Exam 2 - PEDS
The nurse caring for a child on a pediatric intensive care unit notices that when the parents go to work the child is very angry and cries easily. What does the nurse suspect is occurring with this patient? A) Protest phase of separation anxiety B) Regressive behavior C) Detachment from the parents D) Despair
A
The nurse contacts a child life specialist (CLS) to work with children on a pediatric ward. What is the primary goal of the CLS? A) Decrease anxiety and fear during hospitalization and painful procedure. B) Keep children who are hospitalized distracted from pain. C) Perform medical procedures using atraumatic principles. D) Act as a liaison between the nurse and the child.
A
The nurse is assessing heart rate for children on the pediatric ward. What is a normal finding based on developmental age? A) An infant's rate is 90 bpm. B) A toddler's rate is 150 bpm. C) A preschooler's rate is 130 bpm. D) A school-age child's rate is 50 bpm.
A
The nurse is caring for a 14-year-old boy with an osteosarcoma. Which communication technique would be least effective for him? A) Letting him choose juice or soda to take pills B) Seeking the teenager's input on all decisions C) Discussing the benefits of chemotherapy with him D) Avoiding undue criticism of noncompliance
A
The nurse is caring for a 4-year-old girl with special care needs in the hospital. Which intervention would have the most positive effect on this child? A) Taking her on an adventure down the hall B) Helping her do a simple craft project C) Introducing her to children in the playroom D) Limiting the staff providing care for her
A
The nurse is caring for a 7-year-old girl hospitalized in isolation. The nurse notices that she has begun sucking her thumb and changing her speech patterns to those of a toddler. What condition is the girl manifesting? A) Regression B) Suppression C) Repression D) Denial
A
The nurse is caring for a hospitalized 13-year-old girl, who is questioning everything the medical staff is doing and is resistant to treatment. How should the nurse respond? A) "Let's work together to plan your day along with your treatments." B) "The sooner you cooperate, the sooner you are going to leave." C) "If you are more cooperative, perhaps we can arrange a visit from friends." D) "Please don't make me call your parents about this."
A
The nurse is caring for a special needs infant. Which intervention will be most important in helping the child reach her maximum developmental potential? A) Directing her parents to an early intervention program B) Monitoring her progress in elementary school C) Serving on an individualized education program committee D) Preparing a plan for her to transition to college
A
The nurse is conducting a routine health assessment of a 3-month-old boy and notices a flat occiput. The nurse provides teaching and emphasizes the importance of tummy time. Which response by the mother indicates a need for further teaching? A) "I should have him sleep on his tummy." B) "I need to watch him during his tummy time." C) "I need to change his head position while he is in an upright chair." D) "His head has flattened due to the pressure of his head position."
A
The nurse is enlisting the parents' assistance for therapeutic hugging prior to an otoscopic examination. What should the nurse emphasize to the parents? A) "You will need to keep his hands down and his head still." B) "If this does not work, we will have to apply restraints." C) "If you are not capable of this, let me know so I can get some assistance." D) "I may need you to leave the room if your son will not remain still."
A
The nurse has completed diabetic education regarding insulin administration to a 14-year-old child newly diagnosed with diabetes and his family. The nurses knows the teaching was effective if the client and family: A) can list appropriate sites for insulin administration. B) have demonstrated correct insulin administration over the past several days. C) indicate that they understand proper nutrition for a person with diabetes. D) state that they understand hypoglycemic reaction signs and symptoms.
B
The nurse is caring for a 10-year-old boy who is in traction. The boy has a nursing diagnosis of deficient diversional activity related to confinement in bed that is evidenced by verbalization of boredom and lack of participation in play, reading, and schoolwork. What would be the best intervention? A) Offer the child reading materials. B) Enlist the aid of a child life specialist. C) Encourage the child to complete his homework. D) Ask for the parents' assistance.
B
The nurse is caring for a 10-year-old girl who is in an isolation room. Which intervention would be a priority intervention for this child? A) Reduce noise as much as possible. B) Provide age-appropriate toys and games. C) Discourage visits from family members. D) Put on mask prior to entering the room.
B
The nurse is caring for a 7-year-old boy who needs his left leg immobilized. What is the priority nursing intervention? A) Enlist the assistance of a child life specialist. B) Explain to the boy that he must keep his leg very still. C) Apply a clove-hitch restraint to the boy's left leg. D) Explain that a restraint will be applied if he cannot hold still.
B
The nurse is caring for a child who is scheduled to begin chemotherapy. When planning education for the parents, what action by the nurse is most correct? A) Obtain a large classroom to allow the nurse to stand at the front and present information. B) Obtain a small conference room and arrange the chairs in a circle for both the nurse and family members to sit. C) Provide written information to the family and allow them to review it, with instructions to contact the nurse if there are additional questions. D) Provide a video of information to the family, with instructions to contact the nurse if there are additional questions.
B
The nurse is caring for a teen who will be hospitalized for physical rehabilitation for an extended period of time after an auto accident. When working to promote a good working relationship with the teen, what action by the nurse will be most beneficial? A) Allow the teen to control the daily schedule. B) Keep your word with regard to promises and statements made to the teen. C) Allow the teen to make decisions about the plan of care. D) Include the teen in the weekly interdisciplinary care conferences
B
The nurse is caring for an 11-year-old girl preparing to undergo a magnetic resonance imaging (MRI) scan. Which statement would best help prepare the girl for the test and decrease anxiety? A) "You won't hear a sound if you wear your headphones." B) "The machine makes a very loud rattle; however, headphones will help." C) "There are a variety of loud sounds you will hear." D) "The MRI scanner sounds like a machine gun."
B
The nurse is caring for an immunosuppressed 3-year-old girl and is providing teaching to the mother about proper oral hygiene. Which response from the mother indicates a need for further teaching? A) "I really need to carefully check for skin breakdown." B) "I must really scrub her teeth and gums well." C) "I must use a soft toothbrush." D) "I can use a soft gauze sponge to care for her gums."
B
The nurse is caring for families with vulnerable child syndrome. Which situation would be most likely to predispose the family to this condition? A) Having a postterm infant B) Having an infant who is reluctant to feed properly C) Having a child diagnosed with impetigo at age 10 D) Having a child with juvenile diabetes
B
The nurse is conducting a health history for a 9-year-old child with stomach pains. What is a recommended guideline when approaching the child for information? A) Wear a white examination coat when conducting the interview. B) Allow the child to control the pace and order of the health history. C) Use quick deliberate gestures to get your point across. D) Do not make physical contact with the child during the interview.
B
The nurse is incorporating nonverbal communication with verbal communication when explaining the treatment plan for a child with juvenile diabetes. What should the nurse do to communicate effectively with this family? A) Relax; maintain an open posture, with the arms crossed. B) Sit opposite the family and lean forward slightly. C) Use eye contact sparingly to avoid embarrassment. D) Speak a verbal yes or no; do not use head nods.
B
The nurse is inspecting the fingernails of an 18-month-old girl. What finding indicates chronic hypoxemia? A) Nails that curve inward B) Clubbing of the nails C) Nails that curve outward D) Dry, brittle nails
B
The nurse is measuring the blood pressure of a 12-year-old boy with an oscillometric device. The boy's reading is greater than the 90th percentile for gender and height. What is the appropriate nursing action? A) Repeat the reading with the oscillometric device. B) Repeat the blood pressure reading using auscultation. C) Measure the blood pressure in all four extremities. D) Measure the blood pressure with a Doppler.
B
The nurse is preparing to take a tympanic temperature reading of a 4-year-old. In order to get an accurate reading, what does the nurse need to do? A) Pull the earlobe back and down B) Direct the infrared sensor at the tympanic membrane C) Pull the earlobe down and forward D) Remove any visible cerumen from inside the ear canal
B
The nurse is providing home care for the family of an 8-year-old boy who is dying of leukemia. Which action will be most supportive to the parents of the child? A) Encouraging organ and tissue donation B) Being patient with parental indecision C) Getting prior authorization for treatments D) Explaining how anorexia is a natural process
B
The nurse is teaching the student nurse how to perform a physical assessment based on the child's developmental stage. Which statements accurately describes a recommended guideline for setting the tone of the examination for a school-age child? A) Keep up a running dialogue with the caregiver, explaining each step as you do it. B) Include the child in all parts of the examination; speak to the caregiver before and after the examination. C) Speak to the child using mature language and appeal to his or her desire for self-care. D) Address the child by name; speak to the caregiver and do the most invasive parts last.
B
The nurse is using a family interpreter to teach home care to the deaf parents of a child with cystic fibrosis. Which technique of working with an interpreter is unique to this situation? A) Ensuring the parents can read printed material B) Using the child's aunt as interpreter C) Allowing time for interpretation and response D) Expecting the interpreter to know the medical terms
B
A) "How are things going at home?" B) "Is your child sleeping well at night?" C) "How many hours does your child sleep at night?" D) "What time does your child go to bed at night?"
C
The nurse is assessing the neck of an 8-year-old child with Down syndrome. Which finding would the nurse expect during the examination? A) Webbing B) Excessive neck skin C) Lax neck skin D) Shortened neck
C
The nurse is caring for a 13-year-old girl hospitalized for complications from type 1 diabetes. The girl has a nursing diagnosis of powerlessness related to lack of control of multiple demands associated with hospitalization, procedures, treatments, and changes in usual routine. How can the nurse help promote control? A) Ask the child to identify her areas of concern. B) Encourage participation of parents in care activities. C) Offer the girl as many choices as possible. D) Enlist the family's assistance in creating a time schedule.
C
The nurse is caring for a 4-year-old girl who has been hospitalized for over a week with severe burns. Which would be a priority intervention to help satisfy this preschool child's basic needs? A) Encourage friends to visit as often as possible. B) Suggest that a family member be present with her 24 hours a day. C) Explain necessary procedures in simple language that she will understand. D) Allow her to make choices about her meals and activities as much as permitted.
C
The nurse is caring for a toddler with special needs. Which developmental tasks related to toddlerhood might be delayed in the child with special needs? A) Developing body image B) Developing peer relationships C) Developing language and motor skills D) Learning through sensorimotor exploration
C
The nurse is conducting a physical examination of a child following a comprehensive health history. What should be the focus of the physical examination? A) The child B) The parents C) Chief complaint D) Developmental age
C
The nurse is educating a 16-year-old girl who has just been diagnosed with acute myelogenous leukemia. Which statement best demonstrates therapeutic communication? A) Discussing the treatment plan in detail for the next few weeks B) Using medical terms when describing the disease C) Assessing the adolescent's emotional status in private D) Talking about clothing and the stores where she shops
C
The nurse is examining the posture of a male toddler and notes lordosis. What would be the appropriate reaction of the nurse to this finding? A) Explain that the child will need a back brace. B) Refer the toddler to a physical therapist. C) Do nothing; this is a normal condition for toddlers. D) Notify the primary care physician about the condition.
C
The nurse is performing a cultural assessment of an Asian family that has a child hospitalized for leukemia. What is the best technique for providing culturally competent care for this family? A) Research the culture and base care on findings. B) Ask other Asians to explain their culture. C) Just ask the family about their culture and listen. D) Hire an interpreter to explain the family culture.
C
The nurse is reviewing the Adolescent Health Transition Project's recommended schedule for transition planning. According to the schedule, at what age should the nurse explore health care financing for young adults? A) 12 years old B) 14 years old C) 17 years old D) 19 years old
C
The nurse is teaching a group of parents with premature infants about the various medical and developmental problems that may occur. The nurse determines that additional teaching is needed when the group identifies what as a problem? A) Sudden infant death syndrome B) Hydrocephalus C) Peptic ulcer D) Bronchopulmonary dysplasia
C
The nurse is teaching the student nurse how to communicate effectively with children. Which method would the nurse recommend? A) Position self above the child's level to denote authority. B) If possible, communicate with the child apart from the parent. C) Direct questions and explanations to the child. D) Use the medical terms for body parts and medical care.
C
The nurse is working as a community health care nurse. What would be the nurse's focus when providing care of the child? A) Providing care to the individual and family in acute care settings B) Providing care to the indigent in family care settings C) Providing care in geographically and culturally diverse settings D) Providing care for particular age groups or particular diagnoses
C
The nurse knows that effective communication with children and their parents is critical to providing atraumatic quality nursing care. Which statement accurately describes the communication patterns of children? A) Communication patterns are similar from one child to the next. B) Children often use more words than adults to describe their fears. C) Children rely more on nonverbal communication and silence. D) Parents more often require affective communication rather than neutral communication.
C
The nurse working in the emergency room monitors the admission of children. Statistically, for which disorder would children younger than 5 years most commonly be admitted? A) Mental health problems B) Injuries C) Respiratory disorders D) Gastrointestinal disorders
C
The parents of a 2-day-old girl are concerned because her feet and hands are slightly blue. How should the nurse respond? A) "Your daughter has acrocyanosis; this is causing her blue hands and feet." B) "Let's watch her carefully to make sure she does not have a circulatory problem." C) "This is normal; her circulatory system will take a few days to adjust." D) "This is a vasomotor response caused by cooling or warming."
C
The nurse caring for young children in a hospice setting is aware of the following statistics related to the occurrence of death in children. Which statement accurately reflects one of these statistics? A) Each year, about 50,000 children die in the United States; of those, about 15,000 are infants. B) It is unusual for a child's chronic illness to progress to the point of becoming a terminal illness. C) Despite strides made, diabetes remains the leading cause of death from disease in all children older than the age of 1 year. D) Congenital defects and traumatic injuries are the more common causes of diseases leading to death.
D
The nurse is caring for an 8-year-old boy hospitalized for a bone marrow transplant. His parents are in and out of his room throughout the day. Which behaviors of the child would alert the nurse that he is in the second stage of separation anxiety? A) He ignores his parents when they return to his room. B) He cries uncontrollably whenever they leave. C) He forms superficial relationships with his caregivers. D) He sits quietly and is uninterested in playing and eating.
D
The nurse is caring for an 8-year-old girl who requires numerous venipunctures and injections daily. The nurse understands that the child is exhibiting signs of sensory overload and enlists the assistance of the child life specialist. What should the therapeutic play involve to best deal with the child's stressors? A) Puppets and dolls B) Drawing paper and crayons C) Wooden hammer and pegs D) Sewing puppets with needles
D
The nurse is educating the parents of a 7-year-old girl who has just been diagnosed with epilepsy. Which teaching technique would be most appropriate? A) Assessing the parents' knowledge of the anticonvulsant medications B) Demonstrating proper seizure safety procedures C) Discussing the surgical procedure for epilepsy D) Giving the parents information in small amounts at a time
D
The nurse is performing a health history on a 6-year-old boy who is having trouble adjusting to school. Which question would be most likely to elicit valuable information? A) 'Do you like your new school?' B) 'Are you happy with your teacher?' C) 'Do you enjoy reading a book?' D) 'What are your new classmates like?'
D
The nurse is providing discharge planning for a 12-year-old boy with multiple medical conditions. What would be the best teaching method for this child and his family? A) Demonstrate the care and ask for a return demonstration. B) Provide and review educational booklets and materials. C) Provide a written schedule for the child's care. D) Provide a trial period of home care.
D
The nurse is teaching the student nurse about abnormal findings when assessing the breasts of children. What may be associated with renal disorders? A) Swollen nipples upon inspection of a newborn's breasts B) Tender nodule palpated under the nipple of a 10-year-old C) Observation of enlarged breast tissue in a male adolescent D) Observation of a supernumerary nipple along the mammary ridge
D
The nurse is implementing care for a hospitalized toddler. What communication technique would the nurse use with the child to reflect the child's developmental level? A) Allow the child extra time to complete thoughts. B) Communicate solely through play. C) Provide simple but honest and straightforward responses. D) Remain nonjudgmental to avoid alienation.
A
The nurse is inspecting the genitals of a prepubescent girl. Which is a normal sign of the onset of puberty? A) Appearance of pubic hair around 11 to 13 years old B) Swelling or redness of the labia minora C) Presence of labial adhesions D) Lesions on the external genitalia
A
The nurse is preparing to assess the pulse of an 18-month-old child. Which pulse would be most difficult for the nurse to palpate? A) Radial B) Brachial C) Pedal D) Femoral
A
The nurse is teaching the student nurse the sequence for performing the assessment techniques during a physical examination. What is the appropriate order? A) Inspection, palpation, percussion, auscultation B) Inspection, percussion, palpation, auscultation C) Palpation, percussion, inspection, auscultation D) Inspection, auscultation, palpation, percussion
A
The nurse uses family-centered care to care for children in a pediatric office. Upon what concept is family-centered care based? A) The family is the constant in the child's life and the primary source of strength. B) The care provider is the constant in the child's life and the primary source of strength. C) The child must be prepared to be his or her own source of strength during times of crisis. D) The wishes of the family should direct the nursing care plan for the child.
A
The nurse working in community nursing uses epidemiology as a tool. What information can be obtained using this process? A) Health needs of a population B) Cultural needs of a population C) Income levels of a population D) Mortality rates of a population
A
Which would be least effective in gaining the cooperation of a toddler during a physical examination? A) Tell the child that another child the same age wasn't afraid. B) Allow the child to touch and hold the equipment when possible. C) Permit the child to sit on the parent's lap during the examination. D) Offer immediate praise for holding still or doing what was asked.
A
xperienced increased appetite or thirst. What body system is the nurse assessing with this question? A) Endocrine B) Genitourinary C) Hematologic D) Neurologic
A
The nurse is caring for infants having the condition failure to thrive (FTT). Which infants would be at risk for this condition? Select all that apply. A) A newborn baby with tetralogy of Fallot B) An infant with a cleft palate C) An infant born to a diabetic mother D) An infant born to an impoverished mother E) An infant with bronchopulmonary dysplasia F) An infant born to a teenage mother
A,B,D,E
The nurse is providing atraumatic care to children in a hospital setting. What are principles of this philosophy of care? Select all that apply. A) Avoid or reduce painful procedures B) Avoid or reduce physical distress C) Minimize parent-child interactions D) Provide child-centered care E) Minimize child control F) Use core primary nursing
A,B,F
The nurse is questioning the parents of a 2-year-old child to obtain a functional history. Which topics might the nurse include? Select all answers that apply. A) The child's toileting habits B) Use of car seats and other safety measures C) Problems with growth and development D) Prenatal and perinatal history E) The child's race and ethnicity F) Use of supplements and vitamins
A,B,F
The nurse is preparing to perform a dressing change on a 13-year-old client who is being treated for burns he received two weeks ago. The client prefers not to take pain medication before the dressing change because it causes drowsiness. What nursing interventions would provide atraumatic care? Select all that apply. A) The nurse asks the client if he would like the television on during the dressing change. B) The nurse asks the client if a small group of nursing students can observe the dressing change. C) The nurse encourages the client to wear headphones to listen to music during the dressing change. D) The nurse encourages the parent to talk to the child about taking pain medication prior to the procedure. E) The nurse tells the client that the dressing change will not be performed unless pain medication is taken.
A,C
The nurse has obtained the services of an interpreter to assist with communicating with a child and parents who have a limited understanding of English. Which behaviors may impede the communication? Select all that apply. A) The nurse speaks to the interpreter, who then translates the information to the parents and child. B) The nurse speaks with the parents and child, and then the interpreter translates the information to the parents and child. C) The nurse limits the sessions with the interpreter to 1 hour. D) The nurse stops talking every 45 to 60 seconds to allow the interpreter to catch up with the information provided. E) The nurse avoids the use of slang in the exchange of information.
A,C,D
The nurse is preparing a hospitalized 7-year-old girl for a lumbar puncture. Which actions would help reduce her stress related to the procedure? Select all that apply. A) Pretend to perform the procedure on her doll. B) Explain the procedure to her in medical terms. C) Do not allow her to see or touch the equipment. D) Teach her the steps of the procedure. E) Tell her not to pay attention to any sounds she might hear. F) Introduce her to the health care personnel.
A,D,F
A teenage patient tells the nurse that she is being abused by her boyfriend but she doesn't want her parents to know because they won't let her see him any longer. What is the best response by the nurse? A) "It's my responsibility to tell your parents if you are in danger." B) "I understand your fear, but I am obligated to be sure your parents know you are in danger. Would you like for us to talk to them together?" C) "I won't tell them this time, but I must inform you that legally I must inform your parents if abuse is occurring. Next time it happens I will have to tell them." D) "You need to tell them because the abuse isn't going to get any better. It will only escalate no matter what your boyfriend says."
B
After teaching a group of students about therapeutic play, the instructor determines that additional teaching is needed when the students identify what as a characteristic of therapeutic play? A) Focus on coping B) Use of a highly structured format C) Dramatization of emotions D) Expression of feelings
B
The nurse is admitting a 7-year-old child to the medical-surgical unit. The child answers questions with very short answers, makes little eye contact with the nurse, and looks to the parent to answer most questions. Which interventions would be appropriate during this admission assessment? Select all that apply. A) Tell the child that you are going to be their nurse so it would be best if they answered your questions. B) When asking questions, look at the child as well as the parent. C) Sit at the child's eye level during the admission questioning process. D) Stop asking questions for the present time and return later when the child feels more comfortable. E) Ask the child if they are always nervous around new people.
B,C
The nurse is preparing a nursing care plan for a child hospitalized for cardiac surgery. Which are examples of interventions that nurses perform in the 'building a trusting relationship' stage? Select all that apply. A) Gathering information about the child using the child's own toys B) Preparing the child for a procedure by playing games C) Explaining in simple terms what will happen during surgery D) Allowing the child to devise an exercise plan following surgery E) Praising the child for how well he is doing following instructions F) Giving the child a favorite toy to cuddle following a painful procedure
B,C
A mother brings her 3-year-old daughter to the emergency department because the child has been vomiting and having diarrhea for the past 36 hours. When assessing this child's temperature, which method would be least appropriate? A) Oral B) Tympanic C) Rectal D) Axillary
C
The nurse is implementing interventions to prevent physical stressors for a 9-year-old child receiving chemotherapy in the hospital. What is an example of using atraumatic care for this child? A) Use restraint or 'holding down' of the child during the procedure to prevent injury. B) Have the parent stand near and/or rub the child's feet during the procedure. C) Insert a saline lock if the child will require multiple doses of parenteral medications. D) Avoid using numbing techniques for multiple blood draws or IV insertion.
C
The nurse is preparing a child and his family for a lumbar puncture. Which would be a primary intervention instituted to keep the child safe? A) Distraction methods B) Stimulation methods C) Therapeutic hugging D) Therapeutic touch
C
The nurse is consulting with a child life specialist (CLS) to help minimize the stress of hospitalization for a child. Which services would the CLS provide? Select all answers that apply. A) Medical preparation for tests, surgeries, and other medical procedures B) Support before and after, but not during, medical procedures C) Activities to support normal growth and development D) Grief and bereavement support E) Emergency room interventions for children and families F) Only inpatient consultations with families
C,D,E
The nurse is looking into the Individuals with Disabilities Education Improvement Act of 2004 to help provide resources for a client with multiple chronic diseases. What are mandates of this legislation? Select all that apply. A) The law mandates government-funded care coordination and special education for children up to 8 years of age. B) This early intervention program is a state-funded program run at the federal level. C) This federal law allows each state to define "developmental disability" differently. D) An evaluation of the child's physical, language, emotional, and social capabilities is performed to determine eligibility. E) The primary care nurse manages the developmental services and special education that the child requires. F) The goal is to maintain a natural environment, so most services occur in the home or day care center.
C,D,F
A nurse is assessing the fontanels of a crying newborn and notes that the posterior fontanel pulsates and briefly bulges. What do these findings indicate? A) Increased intracranial pressure B) Overhydration C) Dehydration D) These are normal findings.
D
The nurse is assessing the heart rate of a healthy school-age child. The nurse expects that the child's heart rate will be in what ranges? A) 80 to 150 bpm B) 70 to 120 bpm C) 65 to 110 bpm D) 60 to 100 bpm
D
The nurse is caring for a 4-year-old boy with Ewing sarcoma who is scheduled for a computed axial tomography (CAT) scan tomorrow. Which is the best example of therapeutic communication? A) Telling him he will get a shot when he wakes up tomorrow morning B) Telling him how cool he looks in his baseball cap and pajamas C) Using family-familiar words and soft words when possible D) Describing what it is like to get a CAT scan using words he understands
D
The nurse is performing a physical examination on a sleeping newborn. Which body system should the nurse examine last? A) Heart B) Abdomen C) Lungs D) Throat
D
The nurse is providing home care for a 1-year-old girl who is technologically dependent. Which intervention will best support the family process? A) Finding an integrated health program for the family B) Teaching modifications of the medical regimen for vacation C) Assessing family expectations for the special needs child D) Creating schedules for therapies and interventions
D
A 7-year-old boy has reentered the hospital for the second time in a month. Which intervention is particularly important at this time? A) Assessing his parents' coping abilities B) Seeking his parents' input about their child's needs C) Educating his family about the procedure D) Notifying the care team about his hospitalization
A
The mother of a hospitalized child reports that her daughter, who is having some difficulty eating, just had a 4-ounce cup of ice chips. The nurse documents this on the child's intake flow sheet as how much? A) 2 ounces B) 4 ounces C) 6 ounces D) 8 ounces
A
The nurse referring a child to home care discusses the advantages and disadvantages with the child's family. What are disadvantages of this method of health care? Select all that apply. A) The nurse is performing care of the child in the family's home. B) The home care nurse is not always equipped to perform technical care. C) The out-of-pocket cost of home care is more expensive. D) The technical procedures may be overwhelming for the family. E) The financial burden may cause more stress for the family. F) The child does not receive continuity of care provided in the hospital setting.
A,C,D,E
The nurse is assessing the temperature of a diaphoretic toddler who is crying and being uncooperative. What would be the best method to assess temperature in this child? A) Oral thermometer B) Axillary method C) Temporal scanning D) Rectal route
B
An adolescent is scheduled for outpatient arthroscopic surgery on his knee next week. As part of preparing him for the procedure, which action would be most appropriate? A) Discussing the events with the adolescent and his mother upon arrival the morning of the procedure B) Providing detailed explanations of the procedure at least a week in advance of the procedure C) Encouraging the parent to stay with the adolescent as much as possible before the procedure D) Answering the adolescent's questions with simple answers, encouraging him to ask the surgeon
B
For which children would the nurse conduct an immediate comprehensive health history? A) A child who is brought to the emergency room with labored breathing B) A child who is a new client in a pediatric office C) A child who is a routine client and presents with signs of a sinus infection D) A child whose condition is improving
B
The child life specialist (CLS) is preparing a 6-year-old child for a magnetic resonance imaging (MRI) scan. Which statement reflects the use of atraumatic principles when explaining the procedure? A) 'You will be taken to a magnetic resonance imaging machine for an x-ray of your liver.' B) 'You may hear some loud noises when you are lying in the machine, but they won't hurt you.' C) 'You have nothing to worry about; the MRI machine is safe and will not cause you any pain.' D) 'Let's just get you to the x-ray department for your test and you'll see how simple it is.'
B
The nurse is transporting a 6-month-old with a suspected blood disorder to the nursery. What is the most appropriate method of transporting the child by the nurse? A) A wagon with rails B) Cradle hold C) Football hold D) Over-the-shoulder
D
The nurse is explaining a discharge plan to the parents of an infant being discharged from the hospital. Which characteristic regarding adult learning should the nurse incorporate into her plan? A) Adults are dependent learners. B) Adults are problem focused. C) Adults are future focused. D) Adults do not value past learning.
B
The nurse is helping a 20-year-old woman transition to adult care. Which would be the most important role of the nurse following a successful transition? A) Teacher B) Consultant C) Care provider D) Advocate
B
While auscultating the heart of a 5-year-old child, the nurse notes a murmur that is soft and quiet and heard each time the heart is auscultated. The nurse documents this finding as what grade? A) Grade 1 B) Grade 2 C) Grade 3 D) Grade 4
B
The nurse is performing an admission of a 10-year-old boy. Which actions will help the nurse establish a trusting and caring relationship with the child and his family? Select all that apply. A) The nurse should not minimize the child's fears by smiling. B) The nurse should initiate introductions. C) The nurse should not use formal titles at the introduction. D) The nurse should maintain eye contact at the appropriate level. E) The nurse should start communication with the child first and then move on to the family. F) The nurse should use age-appropriate communication with the child.
B,D,F
Assessment reveals that a child weighs 73 pounds and is 4 feet, 1 inch tall. The nurse calculates this child's body mass index as: A) 19.1 B) 20.7 C) 21.4 D) 24.5
C
When speaking to a group of parents at a local elementary school, the nurse describes school nursing as a specialized practice of nursing based on the fact that a healthy child has a better chance to succeed in school. What best describes the strategy school nurses use to achieve student success? A) They coordinate all school health programs. B) They link community health services. C) They work to minimize health-related barriers to learning. D) They promote student health and safety.
C
The nurse is providing developmentally appropriate care for a toddler hospitalized for observation following a fall down the steps. Which measures might the nurse consider when caring for this child? Select all that apply. A) Use the en face position when holding the toddler. B) Use a bed for toddlers who have an adult present. C) Avoid leaving small objects that can be swallowed in the bed. D) Explain activities in concrete, simple terms. E) Allow the child to select meals and activities. F) Encourage parents to stay to prevent separation anxiety.
C,F
The nurse is caring for a 14-year-old girl with special health needs. What is the priority intervention for this child? A) Encouraging the parents to promote the child's self-care B) Assessing the child for signs of depression C) Discussing how her care will change as she grows D) Monitoring for compliance with treatment
D
The nurse is using pulse oximetry to measure oxygen saturation in a 3-year-old girl. The nurse understands that falsely high readings may be associated with which situation or condition? A) A nonsecure connection B) Cold extremities C) Hypovolemia D) Anemia
D
The nurse is using verbal skills to explain the nursing care plan to parents of a 10-year-old child with cancer. What describes a guideline the nurse should follow to provide appropriate verbal communication? A) Use closed-ended questions that do not restrict the child's or parent's answers. B) Allow the focus to change without redirecting the conversation. C) Restate the child's and parent's comments in your own words. D) Paraphrase the child's or parent's feelings to demonstrate empathy.
D
The nurse is weighing an underweight infant diagnosed with failure to thrive (FTT) and notes that the baby does not make eye contact and is less active than the other infants. What would be a probable cause for the FTT related to the infant's body language? A) Congenital heart defect B) Cleft palate C) Gastroesophageal reflux disease D) Maternal abuse
D
The nurse working with children in a hospital setting notes that they are being discharged earlier and earlier. Which is a primary reason for this trend? A) Nursing shortages B) Increased funding for home care C) National health care initiatives D) Cost containment
D
Which would be least appropriate to include in the discharge plan for a medically fragile child? A) Assisting with referrals for financial support B) Arranging for necessary care equipment and supplies C) Assessing the family's home environment D) Encouraging passive caregiving
D
The nurse is ordered to apply restraints to a toddler who keeps pulling at the tubes in his arm. Which criteria must occur to ensure proper use of these restraints? Select all answers that apply. A) The nurse must check the restraints every 15 minutes while they are in place. B) Secure the restraints with ties to the side rails, not the bed or crib frame. C) Assess the temperature of the affected extremities, pulses, and capillary refill every 15 minutes after placement. D) Use a clove-hitch type of knot to secure the restraints with ties. E) Remove the restraint every 2 hours to allow for range of motion and repositioning. F) Encourage parent participation, providing continuous explanations about the reasons and time frame for restraints.
D,E,F
