaget's cognitive developmental theory. The appropriate response by the nursing student is: "The child:

Answer: has the ability to think abstractly." Rationale: In the formal operations stage, the child has the abilities to think abstractly and solve problems.

A mother of a 3-year-old is concerned because the child is still insisting on a bottle at nap time and at bedtime. The nurse suggests which of the following to the mother?

Answer: "Allow the bottle if it contains water." Rationale: A toddler should not be allowed to fall asleep with a bottle because of the risk of dental caries. If the bottle is allowed in bed, it should contain only water.

A nurse is providing instructions to the mother of a 2-year-old child regarding dental care. Which statement by the mother indicates the need for further instructions?

Answer: "Proper dental care is not necessary for toddlers until their permanent teeth erupt."<--WRONG Rationale: The nurse should instruct the mother that proper dental care to a toddler is important. It is important to instruct the mother to substitute sweets with healthy food items to prevent dental caries.

A nursing student is assigned to care for a hospitalized 2-year-old child. The nursing instructor reviews the plan of care with the student and asks the student to identify the expected behavior of the child in regard to separation anxiety. Which statement by the student indicates an understanding of separation anxiety that can occur in a 2-year-old?

Answer: "The child may ignore the parents when they visit." Rationale: The toddler is particularly vulnerable to separation. A toddler often shows anger at being left by ignoring the parent or by pretending to be more interested in play than in going home.

During a routine well-child checkup for a 2-year-old, the nurse plans to teach the mother proper nutrition and weight gain expectations for her child. The nurse reviews the chart and finds that the toddler's birth weight was 7 pounds 15 ounces. The nurse expects that the child should weigh approximately how much at this time?

Answer: 31 pounds 12 ounces Rationale: By the age of 2½ years, the toddler should have quadrupled his or her birth weight. The child doubles the birth weight by age 5 to 6 months and triples the birth weight by 1 year of age.

A nursing student is preparing a conference on Freud's psychosocial stages of development, specifically the anal stage. Which of the following appropriately relates to this stage?

Answer: Beginning of toilet training Rationale: Toilet training generally occurs during this period. According to Freud, the child gains pleasure from both the elimination and retention of feces

An older client has been prescribed digoxin (Lanoxin). The nurse understands that which age-related change would place the client at risk for digoxin toxicity?

Answer: Decreased lean body mass and glomerular filtration rate Rationale: The older client is at risk for medication toxicity because of decreased lean body mass and an age-associated decreased glomerular filtration rate.

A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention does the nurse suggest to alleviate the child's fears?

Answer: Encourage the child's parents to stay with the child. Rationale: Although the preschooler may already be spending some time away from parents at a day care center or preschool, illness adds a stressor that makes separation more difficult.

According to Erik Erikson's psychosocial developmental theory, the nurse would anticipate an adolescent to be in the stage of: ADOLESCENT STAGE

Answer: Identity vs. role confusion Rationale: An adolescent (1 to 20 years) would be expected to be experiencing Erikson's psychosocial stage of identity vs. role confusion

A nurse is caring for a 14-year-old boy who is hospitalized and placed in Crutchfield traction. The child is having difficulty adjusting to the length of the hospital confinement. Which nursing action would be appropriate to meet the child's needs?

Answer: Let the child wear his own clothing when friends visit. Rationale: Adolescents need to identify with their peers and have a strong need to belong to a group. They like to dress like the group and wear similar hairstyles. Because Crutchfield traction uses skeletal pins, hair dye is not appropriate. The boy should be allowed to wear his own clothes to feel a sense of belonging to the group.

A licensed practical nurse (LPN) is assisting a high school nurse in conducting a session with female adolescents regarding the menstrual cycle. The LPN tells the adolescents that the normal duration of the menstrual cycle is about: MENSTRUAL CYCLE

Answer: Menstrual Cycle---28 days Rationale: The normal duration of the menstrual cycle is about 28 days, although it may range from 20 to 45 days. Significant deviations from the 28-day cycle are associated with reduced fertility. The first day of the menstrual period is counted as day 1 of the woman's cycle.

A nurse is collecting data regarding the motor developmental of a 24-month-old child. Based on the age of the child, the nurse expects to note which highest level of developmental milestone?

Answer: The child uses a doorknob to open a door. Rationale: A 24-month-old would be able to use a doorknob to open a door. At age 15 months, the child could build a tower of two blocks. At age 30 months, the child would be able to snap large snaps and put on simple clothes independently.

A nurse is providing information to nursing assistants regarding caring for the older adult. The nurse tells the nursing assistants that which of the following situations portrays ageism?

Answer: Advising older adults to forgo aggressive treatment Rationale: Ageism is a form of prejudice, in which older adults are stereotyped by characteristics found in only a few members of their group. Fundamental to ageism is the view that older people are different from "me" and will remain different from "me."

An age-appropriate toy for a 1-month-old child is which of the following?

Answer: Nursery mobile Rationale: A nursery mobile is recommended for a 1-month-old child because it provides visual stimulation. If it is a musical nursery mobile, it also serves the purpose of providing auditory stimulation.

A nurse has gathered data about each of the following items about an older client. The nurse understands that which of the following is not a reliable indicator of fluid imbalance for a client in this age group?

Answer: Thirst Rationale: Thirst in the older adult is subjective and is not always consistent with fluid balance. The appearance of oral mucosa, skin turgor, and the differences between intake and output are more reliable measures of fluid balance in the older adult.

The nurse is assessing a 36 mo old during a wellness visit to the pediatrician. The child weighs 43 pounds & is 41 inches tall. After plotting the measurements on the standardized growth charts for a 36 mo old, which should the nurse do next?

Assess the parents' body shape & stature.

The clinic nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of data collection? Select all that apply.

Auscultating lung sounds Obtaining the client's temperature Obtaining information about the client's respirations Rationale: A focused data collection process focuses on a limited or short-term problem, such as the client's complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete data collection includes a complete health history and physical examination and forms a baseline database. Checking the strength of peripheral pulses relates to a vascular assessment, which is not related to this client's complaints. A musculoskeletal and neurological examination also is not related to this client's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete data collection. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment.

The nurse should plan which to encourage rebreak in the client who is a resident in a long-term care facility?

Choosing his social activities Rationale: Autonomy is the personal freedom to direct one's own life as long as it does not impinge on the rights of others. An autonomous person is capable of rational thought. This individual can identify problems, search for alternatives, and choose solutions that allow for continued personal freedom as long as the rights and property of others are not harmed. The loss of autonomy—and, therefore, independence—is a very real fear among older clients. Option 4 is the only choice that allows the client to be a decision maker.

A mother of a 5-year-old child tells the nurse that the child scolds the floor or table if the child hurts herself on the object. According to Piaget's theory of cognitive development, which behavior is this known as?

Egocentric speech Rationale: Animism means that all inanimate objects are given living meaning. Object permanence, the realization that something out of sight still exists, occurs in the later stages of the sensorimotor stage of development. Egocentric speech occurs when the child talks just for fun and cannot see another's point of view. Global organization means that if any part of an object or situation changes, the whole thing has changed.

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply.

Encourage expression of feelings, concerns, and fears. Touch and hold the client's or family member's hand if appropriate. Be honest and let the client and family know that they will not be abandoned by the nurse. Rationale: The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know that they will not be abandoned. The nurse should touch and hold the client's or family member's hand, if appropriate.

A 4 yo diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should the nurse suggest to alleviate the child's fears?

Encourage the child's parents to stay with the child.

The nurse is caring for a 14 yo boy who is hospitalized & placed in Crutchfield traction. The child is having difficulty adjusting to the length of the hospital confinement. Which nursing action would be appropriate to meet the child's needs?

Let the child wear his own clothing when friends visit.

Which are components of Kohlberg's theory of moral development? Select all that apply.

Moral development progresses in relation to cognitive development. A person's ability to make moral judgments develops over a period of time. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. In stage 2 (instrumental relativist orientation), the child conforms to rules to obtain rewards or to have favors returned. Rationale: Kohlberg's theory states that individuals move through the six stages of development in a sequential fashion, but not everyone reaches stages 5 and 6 during his or her development of personal morality. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. It also states that moral development progresses in relation to cognitive development and a person's ability to make moral judgments develops over a period of time. In stage 1 (ages 2 to 3 years; punishment-obedience orientation), children cannot reason as mature members of society because they are too young to do so. In stage 2 (ages 4 to 7 years; instrumental relativist orientation), the child conforms to rules to obtain rewards or have favors returned.

OXYTOCIN

Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding.

PROLACTIN

Prolactin stimulates the secretion of milk.

Which interventions are appropriate for the care of an infant? Select all that apply.

Provide swaddling. Hang mobiles with black-and-white contrast designs. Caress the infant while bathing or during diaper changes. Rationale: Holding, caressing, and swaddling provide warmth and tactile stimulation for the infant. To provide auditory stimulation, the nurse should talk to the infant in a soft voice and should instruct the mother to do so also. Additional interventions include playing a music box, radio, or television or having a ticking clock or metronome nearby. Hanging a bright, shiny object within 20 to 25 cm of the infant's face in the midline and hanging mobiles with contrasting colors (e.g., black and white) provide visual stimulation. Crying is an infant's way of communicating; therefore, the nurse would respond to the infant's crying. The mother is taught to do so also. An infant or child should never be allowed to fall asleep with a bottle containing milk, juice, soda, or sweetened water because of the risk of nursing (bottle-mouth) caries.

The nurse is admitting a 10 mo old who is being hospitalized for a respiratory infection. The nurse develops a plan of care for the infant and includes which intervention?

Providing a consistent routine such as touching, rocking, & cuddling throughout the hospitalization

A client has died, and the nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action?

Remain with the family member without discussing funeral arrangements. Rationale: The family member is exhibiting the first stage of grief (denial), and the nurse should remain with the family member. Option 1 is an appropriate intervention for the acceptance or reorganization and restitution stage. Option 2 may be an appropriate intervention for the bargaining stage. Option 3 may be an appropriate intervention for depression.

The nurse is preparing to assist the health care provider to test the extraocular movements in a client for muscle weakness in the eyes. The nurse anticipates that which physical assessment technique will be done to assess for muscle weakness in the eye?

Testing the six cardinal positions of gaze Rationale: Testing the six cardinal positions of gaze is done to check for muscle weakness in the eyes. The client is asked to hold the head steady, then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the two eyes. A Snellen eye chart checks visual acuity and cranial nerve II (optic). Testing sensory function by having the client close his or her eyes and then lightly touching areas of the face and testing the corneal reflexes check cranial nerve V (trigeminal).

The parents of a 2-year-old arrive at the hospital to visit their child. The child is in the play room and ignores the parents during the visit. The nurse tells the parents that this behavior in a 2-year-old child indicates which?

The child is exhibiting a normal pattern. Rationale: The toddler is particularly vulnerable to separation. A toddler often shows anger at being left by ignoring the parent or pretending to be more interested in play than in going home. The parents of hospitalized toddlers are frequently distressed by such behavior. The toddler normally engages in parallel play and plays alongside (but not with) other children.

The nurse notes that the physical assessment findings for a client with meningeal irritation indicate a positive Brudzinski sign. The nurse understands that which observation was made?

The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Rationale: Brudzinski's sign is tested with the client in the supine position. The examiner flexes the client's head, and there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Decerebrate posturing is abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to note documented in the health record when collecting data related to the respiratory system for this client?

Wheezes Rationale: Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring. A pleural friction rub is heard in individuals with pleurisy (inflammation of the pleural surfaces).