Exam 4 Practice Questions

A 12-year-old female client has been diagnosed with scoliosis with a curvature of 30 degrees. What type of treatment would the nurse anticipate being started on this client? Surgery Exercise Traction Bracing

Bracing

When the nurse is caring for a child presenting with a traumatic injury, which action is priority? Perform a primary assessment Ensure the code cart is available Apply an oxygen saturation monitor Notify the primary health care provider

Perform a primary assessment

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

Sunlight is "too bright"

The nurse suspects sexual maltreatment in a 10-year-old girl. The nurse would assess which primary finding to help make this determination? vaginal discharge regular menses Tanner stage 4 development decreased skin turgor

vaginal discharge

A nurse is interviewing a client who is a survivor of intimate partner violence. The client is telling the nurse about how the violence occurred. Which statement would the nurse interpret as reflecting phase 3 of the cycle of violence? "My spouse yells at me for not having dinner waiting upon arriving home." "My spouse apologizes and tells me I will never be hit again." "My spouse threw me against the wall and started punching my face." "My spouse calls me stupid and incompetent, questioning why we ever married."

"My spouse apologizes and tells me I will never be hit again."

A child with attention deficit/hyperactivity disorder is prescribed long-acting methylphenidate. What information would the nurse include when teaching the child and his parents about this drug? "Take this drug every day in the morning when you wake up." "This drug may cause drowsiness, so be careful when doing things." "Some increase in appetite may occur, so watch how much you eat." "Give the drug three times a day: morning, midday, and after schoo

"Take this drug every day in the morning when you wake up."

A school-age child diagnosed with depression is receiving antidepressant therapy. What behavior would the nurse instruct the parents to watch for (and notify the physician immediately) if demonstrated by the child? Gastric upset Urinary retention Loss of interest Sedation

Loss of interest

**Which finding in Hillary's history would cause the nurse to alert Child Protective Services because the nurse suspects child maltreatment? Hillary's mother described her as "not pretty." Hillary has a previous health visit for "multiple bruises." Hillary's mother is under severe stress because of her job. Hillary's mother described her as "clumsy."

Hillary's mother described her as "not pretty."

The nurse recognizes that if the infant is following normal development, the infant will be able to focus and follow an object with the eyes by what age? 2 months of age 1 month of age 21 days of age 7 days of age

2 months of age

Tasha is diagnosed as having bacterial meningitis, and her plan of care is being amended in light of this diagnostic finding. How long should the care team maintain respiratory precautions for this condition after Tasha begins an antibiotic? 4 hours 24 hours Until her core body temperature returns to normal Until her arterial blood gases return to normal

24 hours

A 9-year-old girl who has fallen from a second-story window is brought to the emergency department. Which assessment would be the priority? Using the appropriate pain assessment scale Asking the child if she knows where she is Monitoring oxygen saturation levels Evaluating pupils for equality and reactivity

Monitoring oxygen saturation levels

A child and mother come into the orthopedic clinic. The mother is concerned about her child who has recently been diagnosed with scoliosis. The mother asks about surgical treatment and if it will be necessary. The nurse bases her response on knowledge that surgery is implicated for curvatures greater than: 40 degrees. 25 degrees. 20 to 25 degrees. 25 to 30 degrees.

40 degrees.

Which is the best way for the nurse to approach a child who is blind? A.Call the child's name and then identify herself/himself. B.Call the child's name and then touch him. C.Touch the child and then identify herself/himself. D.Touch the child and then say his name.

A.Call the child's name and then identify herself/himself. (Rationale: Touching a child before he or she realizes you are there can be frightening.)

Question 11 of 20 An infant is diagnosed with a congenital cataract. What would the nurse expect to assess? Misalignment of the eyes Enlarged eye appearance Absent red reflex Rapid irregular eye movement

Absent red reflex

During a routine well-child check the caregiver of a 10-year-old tells the nurse that her child has recently starting passing stool into his underwear. This behavior indicates a symptom of which disorder? Enuresis Echolalia Encopresis Encephalopathy

Encopresis

The child diagnosed with muscular dystrophy uses a method of rising from the floor which is referred to as which of the following? Gowers sign Legg-Calvé-Perthes Boston brace Milwaukee brace

Gowers sign

A parent calls the nurse triage line to say the child accidentally got hit in the eye and the parent believes the child will have a black eye. Which instruction is important for the nurse to provide this parent? Assure the parent that the scleral hemorrhages will resolve. Place ice on the eye for 20 minutes/off the eye for 20 minutes for 24 hours. Administer acetaminophen if needed for pain. Refer the child to an ophthalmologist for further evaluation.

Place ice on the eye for 20 minutes/off the eye for 20 minutes for 24 hours.

The nurse is caring for a child with a possible diagnosis of muscular dystrophy. The nurse explains to the parents that which of the following will likely be used to confirm this child's diagnosis? blood work a surgical consult an x-ray a muscle biopsy

a muscle biopsy

A nurse is developing a plan of care for a victim of intimate partner violence. Which intervention would be least appropriate for the nurse to include? discussing the client's legal and personal rights assisting the client to project anger teaching the client about the cycle of violence providing information about a safe home and crisis line

assisting the client to project anger

Which action is the nursing priority when suspecting that a pediatric client is abused? ensuring client care and safety maintaining a nonjudgmental attitude notifying the proper authorities upholding the HIPAA privacy rule

ensuring client care and safety

The nurse is caring for a child admitted with juvenile idiopathic arthritis (JIA). Which clinical manifestation would likely have been noted in the child with this diagnosis? difficulty standing and walking inflammation of the joints pain in the groin and a limp poor posture and malformed vertebrae

inflammation of the joints

A 5-year-old child has frequent visits to the school nurse's office. Which assessment data should alert the nurse that this child may be a victim of physical neglect? evidence of bruising on multiple parts of the body malnourished with frequent absences from school isolated from classmates with poor self-esteem inappropriate knowledge of sexual terms and actions

malnourished with frequent absences from school

A child is admitted to the pediatric unit with osteomyelitis. The child is to be placed on antibiotics. The nurse expects antibiotic coverage to include which of the following as the most common cause of osteomyelitis? Staphylococcus aureus Haemophilus influenzae mycobacterium streptococcus group B

Staphylococcus aureus

A nurse is preparing discharge instructions for a child treated for ingestion of an unknown amount of ibuprofen. The child was treated with an activated charcoal gastric lavage. Which piece of information should the nurse include to provide anticipatory guidance to the parent? The child will continue taking the chelating agent. The mouth sores will heal over several weeks. Stools will be black in color for the next few days. Blood tests will be needed to check liver function.

Stools will be black in color for the next few days.

The nurse is caring for a client in an abusive situation. In developing a plan of care, which factors does the nurse consider? Select all that apply. Until children reach school age, they are usually not affected by parental discord. Economic factors rarely play a role in the decision to stay in abusive relationships. Substance use is a common factor in abusive relationships. It often takes several attempts before a woman leaves an abusive situation. Women in abusive relationships usually feel isolated and unsupported.

Substance use is a common factor in abusive relationships. It often takes several attempts before a woman leaves an abusive situation. Women in abusive relationships usually feel isolated and unsupported.

Suppose Tasha has a tonic-clonic seizure while in the hospital. Which of the following items should the nurse keep available at the bedside for a child known to have generalized seizures? (Select all that apply.) Suction Tracheostomy tube Oxygen Call bell Padded tongue blade

Suction Oxygen Call bell

The nurse is caring for a victim of intimate partner violence who needs emotional support. What nursing actions are appropriate for this client? Select all that apply. Teach strategies for problem-solving and stress management. Allow the client to make as many decisions as possible. Tell the client how your friend dealt with intimate partner violence. Explain how alcohol can cause intimate partner violence. Encourage the client to attend support groups.

Teach strategies for problem-solving and stress management. Allow the client to make as many decisions as possible. Encourage the client to attend support groups.

The elementary school nurse is caring for four clients with physical injuries. Which child would require follow-up? An 8-year-old with bruising noted on the inner aspect of the arms A 5-year-old with two bruises of different stages on the shoulder and knee A 6-year-old with abrasions on the elbows and knees A 12-year-old with a bruise on the right hip

An 8-year-old with bruising noted on the inner aspect of the arms

A 14-year-old girl arrives at the hospital in a comatose state. Her father, who found her comatose in her room, tells the nurse that she has an opiate addiction. Which of the following would confirm that the coma was caused by opiate intoxication? Both pupils are pinpoints. Both pupils are dilated. One pupil is dilated and the other is normal. One pupil is dilated and the other deviates downward.

Both pupils are pinpoints.

Jeffrey's mother said she was worried her son might be developing muscular dystrophy. A clinical care map for children who have this disease should prioritize which action? Urging them to rest most of the day to avoid systemic fatigue Helping them to avoid weight gain so they can be mobile longer Cautioning them not to eat foods that contain purines Encouraging a diet rich in calcium to prevent osteoporosis

Helping them to avoid weight gain so they can be mobile longer

What age group is most vulnerable to toxic fumes or asphyxiation? middle adults young children adolescents young adults

young children

A nursing instructor is teaching about eye disorders in childhood. Which statement made by a student indicates a need for further instruction? "A cataract is a marked opacity of the lens." "Cataracts are only present in adults." "Cataracts can be present at birth." "Glaucoma is caused by increased intraocular pressure."

"Cataracts are only present in adults."

The nurse is caring for a 6-year-old boy with Russell traction applied to his left leg. Which intervention would be most appropriate to prevent complications? Assess the popliteal region carefully for skin breakdown. Adjust the weights as needed. Provide pin care as needed. Clean and massage his entire leg daily.

Assess the popliteal region carefully for skin breakdown.

A child is born with clubfoot (congenital talipes equinovarus). The child later receives a cast on the affected leg to correct the problem. Which measure should the nurse mention to the mother to ensure good circulation in the affected leg? Change the infant's diapers frequently. Apply Denis Browne splints to the infant each night. Perform passive foot exercises. Check the infant's toes for coldness or blueness.

Check the infant's toes for coldness or blueness.

Antibiotic therapy to treat meningitis should be instituted immediately after which event? Collection of cerebrospinal fluid (CSF) and blood for culture Identification of the causative organism Admission to the nursing unit Initiation of IV therapy

Collection of cerebrospinal fluid (CSF) and blood for culture

The nurse is caring for a child who fractured the arm in an accident. A cast has been applied to the child's right arm. Which action(s) should the nurse implement? Select all that apply. Document any signs of pain. Check capillary refill time in the both arms. Wear sterile gloves when removing or touching the cast. Monitor the color of the nail beds in the right hand. Wear a protective gown when moving the child's arm.

Document any signs of pain. Check capillary refill time in the both arms. Monitor the color of the nail beds in the right hand.

The student nurse is developing a care plan for a child who suffered a fractured tibia and will have a cast on his lower leg for approximately 6 weeks. Which nursing diagnosis would be the priority for this client? Deficient diversional activities related to a need for imposed activity restriction for 6 weeks Pain related to chronic inflammation of the lower leg Impaired physical mobility related to a cast on the leg Situational low self-esteem related to the use of a walker

Impaired physical mobility related to a cast on the leg

**A 9-year-old boy was in a car accident. The child is suffering from posttraumatic stress disorder. Which would be the best approach for treatment? Sensory integration technique Individual psychotherapy sessions Psychostimulant medications Antipsychotic medications

Individual psychotherapy sessions

The nurse is caring for a child who has suffered a head injury and has had an ICP monitor placed. Which prescription by the health care provider would the nurse question?-Place in an indwelling urinary catheter.-Administer dexamethasone, dosage determined by the pharmacist.-Administer mannitol IV, dosage determined by the pharmacist.-Initiate an IV of 0.9% NS to run at 250 mL/hr.

Initiate an IV of 0.9% NS to run at 250 mL/hr. ( Rapid administration of IV fluids may increase ICP. An IV rate of 250 mL/hr can be considered a rapid infusion. Corticosteroids such as dexamethasone can reduce cerebral edema. Osmotic diuretics, such as mannitol, can reduce pressure. Because of the administration of the osmotic diuretic, indwelling urinary catheters are typically inserted.)

Jason's parents are in distress because they fear that his ICP is increasing. The nurse wants to reassure his parents that Jason is being monitored closely. Which event would be most indicative that his ICP is increasing? Jason refuses to let the nurse assess his tympanic temperature. Jason asks the nurse to read the same story to him over and over. Jason can't remember a thing about how his injury happened. Jason's temperature and blood pressure are both slowly increasing

Jason's temperature and blood pressure are both slowly increasing

A nurse is caring for a stable toddler diagnosed with accidental poisoning due to the ingestion of cleaning solution. What must be included in teaching parents about how to protect a toddler from accidental poisoning? Label poisonous solutions. Do not leave the toddler alone. Closely monitor the toddler's activity. Keep cleaning solutions locked up.

Keep cleaning solutions locked up.

A child returns to the clinic after an episode of external otitis (acute otitis externa) that has resolved. What would the nurse emphasize as the priority for preventing future episodes? Performing handwashing Keeping ear canals dry Adhering to regular follow-up to assess for hearing loss Avoiding upper respiratory tract infections

Keeping ear canals dry

Absence seizures are marked by what clinical manifestation? Brief, sudden onset of increased tone of the extensor muscle Loss of muscle tone and loss of consciousness Loss of motor activity accompanied by a blank stare Sudden, brief jerks of a muscle group

Loss of motor activity accompanied by a blank stare

Mrs. Landstrum's adolescent sister, Andrea, is examined in the emergency room because she has pain and a vaginal discharge. Based on the previous study, the nurse determines which person (aside from Andrea herself) as most likely to be the most reliable reporter as to whether Andrea has been sexually maltreated? Andrea's mother, because Andrea says she respects her Megan, a soccer teammate and close friend of Andrea Andrea's father, because he is the patriarch of the family Andrea's soccer coach, because she sees Andrea daily

Megan, a soccer teammate and close friend of Andrea

A nurse is providing care to a child who was involved in a severe car accident. The child sustained significant internal injuries and blood loss. The child has developed refractory shock. Which action is most important for the nurse take? Increase the rate on the child's intravenous fluid infusion. Ask the health care provider to consider changing the child's medications. Make arrangements for the parents to meet with the health care team. Monitor the child closely for any further changes in the child's condition.

Monitor the child closely for any further changes in the child's condition.

Which of the following is true regarding intimate partner violence? Women who are in an abusive relationship experience less abuse while they are pregnant. One in four women will be a victim of violence. Abusers often have outward signs that they are abusers or have a mental illness. Even though women seldom blame themselves for the abuse, they often cannot leave the relationship.

One in four women will be a victim of violence.

A nurse assesses a client who is complaining of calf pain, has a temperature of 101°F (38.3°C) and reports that his leg is very sore. X-rays do not reveal any abnormalities but the client's white count is 21,000 cells and his erythrocyte sedimentation rate is elevated. What problem do these symptoms suggest? Legg-Calves-Perth disease Muscular dystrophy Osteomyelitis Compartment syndrome

Osteomyelitis

Which sign is consistent with autism spectrum disorder (ASD) in a 2-year-old boy? Shows signs of losing attained skills Performs repetitive activity with toys Possesses excellent language development Has below-average intellectual function

Performs repetitive activity with toys

A 6-year-old child is playing. Which play scenarios witnessed by the nurse are indicative that the child is sexually abused? Select all that apply. Stating that boys and girls love each other Playing with a boy and girl doll in a sexually graphic manner Using inappropriate adult language Wanting to play house with the girl having a baby Arranging dolls in unnatural positions for play

Playing with a boy and girl doll in a sexually graphic manner Using inappropriate adult language Arranging dolls in unnatural positions for play

A nurse is assessing a 3-year-old child for possible bacterial meningitis. Which sign would indicate irritation of the meninges? Negative Brudzinski sign Positive Chadwick sign Negative Kernig sign Positive Kernig sign

Positive Kernig sign

A nurse is with Jason when he spills scalding hot water onto his hand. Which of the following would be the best emergency action? Apply a layer of vegetable oil over his hand. Cover his hand with a gauze dressing. Pour cool water from a faucet over his hand. Apply soothing hand lotion to keep the area moist.

Pour cool water from a faucet over his hand.

A nurse has rushed to the site of an accident where members of a family have suffered carbon monoxide poisoning. What is the highest priority action that must take place during carbon monoxide poisoning? Remove the individual from the room. Begin CPR. Give oxygen to the individual. Open the doors and windows of the room.

Remove the individual from the room.

Which nursing assessment data should be given the highest priority for a child with clinical findings related to meningitis? Onset and character of fever Occurrence of urine and fecal contamination Signs of increased intracranial pressure (ICP) Degree and extent of nuchal rigidity

Signs of increased intracranial pressure (ICP)

The nurse is caring for a 3-month-old with nasolacrimal duct obstruction. Which intervention would be most appropriate for the nurse to implement? Referring the child to an ophthalmologist Being careful to prevent spread of infection Applying hot, moist compresses to the affected eye Teaching the parents how to gently massage the duct

Teaching the parents how to gently massage the duct

While assessing a child with a suspected skull fracture, the nurse notes clear fluid draining from the child's nose. What is the priority action by the nurse? Document the finding as otorrhea. Test the fluid with a glucose reagent strip. Ask the child to blow the nose forcefully to clear the fluid. Provide the child with tissues to wipe the nose with instructions not to blow the nose.

Test the fluid with a glucose reagent strip.

Which sign or symptom suggests that a 5-year-old boy who does not maintain eye contact or speak may have autism spectrum disorder (ASD)? The child is highly active and inattentive. The child constantly opens and closes his hands. The child has a long face and prominent jaw. The child has a slight decrease in head circumference.

The child constantly opens and closes his hands.

The nurse is collecting data on a 16-year-old girl with the diagnosis of bulimia. What would the nurse most likely note in this child? The child is a perfectionist and tries hard to please her parents and teachers. The child socializes with friends and shares all her dreams and secrets with them. The child has a ritualistic program of exercise that she does every day after school. The child is of normal weight for her height according to the growth charts.

The child is of normal weight for her height according to the growth charts.

A 14-year-old male is brought to the ER by his parents with a suspected fracture of the arm sustained while playing soccer. An x-ray shows a comminuted fracture. Which of the following best describes this type of fracture? A line crosses the shaft at a 90º angle. The bone is bent, but not broken. There are three or more fracture fragments. There is a diagonal line across the bone.

There are three or more fracture fragments.

The physician of a child with extensive burns tells the nurse an hour after the injury to "monitor him carefully." Which of the following would be the most important factor to monitor closely? A. Urinary output B. Pupillary reaction C. Intracranial pressure D. Sugar and acetone of urine

Urinary output (Rationale: So much fluid enters a burned area and is lost that cardiovascular pressure can fall, decreasing kidney function. Assessing urine output is important to detect kidney function.)

If Carla, the 6-year-old who has strabismus, has to have corrective eye surgery, why would the prevention of vomiting from anesthetic be a high priority? Vomitus could be splashed into the eye. Loss of sodium threatens the integrity of the new lens. Vomiting increases IOP. Loss of fluid causes the globe diameter to shrink.

Vomiting increases IOP.

The nurse is discussing the treatment for a child with attention deficit hyperactivity disorder (ADHD) with a group of school nurses. What would be an appropriate learning setting for a child with ADHD? a classroom with windows facing a playground a classroom in which children self-select their activities a classroom with tables and chairs rather than individual desks a classroom with a plan of study that is followed each day

a classroom with a plan of study that is followed each day

The nursing student correctly identifies the major cause of death in the 1- to 4-year-old age group to be which of the following? congenital disorders cancer accidents immunosuppressive disorders

accidents

The nurse is caring for a client who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnoses? impaired nutrition; less than body requirements activity intolerance anxiety acute pain

acute pain

Nurses at an emergency department seek to develop a plan to help clients who are victims of intimate partner violence. Which component is critical to the success of the plan? avenues for referral an intimate partner violence (IPV) counselor a quality-of-life assessment tool educational materials

avenues for referral

A 12-year-old boy with color blindness asks his nurse what causes this condition. The nurse should explain to him that which of the following eye structures are genetically absent? lenses retinas cones rods

cones

The nurse is educating a group of caregivers about fractures seen in children. One of the caregivers states, "I have heard that if a bone breaks it can cause permanent damage and stop the growth of the bone." This statement is accurate if the break occurs in the: epiphyseal plate. joint. xiphoid process. humerus.

epiphyseal plate.

A woman has brought her 3-year-old to the pediatrician's office for wheezing and a cough. Upon examination, the nurse notes that the child is lethargic, has some areas of skin breakdown, and has poor muscle tone. The child also does not speak and maintains intense eye contact with the nurse during the examination. What would the nurse suspect? ritual abuse caregiver-fabricated illness (formerly Munchausen syndrome by proxy) psychological abuse failure to thrive

failure to thrive

A nurse teaching a parent of a pediatric client instructs that which of the following plays a large role in childhood poisonings? family stress family religion family income family culture

family stress

A type of traction sometimes used in the treatment of the child with scoliosis is called: Dunlop traction. Russell traction. halo traction. Bryant traction.

halo traction.

In understanding the function of the musculoskeletal system, the nurse recognizes that which of the following allows for movement of the body parts? cartilage ligaments joints tendons

joints

A nursing student learning about vision problems correctly identifies which of the following as a symptom and not a disease itself? nystagmus myopia hyperopia astigmatism

nystagmus

The nurse is assessing a 7-year-old with a hearing aid. His mother says he is losing his hearing again. Which finding would the nurse expect to make? the eardrum responding to a puff of air normal term birth soreness of the outer ear overproduction of cerumen

overproduction of cerumen

The nurse is educating the parents of a 6-year-old child about preventing hearing loss. Which topic will be included in the discussion? suddenly doing poorly in school playing the radio loudly tendency to act silly in the classroom prevention and treatment of otitis media

prevention and treatment of otitis media

The nurse will help parents of a child with amblyopia understand that occluding vision in the unaffected eye is therapeutic because: occlusion relieves eye strain in the affected eye. the pain of amblyopia is relieved in both eyes. use of the affected eye promotes vision development. pupil size in the affected eye will increase.

use of the affected eye promotes vision development.

A 7-year-old girl who recently emigrated to the United States from India as a refugee is suffering from night blindness. The nurse recognizes that this condition is caused by a deficiency in which of the following vitamins? vitamin B12 vitamin C vitamin K vitamin A

vitamin A

When caring for an infant who is hospitalized with Haemophilus influenzae meningitis, an important nursing intervention for the child would be for the nurse to: check the child's neurologic status every 2 hours. restrain the child before and during a seizure. place the child in a side-lying position and keep the position using pillows. monitor intake and output and increase fluid intake every 4 hours.

check the child's neurologic status every 2 hours.

Which intervention prevents a 17-month-old child with spastic cerebral palsy from going into a scissoring position? trying to keep the child as quiet as possible placing the child on your hip keeping the child in leg braces 23 hours per day letting the child lie down as much as possible

placing the child on your hip (To interrupt the scissoring position, flex the knees and hips. Placing the child on your hip is an easy way to stop this common spastic positioning. This child needs stimulation and movement to reach the goal of development to the fullest potential. Wearing leg braces 23 hours per day is inappropriate and doesn't allow the child to move freely. Trying to keep the child quiet and flat are inappropriate measures.)

What would the nurse include when teaching parents how to prevent external otitis (acute otitis externa or swimmer's ear)? Using a hair dryer on high to dry the ear canals Wearing ear plugs when swimming Using hydrogen peroxide to dry the canal skin Daily ear cleaning with cotton swabs

Wearing ear plugs when swimming

The nurse is caring for a child with a suspected head injury. The nurse observes for what response to the child's eye reflex examination that would indicate potential increased intracranial pressure (ICP)? While stimulating the child's foot, the big toe points upward and other toes fan outward. While calling the child's name, the child stares straight ahead and does not turn to the sound. While turning the child's head to the left, the eyes turn to the right. While assessing the child's pupils, there is no change in diameter in response to a light.

While assessing the child's pupils, there is no change in diameter in response to a light.

A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. The nurse would include which recommendation in the nursing plan? Decrease environmental stimulation Encourage the parents to hold the child Take vital signs every 4 hours Monitor temperature every 4 hours

Decrease environmental stimulation

Based on this study, which action by Carla's teenage brother would cause a nurse the most concern? He listens to music on his computer while he does his homework. He typically listens to sports news on the radio while he eats. He plays varsity basketball in a noisy gymnasium once a week. He listens to music with earbuds when he rides the bus and subway.

He listens to music with earbuds when he rides the bus and subway.

The nurse is assessing the respiratory status and lungs of a 6-year-old child. What finding would the nurse report immediately? Minimal air movement through the lungs High-pitched breath sounds over the trachea Resonance over the lungs on percussion Low-pitched bronchial sounds over the periphery

Minimal air movement through the lungs

The vision impairment in which the child can see objects at close range but not at a distance is known as: Myopia Esotropia Hyperopia Exotropia

Myopia

The nurse is caring for a 4-year-old client with head trauma. Which intervention should the nurse anticipate first? Mannitol administration Neck stabilization with brace Intracranial pressure monitoring Dexamethasone therapy

Neck stabilization with brace

Based on this literature, which activity should the nurse advise Jeffrey not to do with his preschool sister? Swinging her by the arms to make her laugh Encouraging her to practice hip-hop dancing Helping her to fly her kite on a windy afternoon Helping her take off a tight sweater or shirt

Swinging her by the arms to make her laugh

Tasha's sister Wanda was diagnosed with CP as an infant. What information would the nurse want her parents to know about her prognosis? Symptoms of CP typically begin to wane just after puberty. The severity of cognitive deficits parallels the severity of physical deficits. CP may occasionally be caused by a childhood vaccine reaction. Symptoms may seem to grow worse as fine motor skill is needed.

Symptoms may seem to grow worse as fine motor skill is needed.

A female client shares that her partner often comes home in the evening after a couple of beers, and is jealous, tense and verbally abusive. He sometimes destroys things, such as breaking a vase of flowers. The client says this makes her feel embarrassed, but she tries to be submissive to her partner to calm him down. The nurse recognizes this interaction as which phase of a relationship with intimate partner violence? Remorseful phase Violent episode phase Tension-building phase Honeymoon phase

Tension-building phase

The nurse is caring for an 8-year-old hospitalized child who is visually impaired. Which nursing intervention would be the highest priority in helping this child reduce anxiety related to hospitalization? The nurse takes the child to the playroom and lets her touch the toys. The nurse encourages the child to call her friends on the telephone. The nurse talks to the child when entering and leaving the room. The nurse stays with the child during meals and helps her eat.

The nurse talks to the child when entering and leaving the room.

**During a well-child visit, the nurse assesses an infant's ability to suck on a pacifier. The nurse is assessing which cranial nerve? Facial Trigeminal Accessory Olfactory

Trigeminal

A child is brought to the emergency department (ED) from the site of a chemical fire. The paramedics report that the client has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. During assessment, the child verbalizes no pain in the right arm and the skin appears charred. Based on these assessment findings, what is the depth of the burn on the client's right arm? full partial-thickness deep partial-thickness full-thickness superficial partial-thickness

full-thickness

What is the most frequently injured solid organ in a penetrating trauma? lungs liver pancreas brain

liver

The school nurse is doing a presentation to a group of caregivers of children diagnosed with scoliosis. One of the caregivers asks the nurse about structural scoliosis. Which condition is involved with the diagnosis of structural scoliosis? unequal leg length rotated and malformed vertebrae muscle spasm caused by trauma poor posture

rotated and malformed vertebrae

A 5-year-old child is exhibiting manifestations of hypotension. What is the first-line treatment for poor perfusion and hypotension? atropine epinephrine volume replacement sodium bicarbonate

volume replacement

The nurse is caring for an 8-year-old child in traction. The client has been in an acute care setting for 2 weeks and will require an additional 10 days in the hospital. The client is showing signs of regression with thumb sucking and pleas for the now tattered baby blanket. What would be the most helpful intervention? "Do you want a book to read?" "Would you like a coloring book?" "Let's ask your parents to bring your friends for a visit." "You are too big to suck your thumb."

"Let's ask your parents to bring your friends for a visit."

The health care provider is unsure of physical symptoms and diagnosis of a pediatric client. The health care provider is prescribing diagnostic testing to determine possible poisoning by the parent. When the parent asks why laboratory work is being drawn, which response is best? "It is hospital policy to draw laboratory work daily to monitor the client status." "Since we have not found the cause of the illness yet, the health care provider has ordered more blood tests." "I am not really sure at this time. I just saw it on the prescription sheet." "We are drawing laboratory work to rule out poison in the child's system."

"Since we have not found the cause of the illness yet, the health care provider has ordered more blood tests."

The nurse is speaking with the parents of a child who has a cast. The parents state that the child reports itching in the area of the cast. What is the best response by the nurse? "Itching is common. It's nothing to worry about." "Blowing cool air with a fan or hair dryer may relieve the feeling." "A small amount of lotion or baby oil can be poured in the cast to moisturize the area." "You can put a pencil or coat hanger and scratch the area but don't let your child put anything down the cast without you there."

"Blowing cool air with a fan or hair dryer may relieve the feeling."

During a prenatal assessment, the nurse observes that the client is quiet and withdrawn. The client keeps asking if her partner can come into the examination room, because the partner does not like to be kept waiting. Which question would be most important for the nurse to ask before the partner comes into the examination room? "Is something bothering you?" "Why do you keep asking for your partner?" "What happens when you and your partner argue?" "Do you feel safe in your home?"

"Do you feel safe in your home?"

According to the American Psychiatric Association (DSM-5, 2013), a client with anorexia nervosa has a body image disturbance in which one's body weight or shape is not experienced realistically. Which statement by a client would best validate this criterion? "Being this skinny really isn't a good idea for my health." "When I see myself in the mirror, I can see my ribs." "My stomach really sticks out and looks fat." "I realize I am a quite thin, but I am trying to gain weight."

"My stomach really sticks out and looks fat."

The child's palm represents approximately which percentage of the total body surface area (TBSA)? 15% 5% 10% 1%

1%

A 13-year-old adolescent has had a near-drowning experience. The nurse notices the client has labored breathing and a cough. What is the priority intervention? Perform postural drainage every hour. Administer 100% oxygen by mask. Check the client's capillary refill time. Have the client sit up straight in a chair.

Administer 100% oxygen by mask.

A nurse is applying a cast to a 12-year-old boy with a simple fracture of the radius in the arm. What is most important for the nurse to do when she has finished applying the cast? Cut a window in the cast over the wrist X-ray the cast to make sure the bones are aligned properly Apply a tube of stockinette over the cast Assess the fingers for warmth, pain, and function

Assess the fingers for warmth, pain, and function

**The nurse is educating a parent support group for teens with anorexia. Which of the following statements would the nurse suggest for the parents? Discuss food and calories with the teen. Avoid making comments about the teen's appearance. Discuss weight with the teen. Tell the teen not to talk to peers or counselors.

Avoid making comments about the teen's appearance.

The nurse is discussing with a parent the difference between a breath-holding spell and a seizure. The nurse will be correct in telling the parent which information in regard to seizures? Seizures are typically provoked by pain. The electroencephalogram (EEG) is normal during a seizure. Seizures are typically outgrown by 4 years of age. Convulsive activity often occurs in seizures.

Convulsive activity often occurs in seizures.

The mother of an 8-year-old boy is concerned that her son has attention deficit hyperactivity disorder. She describes the symptoms he demonstrates. Which behavior should the nurse recognize as an example of impulsiveness? Repeating words or phrases spoken by others Constantly fidgeting in his chair and shaking his foot Inability to answer a question posed by his teacher because he was daydreaming Jumping out of his seat in the middle of class and running to the bathroom without the teacher's permission

Jumping out of his seat in the middle of class and running to the bathroom without the teacher's permission

A 9-year-old girl who is suspected of having an infection of the central nervous system (CNS) is undergoing a lumbar puncture to withdraw cerebrospinal fluid (CSF) for analysis. The nurse knows that the needle will be introduced into the subarachnoid space at the level of which of the following vertebrae? L1 or L2 L4 or L5 T3 or T4 C1 or C2

L4 or L5

The nurse is assessing the neurologic status of an infant. What would the nurse identify as an abnormal finding? Making eye contact with the nurse Soft, flat anterior fontanel (fontanelle) Lack of interest in surroundings Vigorous crying

Lack of interest in surroundings

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

Protecting the child from harm during the seizure

**A 10-year-old girl with ADHD has been on methylphenidate for 6 months. The girl's mother calls and tells the nurse that the medication is ineffective and requests an immediate increase in the child's dosage. What should the nurse say? "Let me talk to the doctor about this." "Let's wait a few more weeks before we do anything." "Let's set up an appointment as soon as possible." "What does the teacher say?"

"Let's set up an appointment as soon as possible."

The nurse is performing a physical assessment for an 8-year-old child with an earache. Which sign or symptom indicates external otitis (acute otitis externa or swimmer's ear)? The tympanic membrane reacts to a puff of air. The ear canal is devoid of cerumen. Symptoms of upper respiratory infection are present. The child cries out when the ear is grasped.

The child cries out when the ear is grasped.

In addition to physical examination, what is another important way that nurses know physical abuse is confirmed? spinal tap blood tests radiography none of the above

radiography

A nurse is performing a physical examination of a pregnant woman. During examination, the nurse notices a bruise on the client's abdomen. Which action should the nurse take? Make a note in the client's chart regarding the finding, and plan to observe for other signs of intimate partner violence in the future. Ask the client to account for the bruise. Assume that the bruise is from an accident and not worry about it. Assume that the bruise is from intimate partner violence, and call the police while the client is still in the room.

Ask the client to account for the bruise.

A client has been seen and treated in the emergency room several times for injuries that are deemed suspicious. The client is reluctant to participate in a screening process. How best can the nurse provide reassurance to this client? Giving assurances of help Being nonjudgmental Establishing a plan to protect the client Having the client be honest about the injuries

Being nonjudgmental

**A school nurse is caring for a child with autism who needs his midday medications. Which intervention by the nurse would best address the child's needs in administering the medication? Discuss with the parents how they administer medications at home. Offer the child his choice of beverages to drink when she takes the medication. Show the child on the clock what time it is and tell him it is time for his medications. Tell the child that he must take the medication now.

Discuss with the parents how they administer medications at home.

An 8-year-old boy comes to the emergency room with an eye injury after having a glass bottle shatter near his face. Which intervention should the nurse do first while assisting this client? Instill a few drops of a topical anesthetic into the affected eye Grasp the eyelashes of the upper eyelid and evert it Press firmly on the lower lid with the fingertip until it turns out Touch the glass fragment in the eye with a moistened, sterile, cotton-tipped applicator

Instill a few drops of a topical anesthetic into the affected eye

The nurse is caring for a child who had a cast on his lower leg placed two hours ago. When assessing the child's foot, the nurse notes that the toes are cool and the child reports extreme pain. What is the best action by the nurse? Notify the health care provider of the findings immediately. Apply ice bags to the child's foot and ankle. Reposition the leg on pillows so that it is above the level of the child's heart. Administer prescribed pain medication.

Notify the health care provider of the findings immediately.

In caring for a child who has been admitted after being sexually abused, which intervention would be included in the child's plan of care? Weigh on the same scale each day. Test the urine for glucose upon admission. Observe for signs of anxiety. Encourage frequent family visits.

Observe for signs of anxiety.

he nurse is conducting a community educational program for parents of school-aged children. What would the nurse include in education plan in regards to the potential for drug and alcohol consumption in the school-age population? When discussing drugs and alcohol consumption, keep the conversation light and avoid hard facts. Parental modeling of drug and alcohol avoidance is vital at this age. If the child is experimenting with drugs or alcohol, parental anger is the best approach. Peer groups have little influence on this age group, so allowing freedom of friends is important.

Parental modeling of drug and alcohol avoidance is vital at this age.

After performing eye tests, the school nurse notes a child has symptoms of myopia. Which recommendation will the nurse make to the child's teacher? Place the child close to the blackboard. Place the child further back in the room. Enable the captions with videos. Request a reader to help the child.

Place the child close to the blackboard.

What would the nurse do first for a 5-year-old child with profound bradycardia? Administer epinephrine as prescribed. Use warming blankets. Provide oxygen at 100%. Administer atropine as prescribed.

Provide oxygen at 100%.

The nurse is taking a health history for a 9-year-old child with conjunctivitis. Which finding would suggest that this is allergic conjunctivitis? Family history of conjunctivitis Exposure to infective agents Recent upper respiratory infection Recently helped clean the basement

Recently helped clean the basement

Which nursing diagnosis would be appropriate for teaching interventions for a single mother who leaves her toddler unattended in the bathtub? Noncompliance Risk for imbalanced body temperature Risk for suffocation Risk for falls

Risk for suffocation

The nurse is caring for a child admitted with focal onset motor seizures (simple partial motor seizures). Which clinical manifestation would likely have been noted in the child with this diagnosis? The child was rubbing the hands and smacking the lips. The child was dizzy and had decreased coordination. The child had shaking movements on one side of the body. The child had jerking movements in the legs and facial muscles.

The child had shaking movements on one side of the body

In collecting data on a 7-year-old child with a possible diagnosis of school phobia, the nurse directs questions related to the following topics. Which would most likely be a cause of the child having school phobia? The child may be a poor student and be afraid of failing grades. The child may have a language barrier. The child may have a fear of being separated from the parent. The child may be bored and feels more intellectually stimulated at home.

The child may have a fear of being separated from the parent.

A nurse is reviewing the results of a lumbar puncture of a child. The nurse identifies which results as being abnormal? Select all that apply. cloudy in color trace amounts of glucose trace amounts of protein specific gravity of 1.011 granulocytes are present

cloudy in color specific gravity of 1.011 granulocytes are present

A nursing student is learning about structural problems of the eye in children. The student correctly identifies incomplete closure of the facial cleft as which of the following? ptosis coloboma hyperopia strabismus

coloboma

The nurse observes an adolescent who appears to be persistently sad, has angry outbursts, has a decreased appetite and complains of headache frequently. Additionally, the mother reports that the teen is somewhat defiant and has been missing her curfews. The nurse recognizes that these are all signs of what problem? Substance abuse Striving for independence Depression Alcohol abuse

Depression

The nurse is preparing a child experiencing new-onset seizures for an electroencephalogram (EEG) test. How can the nurse best explain this procedure to the child? Assure the child the procedure will not hurt. Tell the child he or she can take a nap during the procedure. Show the child a video of the procedure. Use a doll with electrodes attached to the head.

Use a doll with electrodes attached to the head.

The nurse is caring for a client suspected of being a victim of human trafficking. Which question, when given priority by the nurse during the admission interview, demonstrates a need for additional training? "Can you leave your job if you find a better one?" "Are you working toward achieving American citizenship?" "Can you get in touch with your family easily?" "Are you afraid of those you work for?"

"Are you working toward achieving American citizenship?"

Symptoms of schizophrenia often begin in adolescence, so the nurse reviews Cheyenne's history with a psychiatric-mental health nurse. Which statement by Cheyenne would signal to the nurses she is developing symptoms of schizophrenia? "I absolutely hate babysitting for my younger brother on week nights." "Both my English and math teachers gave me bad marks last quarter. I got so mad." "My father seems more worried about his health than he does about mine." "At night, I can hear my friends plotting against me through the water pipes."

"At night, I can hear my friends plotting against me through the water pipes."

Hillary's mother reveals that she was raped when she was a teenager. What is the most important question to ask before beginning a physical assessment for an adolescent who has been raped? "Have you bathed or showered since the attack?" "Did the rape feel more sexual or more violent?" "Was anything stolen from you during the attack?" "Can you think of a way you could have prevented this?"

"Have you bathed or showered since the attack?"

The nurse is caring for a child who will be given activated charcoal due to an unintentional poisoning. Which statement by a parent indicates a need for further education? "My child will drink the charcoal; it will be mixed with water and some sweet syrup." "If she can't drink the charcoal, the nurse will put a tube down my child's throat into the stomach and put the medication in it." "The charcoal will help to deactivate the poison that is in my child's system." "I need to check my child's stools for the next few days; if they are black, that means there is blood in the stool."

"I need to check my child's stools for the next few days; if they are black, that means there is blood in the stool."

A nurse is collaborating with a licensed practical nurse in the care of a child with an elbow cast. What information about an elbow cast should all care team members to be aware of? The cast must be constructed from fiberglass, not plaster of Paris. Edema at the elbow from a too tight cast can cause severe nerve damage. The child should expect to have low-grade pain following application. These casts often get dirty and so lead to humeral osteomyelitis.

Edema at the elbow from a too tight cast can cause severe nerve damage.

A child is brought to the clinic after tripping over a rock. The child states, "I twisted my ankle" and is given a diagnosis of a sprain. What intervention is most important for the nurse to include in the discharge instructions for this child? Take a nonsteroidal anti-inflammatory drug (NSAID) for pain as prescribed. Use a compression dressing for 72 hours. Maintain bed rest with the leg elevated for 36 hours. For the first 24 hours, apply ice for 20 minutes and remove for 60 minutes.

For the first 24 hours, apply ice for 20 minutes and remove for 60 minutes.

A child with an intellectual disability is evaluated and found to have an intelligence quotient (IQ) of 65. The nurse interprets this as reflecting which category of intellectual disability? Moderate Severe Mild Profound

Mild

The nurse is preparing a room for a child being admitted with meningitis. What is the appropriate action by the nurse? Ensure that lights and televisions work properly to provide stimulation while the child is hospitalized. Gather appropriate equipment and signage for respiratory isolation precautions. Provide information regarding policies of the unit's playroom for the parents to review. Place multiple pillows in the room to assist with propping the child's head up.

Gather appropriate equipment and signage for respiratory isolation precautions.

The nurse is caring for a child with hearing loss due to damage from chronic inner ear infections. The nurse knows that the child most likely has which type of hearing loss? sensorineural central auditory dysfunction conductive mixed hearing loss

conductive

**When creating a care plan for a child with a head injury, the nurse uses the nursing diagnosis of Risk for excess fluid volume related to administration of hypertonic solution. Which is an appropriated outcome evaluation for this diagnosis? The child's parents state an understanding of treatment of increased intracranial pressure. The child shows no evidence of any altered thought process. The child's lungs remain clear to auscultation. The child's urine specific gravity is between 1.030 and 1.033.

The child's lungs remain clear to auscultation.

The nurse in the acute care setting is caring for a child with deafness. Which nursing intervention is appropriate for this child? Allow the child to sleep in the dark in order to hear better at night. Touch the child gently on the shoulder to let the child know you are present in the room. Allow the child to see the nurse prior to touching or completing any assessments or procedures. Encourage the parents to stay with the child to allow for easier communication for the nursing staff.

Allow the child to see the nurse prior to touching or completing any assessments or procedures.

The mother of a child newly diagnosed with an intellectual disability tells the nurse that her partner disagrees with the diagnosis and believes that the child is perfectly normal. The mother shares with the nurse that she finds this reaction frustrating and confusing. Which action by the nurse would be appropriate in supporting this mother? Suggest that the couple get a second opinion about the child's condition. Reassure the mother that her partner's reaction is a normal stage in the grieving process. Recommend that the couple consider placing the child in foster care until they adjust to the diagnosis. Offer to speak with the partner to explain how the diagnosis was reached.

Reassure the mother that her partner's reaction is a normal stage in the grieving process.

Carla, who is 6 years old, has developed amblyopia. Which statement by her mother would assure the nurse that her learning needs are being met? "I place the patch over her weak eye to enhance the vision in her stronger eye." "I place the patch over her good eye to allow the weaker eye to strengthen." "I alternate the patch between eyes every other day so both eyes strengthen." "I can take off the patch while Carla eats to make it easier for her."

"I place the patch over her good eye to allow the weaker eye to strengthen."

A nurse is assessing a child's vision. Which test should the nurse use to test for accommodation? Performing Hirschberg test Having the child touch the fly's wings in an image constructed of colored dots Moving a penlight toward the client's nose and observing whether his eyes can follow it Performing a Weber test

Moving a penlight toward the client's nose and observing whether his eyes can follow it

The prevention of cerebral palsy is the most important aspect of care. Which of the following are focus areas for the prevention of cerebral palsy? Select all that apply. Postnatal prevention of rubella Postnatal prevention of infection Prenatal care to improve nutrition Perinatal monitoring to decrease birth trauma Prenatal prevention of gestational diabetes

Postnatal prevention of infection Prenatal care to improve nutrition Perinatal monitoring to decrease birth trauma

The nurse inspects the eyes of a child and observes that the sclera is showing over the top of the iris. The nurse documents this finding as: Sunsetting Decorticate posturing Nystagmus Doll's eye

Sunsetting

The nurse is performing a physical assessment on a toddler and suspects hearing loss. What symptoms might indicate a problem? Select all that apply. incomplete formed pinna pupils equal and reactive child leaning forward unclear speech white forelock in hair

incomplete formed pinna child leaning forward unclear speech white forelock in hair

**The nurse is observing a child following an eye injury. Which symptom should alert the nurse to the possibility that the child's uninjured eye may be exhibiting signs of an inflammatory reaction? swelling or dryness brightness of vision discharge of purulent drainage an intolerance to light

an intolerance to light

The nurse is assessing a child who has suffered a head injury. Which assessment finding would indicate loss of midbrain functioning? loss of deep tendon reflexes no response to verbal statements arms adducted and flexed on the chest with hands fisted arms adducted and extended with pronation of wrists with fingers flexed

arms adducted and extended with pronation of wrists with fingers flexed (Decerebrate posturing, rigid extension, and adduction of the arms and pronation of the wrists with flexed fingers occurs when the midbrain is not functional. Cerebral loss is shown mainly by decorticate posturing (the child's arms are adducted and flexed on the chest with wrists flexed, hands fisted). Deep tendon reflexes decrease with level of consciousness, but this does not specifically indicate lack of midbrain functioning. No response to verbal statements may indicate a decreased level of consciousness, but it does not indicate lack of midbrain functioning.)

The nurse is caring for a child diagnosed with Sturge-Weber syndrome. Which assessment finding supports this diagnosis? irregular but excessive skin pigmentation all over the child's body port-wine birthmark on the upper part of the face pigmented nevi or café-au-lait spots on the child's chest and arms soft cutaneous tumors on the child's skin along nerve pathways

port-wine birthmark on the upper part of the face

A child has recently been diagnosed with cataracts. The treatment for cataracts is: eye drops to lower the pressure. wearing a patch until the cloudiness clears. there is no treatment for childhood cataracts. surgery.

surgery.

Nursing students are learning about inflammation and infections of the eyes in children. What does the instructor identify to the class as a major cause of eye infections in the newborn? transfer of vaginal secretions lack of vitamin C postmaturity lack of cell-mediated immunity

transfer of vaginal secretions

A nurse is reviewing the medical record of a child who has sustained a fracture. Documentation reveals a bowing deformity. The nurse interprets this fracture as: bone buckling due to compression. bone that breaks into two pieces. significant bending without actual breaking. incomplete fracture.

bone buckling due to compression.

In which example of a burn would the nurse most likely suspect abuse? a sunburn a partial-thickness or second-degree burn on the child's palm A partial-thickness or second-degree burn on the child's bottom a superficial or first-degree splash burn on the child's forearm

A partial-thickness or second-degree burn on the child's bottom

A nurse is observing a 10-year-old boy who is in the waiting room of a pediatrician's office. Another child on the other side of the room removes the lid from a toy box, and the 10-year-old boy screams and then cries briefly. Noticing his shoelaces, he begins laughing and untying them. The nurse recognizes this behavior as an example of: labile mood. flat affect. catatonia. echolalia.

labile mood.

A nurse is performing a physical examination of a child with a suspected fracture. Which assessment technique would the nurse assume would not be used? Observation Inspection Auscultation Palpation

Auscultation

Haemophilus influenzae meningitis is usually spread by which method of transmission? fecal contact droplet intravenous

droplet

Legg-Calvé-Perthes disease (LCPD) is more likely to be seen in which group? Hispanic girls Asian girls Black boys white boys

white boys

The nurse is talking with the mother of a 4-year-old boy who will soon be going to a pre-kindergarten program. The child has had the Snellen vision test done at home, and he was unable to distinguish the pictures at the distance that would indicate his vision is normal. The child's mother asks the nurse if he will need glasses. Which statement made by the nurse would be most appropriate regarding the child's vision? "A child's vision is not completely developed by this age. Your child might outgrow this nearsightedness." "He is likely to have a slight astigmatism, which almost always needs to be corrected by glasses." "His vision problem will get in the way of his learning, so he will probably have to have glasses before he starts school." "He might be suffering from hyperopia and probably will need glasses now."

"A child's vision is not completely developed by this age. Your child might outgrow this nearsightedness."

A member of the child maltreatment team offers Hillary anatomically correct male and female dolls for her to play with. When Hillary begins playing, she places the male doll's penis in the female doll's mouth. How should the nurse best respond? "Do you think it's wrong that the dolls do that?" "I bet you're playing a game you've seen on TV." "Are the dolls playing a game? Tell me about it." "Okay, can you please put the dolls down now?"

"Are the dolls playing a game? Tell me about it."

The nurse manager is educating staff about the mandate of health care workers to report suspected child abuse. A staff member asks, "What if you are not certain that it is an abuse situation. What should the nurse do?" The nurse manager is most correct when providing which answer? "Collaborate with another professional to help make the decision." "Make sure that you are certain of abuse before reporting it." "Get confirmation from the family of the abuse before you report the information." "Feel comfortable about reporting your suspicion as the law protects you."

"Feel comfortable about reporting your suspicion as the law protects you."

The nurse is providing teaching to the parents of a child recently prescribed carbamazepine for a seizure disorder. Which statement by a parent indicates successful teaching? "This medication may cause him to have trouble sleeping. He may need something else to help him sleep." "I'm glad to know he will only need this medication for a short time to stop his seizures." "I need to watch for any new bruises or bleeding and let my health care provider know about it." "I will give the medication to him when I first wake him up in the morning."

"I need to watch for any new bruises or bleeding and let my health care provider know about it."

The nurse is obtaining the history from the parents of an infant who is suspected of having infantile glaucoma. Which statement by the parents would help to confirm this suspicion? "His eye looks about the same size as his other eye." "It seems like bright lights really bother him." "He opens his eyes quite frequently when he's awake." "His eye doesn't seem to tear much."

"It seems like bright lights really bother him."

In which age range are women most vulnerable for intimate partner violence? 16 to 24 years 45 years and older 25 to 34 years 35 to 44 years

16 to 24 years

An emergency depatment nurse who suspects child abuse (child maltreatment) should do which of the following? Report it to the authorities. Discuss with a supervisor to ensure protection of client confidentiality. Keep quiet because of fear of being charged with slander if wrong. none of the above

Report it to the authorities.

A 4-year-old girl has been admitted to the emergency department after accidently ingesting a cleaning product. Which treatment is most likely appropriate in the immediate treatment of the girl's poisoning? Intravenous rehydration Administration of activated charcoal Inducing vomiting Gastric lavage

Administration of activated charcoal??

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

Amblyopia

Todd has symptoms of autism spectrum disorder. When reviewing Todd's electronic health record, which of these symptoms does the nurse recognize as being most consistent with this disorder? Lack of short-term memory Audio hallucinations Constant whirling around in a circle Severe depression or emotional lability

Constant whirling around in a circle

The nurse is caring for a child with an eating disorder. Which is the priority treatment for the disorder? Monitor urine for presence of ketones Correct fluid and electrolyte imbalances Develop a behavior modification plan Supervise and document food intake

Correct fluid and electrolyte imbalances

The client is a 9-month-old whose babysitter brings her to the ER. An x-ray shows a spiral fracture of the femur. The babysitter tells the nurse that she found the infant in this condition when she showed up to watch her an hour ago. How should the nurse respond to this situation? Evaluate the infant for an underlying musculoskeletal disorder. Arrange for the parents to come in for an evaluation for possible physical abuse. Ask the babysitter to advocate for the child and report the incident to the authorities. Evaluate the child for a seizure disorder, as that is probably why the infant is injured.

Arrange for the parents to come in for an evaluation for possible physical abuse.

A 12-year-old boy has broken his arm and is showing signs and symptoms of shock. Which action should the nurse take first? Establish a suitable IV site. Begin hyperventilation. Draw blood for type and cross-match. Provide oral analgesics as ordered.

Establish a suitable IV site.

Which initial interview technique would be least effective in gathering information from a suspected abuse victim? Ask open-ended, nonjudgmental questions of the client. Convey to the client that the abuse is not her fault, such as "No one deserves to be treated like this." Avoid questions that appear accusatory such as "Why don't you just leave him?" Ask the client to strip down and show you where she has been hurt.

Ask the client to strip down and show you where she has been hurt.

Cheyenne tells the nurse she had a transient tic disorder when she was in grade school. The nurse would rate Cheyenne's subsequent care as most adequate if it included assessment for which of the following? Signs she has developed a convulsive disorder Lack of sensitivity to pain from autistic disorder Gastrointestinal symptoms because she likely has pica Depression because she has a loss of self-esteem

Depression because she has a loss of self-esteem

An emergency nurse is caring for a teenager who has just been sexually assaulted. Which actions should be taken at this time? Select all that apply. Determine if the client has showered or bathed since the assault. Assign a supportive, calming same-gender nurse to provide care. Provide privacy and explanations throughout examination. Provide prophylaxis for sexually transmitted infections. Obtain blood samples and anal cultures, vaginal cultures if female. Ensure that legal action is initiated against the perpetrator.

Determine if the client has showered or bathed since the assault. Assign a supportive, calming same-gender nurse to provide care. Provide privacy and explanations throughout examination. Provide prophylaxis for sexually transmitted infections. Obtain blood samples and anal cultures, vaginal cultures if female.

A nurse is working with a client who is anticipating the possibility of leaving a relationship with intimate partner violence. In helping the client make the decision to leave or to stay in the abusive situation, which action would be most important for the nurse to take? Ensure the client understands the behaviors inherent in the cycle of intimate partner violence. Suggest that the client legally change his or her name and move out of state. Assist the client in finding a new apartment and a new job. Explain to the client how to develop a safety plan for leaving the relationship.

Explain to the client how to develop a safety plan for leaving the relationship.

The nurse is caring for a client believed to be a victim of human trafficking. What action is most important for the nurse to perform? Notify the authorities. Test for pregnancy. Gain the client's trust. Assess for bruising.

Gain the client's trust.

Parents of a school-age child experiencing encopresis are discussing the problem with the child's health care team. Their understanding of this problem is indicated when the parents respond in what manner? They can help the child by trying to control his stooling pattern with medications. Encopresis always indicates that the child is constipated and needs nutritional counseling. If there is no organic cause for the problem, the family may need to explore counseling for an emotional problem. He needs to be allowed to make his own decisions or choices about his life.

If there is no organic cause for the problem, the family may need to explore counseling for an emotional problem.

A 14-month-old trauma victim has arrived in the emergency department. What client priority will the nurse need to address first? Risks from reduced core temperature Increased metabolic demands Possible tissue damage from hypoxia Inadequate systemic perfusion

Inadequate systemic perfusion

**A caregiver who works in the hospital brings his 9-year-old son to the emergency room with a spiral fracture of the tibia. The caregiver reports that the injury occurred when the boy's 5-year-old sister hit him with wooden bat. The injury is inconsistent with an impact and with the sister's strength. Which of the following would be appropriate for the nurse to do in this situation? Leave the treatment area and call the police. Tell the caregiver that the story is not plausible and ask what really happened. Let the hospital administrator know so that the hospital can take any necessary action. Leave the treatment area and call the social services department in the hospital.

Leave the treatment area and call the social services department in the hospital.

A 19-year-old male client is brought to the emergency department after being raped. Which nursing action is most appropriate at this time? Assist the client with showering and changing into clean clothing. Listen to the client's description of what happened. Provide information on counseling centers to the client. Help the client determine how to prevent a future rape.

Listen to the client's description of what happened.

A nurse is planning care for Jeffrey, who has osteomyelitis. Which of the following interventions should the nurse prioritize in the care plan? Maintain Jeffrey's IV antibiotic therapy. Teach his parents about the root causes of his infection. Restrict his fluid intake to increase his hematocrit level. Fully assist Jeffrey with his activities of daily living.

Maintain Jeffrey's IV antibiotic therapy.

The nurse is working with a client who is in a relationship with a man who controls her activities, calls her names, and occasionally hits her. What are the goals in the treatment of this client? Select all that apply. Involve the police in the situation Maximize the client's safety Empower the client to take control Provide support to the client Hospitalize the client to protect her

Maximize the client's safety Empower the client to take control Provide support to the client

The physician has ordered rectal diazepam for a 2-year-old boy with status epilepticus. Which instruction is essential for the nurse to teach the parents? Gradually reduce the dosage as seizures stop. Monitor for an allergic reaction to the medication. Monitor their child's level of sedation. Watch for fever indicating infection.

Monitor their child's level of sedation.

Carla is diagnosed as having otitis media. When interpreting the documentation in Carla's electronic health record, the nurse should recognize that this diagnosis differs from otitis externa in what way? Otitis media occurs from swimming; otitis externa typically follows a common cold. Otitis media involves the middle ear; otitis externa involves the outer canal. Otitis media involves the eardrum; otitis externa involves the cochlear nerve. Otitis media does not cause pain; otitis externa produces throbbing pain.

Otitis media involves the middle ear; otitis externa involves the outer canal.

A client has recently been treated in the emergency department for trauma to the head as a result of intimate partner violence (IPV). The client states to the nurse the desire to go back home to the partner upon discharge. Which action will the nurse take first? Encourage the client to file a restraining order against the partner. Ensure the client understands the severity of the sustained injury. Have the local authorities speak with the client before discharging. Provide the client with components of an IPV safety plan.

Provide the client with components of an IPV safety plan.

A 7-year-old girl is in the intensive care unit following a bicycle accident. Which would be most helpful in providing support to the girl's parents? Giving them brief explanations of procedures Describing the treatment plan for their daughter Providing honest answers in a reassuring manner Encouraging them to read to their daughter

Providing honest answers in a reassuring manner

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

Reposition the child's foot on a pressure-reducing device.

A woman arrives at the prenatal clinic and is accompanied by her partner. Which behaviors would be suggestive of intimate partner violence (IPV)? Select all that apply. The pregnant client looks at the examiner when asked questions. The partner is overly protective of the pregnant client. The client asks questions of the nurse about her pregnancy. The partner answers questions for the pregnant client. Poor weight gain during the pregnancy and low-birth-weight infant

The partner is overly protective of the pregnant client. The partner answers questions for the pregnant client. Poor weight gain during the pregnancy and low-birth-weight infant

The nurse is caring for a client who is a victim of sexual violence. How can the nurse best support the necessary grieving process? teaching the client stress management strategies actively listening to the client as he or she talks about the experience reinforcing the fact that violence is never deserved educating the client about the symptoms of posttraumatic stress disorder

actively listening to the client as he or she talks about the experience

A 4-year-old girl is brought to the emergency room following ingestion of large amounts of acetaminophen (Tylenol). Which of the following interventions does the nurse expect? assessing for consciousness performing hands-only CPR administration of acetylcysteine stimulation of vomiting

administration of acetylcysteine

An adolescent has been diagnosed with oppositional defiant disorder. Which symptom does the nurse anticipate? angry outbursts directed at authority figures frequent arrests and conflict with legal authorities typical teenage defiance behavior with parents disruptive behavior toward siblings and peers

angry outbursts directed at authority figures

A young mother has brought her child into the clinic. As part of the assessment, the nurse is completing a developmental history. This evaluation will include: Select all that apply. assessment of whether the child has met normal developmental milestones. assessment of current cognitive functioning. assessment of whether the child has met normal biologic milestones. assessment of current behavioral functioning. assessment of financial concerns.

assessment of whether the child has met normal developmental milestones. assessment of current cognitive functioning. assessment of current behavioral functioning.

A parent brings a preschooler to the behavioral clinic for evaluation. Upon entering the room, the child appears not to notice the nurse's presence. The child screams upon the nurse's touch. What condition should the nurse suspect? Down syndrome autism spectrum disorder Findings are normal for a preschooler. learning disability

autism spectrum disorder

The nurse is providing community education regarding accidents in the infant, toddler, and preschool population. When designing educational materials, which types of accidents would be included? Select all that apply. falls motor vehicles water immersions hyperthermia burns

falls motor vehicles water immersions burns

The nurse caring for a child who has been put into a leg cast must be on the alert for signs of nerve and muscle damage. Which symptom might be an early warning signal that the child has developed compartment syndrome? The child: has a weak femoral pulse. feels increasing severe pain. has blue-looking nail beds on the toes. cannot plantarflex his foot.

feels increasing severe pain.

A school nurse is working with a group of adolescents. Which assessment findings might prompt the nurse to screen for eating disorders? Select all that apply. menstrual irregularity weight fluctuation absence of hunger frequent nurse visits erosion of teeth

menstrual irregularity weight fluctuation erosion of teeth

A nursing instructor identifies a need for further teaching when a student makes which of the following statements? "Color blindness is inherited as a sex-linked disorder." "Color blindness can be treated." "Structural problems of the eye in children tend to be congenital or present at birth." "There is no therapy for color vision deficit."

"Color blindness can be treated."

A 6-year-old has had a viral infection for the past 5 days and is having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which question? "What type of fluids did your child take when he had a fever?" "Did you use any medications, like aspirin, for the fever?" "How high did his temperature rise when he was ill?" "Did you give your child any acetaminophen, such as Tylenol?"

"Did you use any medications, like aspirin, for the fever?"

**When does the nursing instructor tell students is the best time to do a first hearing and vision test on a child? in the first few days of life at 6 weeks at 1 month check at 3 month check

in the first few days of life

A child who weighs 53 lbs (24 kg) is receiving fluid volume replacement as part of the treatment for shock. The nurse is evaluating the child's hourly urinary output to determine if the child's condition is improving. Which output would the nurse interpret as most indicative of improvement? 12 ml 22 ml 15 ml 30 ml

30 ml

A pediatric client has recently been prescribed methylphenidate. The parent calls the office and insists the medication is not working. How will the nurse respond? "Tell me why you believe the medication is not working." "Perhaps another medication will be better for your child." "Your child's dosage may need to be increased." "Tell me how you are administering the medication."

"Tell me why you believe the medication is not working."

The nurse is educating the family of a 7-year-old with epilepsy about care and safety for this child. What comment will be most valuable in helping the parent and the child cope? "If he is out of bed, the helmet's on the head." "You'll always need a monitor in his room." "Bike riding and swimming are just too dangerous." "Use this information to teach family and friends."

"Use this information to teach family and friends."

The nurse is working with a group caregivers of children who are diagnosed with autism. Which statement made by the parents shows an example of echolalia? "When we were in a room with a high ceiling, she was so excited when she said hello and she heard her voice that she said it over and over." "She was at the park and the older kids were playing a game and she was staring at them as if she was wanted to try to copy what they were doing." "When she watches TV and hears a commercial, she repeats one word from the commercial but doesn't seem to understand what she is saying." "When reading her a story book about owls, her sister kept telling her that when owls made noises they sounded like an echo. She seemed to understand that animals sounded different from people."

"When she watches TV and hears a commercial, she repeats one word from the commercial but doesn't seem to understand what she is saying."

**The mother of a 10-year-old boy phones the school nurse. The child has attention deficit/hyperactivity disorder (ADHD) and must go to the office to take medication at lunchtime. The child informed the mother that classmates have been making fun of him because he no longer wants to take the medication. Which is the nurse's best response? "You can speak with your doctor about extended-release medications for the treatment of ADHD." "Tell your son if he doesn't take his medication, his grades may suffer." "He must take his medication; just tell your son to ignore the kids." "I will tell his teacher to talk with the kids causing trouble."

"You can speak with your doctor about extended-release medications for the treatment of ADHD."

A 7-month-old is scheduled for surgical correction of strabismus. The child's mother says to the nurse, "I'm glad my child will never have to wear that patch again." Which of these responses would be most appropriate for the nurse to make? "Your child will need to wear the patch for a few days to keep him/her from rubbing or putting pressure on the eye." "Your child will need to wear the patch for several months to keep the eye in alignment." "Your child will never need to wear the patch again." "Your child will have to be in restraints for a week to keep him/her from rubbing the eye."

"Your child will need to wear the patch for a few days to keep him/her from rubbing or putting pressure on the eye."

The nurse is caring for a group of children on the pediatric unit. The nurse should collect further data and explore the possibility of child abuse in which situation? A 6-year-old with a greenstick fracture of the wrist, which the caregiver reports as having been caused when the child fell while ice-skating. A 7-year-old with a spiral fracture of the humerus, which the caregiver reports as having been caused when the child was hit by a bat swung by a Little League teammate. A 10-year-old with a simple fracture of the femur, which the caregiver reports as having been caused when the child fell down a set of stairs. A 9-year-old with a compound fracture of the tibia, which the caregiver reports as having been caused when the child attempted a flip on a skateboard.

A 7-year-old with a spiral fracture of the humerus, which the caregiver reports as having been caused when the child was hit by a bat swung by a Little League teammate.

Through history taking, the nurse discovers that Hillary's mother is a victim of intimate partner violence. When addressing this issue, what typical characteristic of an intimate partner who is violent toward a female partner should the nurse be aware of? A man has been raised in a family where the father was violent. A man wants to earn more money but has no education. A man is under severe psychological stress. A man has more than three children younger than 10 years old.

A man has been raised in a family where the father was violent.

A mother is suspicious that her adolescent has bulimia because the child seems to be dependent upon laxatives and vomits frequently after eating a meal. What physical finding would be most suggestive of this diagnosis? recurrent strep throat callouses in the palms of her hands weight below the 5th percentile on the growth chart dental erosions and caries

A mother is suspicious that her adolescent has bulimia because the child seems to be dependent upon laxatives and vomits frequently after eating a meal. What physical finding would be most suggestive of this diagnosis? recurrent strep throat callouses in the palms of her hands weight below the 5th percentile on the growth chart dental erosions and caries

A 3-year-old demonstrates lateral bowing of the tibia. Which signs would indicate that the boy's condition is Blount disease rather than the more typical developmental bowlegs (genu varum)? A sharp, beaklike appearance to the medial aspect of the proximal tibia on x-ray The malleoli are touching The condition is bilateral The medial surfaces of the knees are more than 2 in apart

A sharp, beaklike appearance to the medial aspect of the proximal tibia on x-ray

When teaching a group of parents about the skeletal development in children, what information will the nurse provide? Children's bones have a thin periosteum and limited blood supply. The infant's skeleton has undergone complete ossification by birth. The growth plate is the area of growing tissue near the ends of flat bones. A young child's bones commonly bend instead of break when an injury occurs.

A young child's bones commonly bend instead of break when an injury occurs.

In caring for a child being treated for scoliosis, the highest priority goal is which of the following? The child's skin integrity will be maintained. The child will verbalize acceptance of the treatment. The child will remain free of injury. The child will participate in age-appropriate activities.

The child will remain free of injury.

A 9-year-old client who suffered a head injury has strabismus. The nurse assesses the client for intracranial pressure (ICP). Which additional intervention is most important for the nurse to perform? Place the child on fall precaution. Assess the level of consciousness (LOC). Place a patch over the client's affected eye. Notify the primary health care provider.

Assess the level of consciousness (LOC).

The nurse is teaching a group of parents about eyes and eye concerns. The nurse tells these caregivers about a condition that occurs when unequal curvatures in the cornea bend the light rays in different directions and this causes images to be blurred. The condition the nurse is referring to is: Myopia Refraction Hyperopia Astigmatism

Astigmatism (Astigmatism is caused by unequal curvatures in the cornea that bend the light rays in different directions and produce a blurred image. Refraction is the way light rays bend as they pass through the lens to the retina. Myopia is nearsightedness; and hyperopia is farsightedness)

The nurse is assessing a child and notes S-shaped curvature of the spine. What terminology would the nurse use when documenting this assessment finding? lordosis sway back idiopathic scoliosis kyphosis

idiopathic scoliosis

A nurse is assessing an adolescent with a suspected increased intracranial pressure. What assessment finding would support this diagnosis? Select all that apply. temperature 96.6° F (36° C) heart rate of 55 bpm blood pressure 158/58 mm Hg respiratory rate of 36 breaths/min pupils slow to react to light

heart rate of 55 bpm blood pressure 158/58 mm Hgn pupils slow to react to light

Carla is diagnosed as having a bacterial conjunctivitis of her right eye, and the unit has a standardized care plan and educational materials that address this common diagnosis. What instruction should the nurse check in these clinical resources? Keep the infected eye tightly closed by covering it with clean gauze. Do not apply the eye drops for more than 3 days in order to prevent a rebound. Clean the eye discharge away from the inner to the outer canthus. Caution Carla not to blow her nose for the next 24 hours.

Clean the eye discharge away from the inner to the outer canthus.

The nurse is caring for a 14-year-old boy in Buck traction for a slipped capital femoral epiphysis (SCFE). What information would the nurse include when completing a neurovascular assessment of the affected leg? Select all that apply. Capillary refill Pulse Sensation Color

Capillary refill Pulse Sensation Color

In understanding the development of the musculoskeletal system, the nurse recognizes that what is implanted in a gel-like substance during fetal life? Tendons Cartilage Ligaments Joints

Cartilage

Sage is found to have an elevated serum lead level. What is the most common source of lead poisoning in young children that would contribute to this assessment finding? Smelling lead fumes from cooking utensils Swallowing batteries that fall out of toys Drinking lead-contaminated drinking water Chewing on chips of flaking lead-based paint

Chewing on chips of flaking lead-based paint

The nurse is working with a group of caregivers of school-aged children discussing fractures. The nurse explains that if the fragments of fractured bone are separated, the fracture is said to be: Spiral Incomplete Greenstick Complete

Complete

Which is essential in working with caregivers who have been affected by abuse? Developing a therapeutic relationship Arranging family meetings to discuss issues Providing details on social services in the community Knowing the legal system

Developing a therapeutic relationship

An adolescent male tells the nurse that he has been smoking cigarettes for the last 3 years. The nurse recognizes that this adolescent is at the greatest risk of substance abuse based upon what family history finding? He is a B to C student in school. He has been previously diagnosed with depression. He is the oldest child in the family. He is from a family of higher socioeconomic status.

He has been previously diagnosed with depression.

The nurse working in the obstetrics clinic is completing an assessment and concerned about possible signs of intimate partner violence during pregnancy. Further abuse screening is completed if the nurse documents which? Select all that apply. Noncompliance with treatment Unrealistic fears Weight fluctuations Difficulty with physical exams More weight gain than recommended Poor attendance at prenatal visits

Noncompliance with treatment Unrealistic fears Weight fluctuations Difficulty with physical exams Poor attendance at prenatal visits

Jeffrey's 10-year-old sister has JA, and her mother is eager to explore alternative methods of pain control in addition to standard approaches of analgesia. The standard approach to analgesia with JA is: Applying ice to painful joints to reduce inflammation Having joints scraped biannually during an arthroscopy Applying topical hydrocortisone to affected joints Taking an NSAID on a daily basis

Taking an NSAID on a daily basis

Which adolescent behavior is most common if the parents have substance use problems? Staying away from the house Taking on adult responsibilities Telling everyone of the parental issues Being clingy to teachers at school

Taking on adult responsibilities

A 9-year-old boy is suffering from headaches but has no signs of physical or neurologic illness. Which intervention would be most appropriate? Review the signs of increased intracranial pressure with parents. Teach the child and his parents to keep a headache diary. Have the child sleep without a pillow under his head. Have the parents call the doctor if the child vomits more than twice.

Teach the child and his parents to keep a headache diary.

The nurse is caring for a child diagnosed with Legg-Calvé-Perthes disease (LCPD). What is the most important nursing intervention for the nurse to include in working with this child and his caregivers? The nurse should provide information when the child or caregiver requests it. The nurse should support the caregivers in restricting activity during the treatment. The nurse should help the caregivers to understand and help the child to effectively use the corrective devices. The nurse should be a contact person when the child is hospitalized.

The nurse should help the caregivers to understand and help the child to effectively use the corrective devices.

A child has been diagnosed with strabismus. After further examination, the client is told that the resting position of the right eye is convergent. The nurse further explains that this means which of the following? One pupil is higher than the other. The resting position of the eye is turned out. The same eye deviates constantly. The resting position of the eye is turned in.

The resting position of the eye is turned in.

The student nurse is preparing a presentation on dental trauma care in children. What information should the student include? If a permanent tooth is knocked out, it should be rinsed with water, put on ice, and brought to the emergency department. Permanent teeth are typically not able to be reimplanted successfully. If a child has a deciduous tooth knocked out, it should be cleaned with an antiseptic and brought to the emergency department to be replaced. When a permanent tooth is knocked out, it should be rinsed in water and then placed in milk and brought to the emergency department.

When a permanent tooth is knocked out, it should be rinsed in water and then placed in milk and brought to the emergency department.

A nurse is describing the cycle of violence to a community group. When explaining the first phase, the nurse would include which description? characterized by tension-building and minor battery associated with loss of physical and emotional control like a honeymoon that lulls the victim somehow triggered by the victim's behavior

characterized by tension-building and minor battery

A child with a severe head injury arrives in the emergency department. Parents inform the nurse that after the injury they have not been able to rouse the child. This nurse provides a report to the health care provider and suggests that the client may be experiencing which? coma stupor dementia delirium

coma

A parent brings a child to the pediatric clinic, stating that the child was diagnosed with attention deficit hyperactivity disorder (ADHD). Which symptoms does the nurse anticipate finding with this child? inattention, impulsive, and hyperactivity excess motor activity, learning disability, and depression hyperactivity, defiant, and disruptive visual impairment, hyperactivity, oppositional defiant

inattention, impulsive, and hyperactivity

The nurse is doing neurovascular checks on a child who has had a cast applied to treat a fracture. The nurse observes for diminished or absent sensation and numbness or tingling. In doing this the nurse is monitoring for which symptom? pallor paralysis paresthesia pain

paresthesia

An infant arrives at the emergency department with vomiting, seizures, and irritability for the last 8 hours. A radiograph confirms bleeding into the space between the dura and arachnoid membrane. What diagnosis would the nurse expect the physician to make for this client? subdural hematoma skull fracture concussion epidural hematoma

subdural hematoma

An obviously pregnant woman appears for her first prenatal visit. She reports a headache and generalized abdominal pain which has persisted over the past couple months. Which question should the nurse prioritize after determining the client is approximately 24 weeks' gestation, appears nervous, and is reluctant to have a full physical assessment? "Do you have a family history of thyroid disease?" "How much activity have you been able to fit into your schedule?" "Do you feel safe at home?" "Have you been taking a prenatal vitamin?"

"Do you feel safe at home?"

Parents of a 36-month-old child confide in the clinic nurse that their child does not speak and spends hours staring at their ceiling fan. They are worried that their child may have autism spectrum disorder. Which question would be important for the nurse to ask the parents? "Do you have trouble keeping child care providers for your child?" "Does your child already attend therapies such as speech therapy?" "Does your child come and hug you or seek comfort from you?" "Does your child have siblings?"

"Does your child come and hug you or seek comfort from you?"

During a wellness health check, a 10-year-old child reports not liking school because the child is getting picked on by other children. The child's parents state a desire to know what the child did to cause the bullying. Which statement by the nurse is most therapeutic? "The most important thing for your child to understand is that he or she is not to blame for the bullying." "Please explain any injuries that have resulted." "This must be reported to the appropriate officials immediately." "Some children are just more prone to being picked on."

"The most important thing for your child to understand is that he or she is not to blame for the bullying."

The nurse is assessing a child diagnosed with juvenile myasthenia and has been prescribed neostigmine. Which statement by the parent indicates a need for further education? "We will have to learn to live without our air-conditioner. I don't want my child to get too cold." "We will watch for any increased muscle weakness. It may be caused by disease or by too much medication." "Excessive drooling may happen with this medication. We will notify the health care provider if this happens." "I will make sure my child takes the medicine with some crackers and milk."

"We will have to learn to live without our air-conditioner. I don't want my child to get too cold."

The nurse is speaking with the parents of a child prior to surgery to place a distraction device to his tibia. What statement by a parent indicates a need for further education? "We will turn the rods every day, they will be moved about 10 mm each time." "The device will be left in place until the bone is fully healed." "We have bought some new wider-legged pants that can help cover the device so people don't stare at it." "This device will help lengthen my child's leg so they both are the same length."

"We will turn the rods every day, they will be moved about 10 mm each time."

The nurse is caring for a child with suspected increased intracranial pressure (ICP). Which assessment finding would indicate increased ICP? hyperthermia hypertension poor handwriting tachypnea

hypertension

The nurse is completing the physical assessment of a 12-year-old child who has a series of bruises in various stages of healing. When asked about the bruises the child appears frightened and offers inconsistent accounts about how the child got the bruises. The nurse suspects abuse. Which initial action of the nurse is most appropriate? Document the bruises and any statements made by the child relating to them. Ask the child to provide a written statement of how he or she got the bruises. Take photographs of the bruises. Interview the child's parents about the origin of the bruises.

Document the bruises and any statements made by the child relating to them.

Which type of abuse is reported most quickly to the police? Incest Emotional abuse Neglect Sexual assault

Sexual assault

Parents of children like Todd, who has a moderate intellectual disability, often develop chronic sorrow or complicated grieving. Which of the following events would most likely increase sorrow for Todd's parents? After an extended time alone as a family, such as a vacation When Todd receives his scheduled immunizations When children Todd's age reach a milestone that Todd does not achieve After spending time with Todd's extended family

When children Todd's age reach a milestone that Todd does not achieve

**The nurse is observing a group of 2- and 3-year-olds in a play group. Which behavior noted in one of the children indicates to the nurse that the child may have autism spectrum disorder (ASD)? After another child takes a toy, the child cries and stomps his feet. While the other children are eating a snack, the child walks around the room feeling the walls and ignores the caregiver who offers him a snack. A child playing in the kitchen area pretends to pour a glass of milk and repeats this over and over. A child flips the light switch off and on until the caregiver asks her to stop and join the other children in playing.

While the other children are eating a snack, the child walks around the room feeling the walls and ignores the caregiver who offers him a snack.

If the following data was collected on a group of children, which of the following would most likely be evaluated as possibly related to child abuse (child maltreatment)? Select all that apply. a child who has a spiral fracture in the femur a child whose CT scan shows an unexplained cerebral hemorrhage a child whose blood work shows evidence of anemia a child whose X-ray shows bone fractures in various stages of healing a child who has frequent nausea and diarrhea

a child who has a spiral fracture in the femur a child whose CT scan shows an unexplained cerebral hemorrhage a child whose X-ray shows bone fractures in various stages of healing

Which client would be the most likely person to be diagnosed with idiopathic scoliosis that requires treatment? a young adolescent female a teenage male a school-age male a school-age female

a young adolescent female

A young client comes to the emergency department after getting being hit in the head while playing football. The boy states that he does not remember anything from a few minutes before to a few minutes after the injury. He reports having a slight headache; he vomited once on the way to the hospital. What does the nurse expect the diagnosis to be for this client? epidural hematoma skull fracture subdural hematoma concussion

concussion

A young client with symptoms similar to those of a concussion comes to the emergency department. This client also has focal seizures, eye deviation, and some loss of speech. Which of the following should the nurse suspect? contusion subdural hematoma epidural hematoma coma

contusion

The nurse is caring for a child who was snowboarding without gloves. The child is diagnosed with third-degree frostbite. What assessment findings support this diagnosis? blisters appearing on the fingers after they were rewarmed and child reporting pain in the fingers fingers appearing white red, cold fingers fingers appearing black with greenish drainage noted

fingers appearing white

A nursing instructor is teaching students about vision disturbances in children. In reviewing the anatomy of the eye, what does the instructor tell students is the area of closely packed cones where color is best perceived? posterior chamber sclera fovea centralis canal of Schlemm

fovea centralis

A nurse is discussing concerns about possible child abuse (child mistreatment) with the nursing supervisor. Which statement by the nurse requires correction by the supervisor? "I understand nurses can lose their license for not reporting suspected child abuse (child mistreatment)." "I realize that nurses have an obligation to report suspected child abuse (child mistreatment)." "I will need to look up the protocol for reporting suspected child abuse (child mistreatment)." "HIPAA prevents nurses from disclosing confidential information from parents."

"HIPAA prevents nurses from disclosing confidential information from parents."

A child, accompanied by a parent, is brought to the emergency department after sustaining an injury from a fall. The nurse is assessing the child. Which question is important for the nurse to ask the parent first? "What time did the injury occur?" "Does your child have any allergies?" "How did your child get hurt?" "Did your child lose consciousness?"

"How did your child get hurt?"

The nurse is caring for an infant who is at risk for increased intracranial pressure. What statement by the parent would alert the nurse to further assess the child's neurological status? "She always cries when the person holding her has on glasses...I guess glasses scare her." "She is a pretty happy baby, unless her diaper is wet, then she cries until we change her diaper." "She typically breastfeeds, but lately we have had to supplement with some rice cereal." "She has been irritable for the last hour....seems like she is just upset for some reason."

"She has been irritable for the last hour....seems like she is just upset for some reason."

A child with a severe head injury arrives at the emergency department very groggy. She is subsequently difficult to arouse for several hours. The nurse would document this condition as which of the following? delirium coma eementia stupor

stupor

A client at 36 weeks' gestation presents in the emergency department with a broken arm. The client states, "I fell while cooking dinner." During the assessment, the nurse notes no prenatal care for this pregnancy, as well as bruises in multiple stages of healing on the client's abdomen, arms, and chest. What action will the nurse perform next? Provide brochures on shelters for victims of intimate partner violence Document the findings in the client's chart Notify the health care provider of the findings Ask the client how she acquired the bruises

Ask the client how she acquired the bruises

As the elementary school nurse is documenting student contact in the health room, which student is most concerning? The student who repeatedly reports vague physical complaints and has nightmares. The student who verbalizes fatigue and wants to lay down. The student who frequently needs the rescue inhaler for wheezing. The student who needs assistance in completing glucose testing.

The student who repeatedly reports vague physical complaints and has nightmares.

A nurse has received the above hand-off report from the emergency department. The nurse creates a plan of care for the child. What is the nurse's priority in providing care for the child? hydration infection prevention thermoregulation gas exchange

gas exchange

A nurse is working with the burn clinic at a local hospital. Which types of burns would the nurse address with the health care provider and social worker? Select all that apply. hand burns with a pattern linear pattern burns small, round burns burns from a house fire burns received from the sun on commonly exposed areas

hand burns with a pattern linear pattern burns small, round burns

A 10-year-old child comes to the emergency department as a victim of abuse. The child's parent reports that the child was hit repeatedly with a baseball bat a few hours prior. The initial assessment indicates the child's blood pressure is 84/40 mm Hg. The nurse would further assess the child for what finding? history of cardiac structural heart disease or arrhythmias injuries resulting in ongoing blood loss signs of septic shock resulting from infection allergies, specifically any history of anaphylactic reactions

injuries resulting in ongoing blood loss

A group of nurses is discussing child abuse (child maltreatment) and one nurse suggests that inadequate parenting skills may lead to child maltreatment. The nurse recognizes that sometimes child maltreatment occurs because the parent: works hard to provide for the family and feels unappreciated. may have unrealistic expectations of the child. is responding appropriately to the child's behavior. believes the child is intentionally trying to make him or her angry.

may have unrealistic expectations of the child.

A nurse is performing a routine physical for a 7-year-old girl who is thin, unwashed, and dressed in rags. Although it is winter time, she has no coat with her. Her teenage brother in the waiting room, however, is dressed in trendy clothes and looks healthy and well-fed. Which of the following should the nurse most strongly suspect regarding this girl? psychological maltreatment sexual maltreatment physical neglect physical maltreatment

physical neglect

A parent expresses concern that the child has an autism spectrum disorder. The nurse obtains a health history of the symptoms to understand the parent's concern. Which question would the nurse ask first? "Is your child happy when friends come to visit?" "Does your child interact with you when playing?" "Does your child respond to his or her name?" "Does your child only eat the same food?"

"Does your child interact with you when playing?"

**A parent brings the child for a well-child visit. During the visit, the parents state the child appears to not be seeing well. To obtain information needed to aid in a diagnosis, which question(s) should the nurse ask the parents? Select all that apply. "Has your child's school work remained good?" "Have you noticed your child squinting?" "Does your child feel the need for a nap after school?" "Has your child been reporting any blurred vision?" "Has your child had a fall bumping the head recently?" "Does your child report a headache when reading?"

"Has your child's school work remained good?" "Have you noticed your child squinting?" "Has your child been reporting any blurred vision?" "Does your child report a headache when reading?"

As part of a local college awareness program, a nurse is interviewing several of the participants about their views on rape. Which statement by a participant will lead the nurse to determine teaching about rape is needed? "Men and women who are raped may take several years to recover emotionally and physically." "Most victims of rape never report the episode to the local authorities or tell anyone about being raped." "What a person wears has no effect on whether that person will be assaulted by someone else." "Health care providers can prevent pregnancy and sexually transmitted infection transmission after a rape."

"Health care providers can prevent pregnancy and sexually transmitted infection transmission after a rape."

The nurse is interviewing the caregiver of a 5-year-old child who has been admitted with bruises on the abdomen and thighs as well as additional bruises in various stages of healing. Which statement made by the caregiver might alert the health care team to the possibility of child abuse (child maltreatment)? "When he is in trouble I make him go to his room." "He just learned to ride his bicycle." "My child goes to day care after school." "His brother just plays too rough with him."

"His brother just plays too rough with him."

Todd's family has a history of ADHD treated by medication. The nurse completes a patient history for Todd, including as assessment of Todd's father's reactions to medication for the same condition. Which of Todd's father's memories from childhood leads the nurse to believe Todd is experiencing an adverse effect of methylphenidate hydrochloride (Ritalin)? "I used to play that I was an astronaut for hours on end." "I was the fattest kid in my gym class." "I hardly ever slept; I would just lay awake for what felt like hours." "I found out that I had iron-deficiency anemia in high school."

"I hardly ever slept; I would just lay awake for what felt like hours."

The nurse is caring for an infant who was injured and developed a subdural hematoma that is to be drained. Which statement by the infant's parent indicates a need for further education about the procedure? "I hope that they won't need to do this more than a couple of times to get all of the blood out." "So they will just stick a needle in the soft spot on my child's head and drain the blood." "I just can't believe my baby is going to have brain surgery. It's so scary." "The medication will help my child sleep during the procedure so my child won't feel anything."

"I just can't believe my baby is going to have brain surgery. It's so scary." (Treatment of a subdural hematoma in an infant is to drain the blood by a subdural puncture, not surgery. A needle is inserted through the anterior fontanel (fontanelle) to drain the blood. The infant receives conscious sedation and must be held very still during the procedure. This may need to be repeated daily to empty the subdural space.)

The nurse is speaking to a parent of a child diagnosed with an autism spectrum disorder. The parent states, "There are medications out there for everything. I cannot believe there is not a medication to help cure my child." What is the best response by the nurse? "You need to speak with your child's health care provider about any medication issues." "You need to shift your focus from curing your child to getting your child scheduled for all of the therapies your health care provider has prescribed." "Medication is not always the answer to all diseases. Your child's autism-based behaviors can be controlled with diet and therapy." "I know you must be frustrated about trying to get the best help for your child. Although there is not a medication to help treat autism spectrum disorders, with various therapies your child can function to the best of one's abilities."

"I know you must be frustrated about trying to get the best help for your child. Although there is not a medication to help treat autism spectrum disorders, with various therapies your child can function to the best of one's abilities."

**When a school nurse asks a middle school student about taking a leadership role in an afterschool program, the student politely declines, stating that he cannot because of the need to care for siblings. Which is the best response? "It is only once or twice a week for a month." "Do your parents work in the evening?" "Can a family member take care of them?' "I see. Tell me more about what you do."

"I see. Tell me more about what you do."

**Which statement made by a new nurse demonstrates an understanding of the prevalence of sexual assault and related violence among the population? "The greatest need for thorough assessment regarding sexual assault and related violence is among those who are dependent and rely on the care of others." "I've come to realize that I need to include questions related to sexual assault and related violence into the assessment of all my clients." "It seems obvious that the greatest number of clients experiencing sexual abuse and related violence are the young and middle-aged adults." "The vast majority of victims of sexual assault and related violence are seen in the emergency room when they seek treatment."

"I've come to realize that I need to include questions related to sexual assault and related violence into the assessment of all my clients."

Eating disorders have a high incidence in adolescents. To see if this also exists in teenage athletes, researchers asked 966 first-year high school students to complete a questionnaire and then sit for an interview as to whether they have or ever had an eating disorder. Results of the study showed that the prevalence of eating disorders was higher in athletes compared to nonathletes (6.9% versus 2.3%). It was also higher in female than male athletes (13.5% versus 3.2%) (Martinsen & Sundgot-Borgen, 2013). Based on the previous study, which statement by Cheyenne, Todd's adolescent sister, would make her at highest risk for developing an eating disorder? "I hate sports. Nothing more athletic than poker interests me." "I've played basketball for 2 years; I like the way I look in uniform." "I don't play a whole lot of sports, but I love watching football games." "I don't know why girls play sports like tennis; they all look so skinny."

"I've played basketball for 2 years; I like the way I look in uniform."

A woman arrives at the neighborhood clinic asking for care related to symptoms that include bruising, lacerations and vague reports of perineal discomfort. The nurse assesses and provides care for the client's physical condition, then questions the client. Which is the best question for the nurse to ask? "Your injuries suggest that you are experiencing physical and or sexual abuse. Would you like to talk about what's happening?" "It appears that your injuries are a result of abuse and violence. Do you feel safe at home?" "Physical abuse is not something you have to tolerate. Would you like me to notify the police?" "Intimate partner violence is a problem among women in our community. Are you experiencing any type of physical or emotional abuse?"

"Intimate partner violence is a problem among women in our community. Are you experiencing any type of physical or emotional abuse?"

A 16-year-old pregnant client presents to the office for the third time this week. While completing the client's admission, the nurse screens for intimate partner violence. The client responds, "I have already told you twice this week I am not being abused. Why do you keep asking me these questions?" Which response by the nurse is best? "Based on your age and being pregnant, you are at high risk." "It is protocol to screen all clients for intimate partner violence at every visit." "You have been here three times this week and I am concerned about you." "It is possible for you to be a victim since your last visit and I want to ensure your safety."

"It is protocol to screen all clients for intimate partner violence at every visit."

The nurse is caring for a client who has been a victim of intimate partner violence (IPV) for a few years. The client states, "My partner has been so sweet to me the last few days by telling me how special I am and bringing me flowers. I believe my partner is sorry and will not do this again." How will the nurse respond? "Your partner is showing caring and loving actions toward you. This could indicate progress from your partner." "It sounds like the honeymoon stage of IPV, which means your partner does not love you and will hurt you again." "It may seem better now, but over time, IPV typically becomes accelerated and more dangerous." "Your partner may love you, but staying in this relationship is not worth the risk of being abused over and over."

"It may seem better now, but over time, IPV typically becomes accelerated and more dangerous."

**The nurse is reinforcing teaching with the caregivers of a child who has been placed in an external fixation device for the treatment of an orthopedic condition. Which statement made by the caregivers indicates an understanding of the external fixation device? "If we see any drainage around the pins when we are cleaning them, we won't be concerned." "It will be hard, but we know our child will be in this device for a long time." "He is very sensitive about the way the device looks. I am glad that his clothes will fully cover it so his friends won't tease him." "We will have to get some of the elastic bandages to place around the pins and pin sites."

"It will be hard, but we know our child will be in this device for a long time."

An adolescent client who has scoliosis and is wearing a Milwaukee brace tells the nurse that she is ugly and cannot wear the same clothing as her friends. Which response by the nurse best addresses this client's altered self-image? "Let's look at some clothing that you can wear with the brace that will look like everyone else's clothes but cover it." "Kids can be cruel sometimes. Has anyone told you that you look different?" "Just hold your head up and be confident in how you look. Look for some after-school activities you can do wearing your brace." "You should not worry about what everyone else is wearing. You look fine."

"Let's look at some clothing that you can wear with the brace that will look like everyone else's clothes but cover it."

The nurse is caring for a child diagnosed 3 months ago with juvenile idiopathic arthritis (JIA). The caregiver states that the child has recently reported little pain and is not currently taking aspirin or NSAIDs. The caregiver also tells the nurse that just to be on the safe side, she is continuing to keep the child from doing physical exercise. The mother states, "I think we have beaten this disease." In working with this child and the caregiver, which statement would be best for the nurse to make? "Let's review some of the instructions. She does need to take an anti-inflammatory every day." "I'm glad you're feeling optimistic. She should exercise now but give her aspirin before she does." "That is not what is best. The medications aren't for pain; she needs to take aspirin every few days." "It sounds as though things are going well. Be sure to restart the medication as soon as there is any flare-up of pain."

"Let's review some of the instructions. She does need to take an anti-inflammatory every day."

A 14-year-old girl is brought to the emergency department saying she was sexually assaulted. She tells the nurse that she feels guilty for having gone to a party where alcohol was being served. What is the nurse's best response? "Alcohol is never good for teenagers; something always happens." "No one deserves to be raped, even going to a party with alcohol." "I can understand how you must feel; that is awful to happen." "It would be better not to go to parties with alcohol until you're older."

"No one deserves to be raped, even going to a party with alcohol."

A nurse is providing teaching to a group of parents on poisoning prevention. The nurse is evaluating the parents' understanding of the teaching. Which statement by a parent requires action by the nurse? "We have hanging plants inside and outside." "I do not allow my toddler to play with the baby powder container." "We have placed childproof locks on our lower cabinets." "Our child helps by bringing the vitamin bottle to me every morning."

"Our child helps by bringing the vitamin bottle to me every morning."

The triage nurse receives a phone call from a client stating, "I was just raped and I need help. What should I do?" Which response by the nurse is a priority? "Go to the nearest rape crisis center for a medical examination." "You need to call the local authorities and they will help you file a report." "Come to the emergency department and do not shower or change clothes." "Tell me if you are in a safe location away from the assailant now."

"Tell me if you are in a safe location away from the assailant now."

A pediatric client has recently been prescribed methylphenidate. The parent calls the office and insists the medication is not working. How will the nurse respond? "Your child's dosage may need to be increased." "Tell me how you are administering the medication." "Tell me why you believe the medication is not working." "Perhaps another medication will be better for your child."

"Tell me why you believe the medication is not working."

A new nurse in the emergency department is caring for a pregnant woman who was beaten by her partner. Which statement by the new nurse would require intervention from the supervising nurse? "That woman must be doing something to get beaten like that." "I don't understand why abused women don't leave their partners." "I will give her information about women's shelters in our area." "She needs an emergency plan in case she ever decides to leave."

"That woman must be doing something to get beaten like that."

A nursing student is learning about the concept of "developmental delay" during a pediatrics rotation. The instructor realizes that the student needs further instruction in this area after stating: "The child with a developmental delay will catch up to peers eventually." "Intellectual disability is one diagnosis that is a type of developmental delay." "Learning disorders fall under the umbrella of developmental disorders." "Autism is one of the most common developmental disorders."

"The child with a developmental delay will catch up to peers eventually."

The nurse is caring for a child with a head injury who required endotracheal intubation is now scheduled for a tracheotomy. The mother asks why the endotracheal tube cannot be kept in place. What is the best response by the nurse? "Your child is getting better and doesn't need the endotracheal tube anymore." "A tracheostomy, or hole in the throat, allows us to better control your child's breathing." "After a few days, your child no longer gets enough oxygen from the endotracheal tube, so they need to change it to keep the oxygen level up." "The pressure from the endotracheal tube can cause the pharynx, or the upper portion of the throat, to become necrotic if it's left in for more than 10 days."

"The pressure from the endotracheal tube can cause the pharynx, or the upper portion of the throat, to become necrotic if it's left in for more than 10 days."

A child is being referred to a mental health specialist, and the parent expresses worry about being a bad parent and failing the child. What is the nurse's best response? "This is the best thing for your child right now." "I know just how you feel; I would feel the same myself." "Don't worry, everything will turn out better when your child gets mental health care." "There are so many stressors on children today that can't be prevented."

"There are so many stressors on children today that can't be prevented."

The caregiver of a child who has had a cast applied to the leg observes the nurse putting adhesive tape strips around the edge of the cast. The caregiver asks the nurse why she is doing this. The best response by the nurse would be: "These make a smooth edge on the cast so the skin is better protected." "We put these on so the child will not pull the padding from under the cast." "In case the child has an accident and misses the bedpan, these can be changed to keep the area dry." "These will help the cast look more attractive so the child won't feel self-conscious."

"These make a smooth edge on the cast so the skin is better protected."

A client states "My spouse loves me. My spouse did not mean to hit me. My spouse felt so bad, I received flowers to show me how sorry my spouse was for hitting me. I know this will not happen again." How will the nurse respond? "It does seem like your spouse is sincere. I believe you will not be hit again." "Will you tell me how many years you and your spouse have been married?" "This is a common action of abusers. It does not mean you will not be hit again." "I recommend you talk to your spouse about how you felt when you were hit."

"This is a common action of abusers. It does not mean you will not be hit again."

The nurse has been teaching the parents of a child diagnosed with osteogenesis imperfecta about the use of bisphosphonates for this condition. What statement by a parent indicates a need for further education? "This medication will cure my child of this disorder." "This medication doesn't prevent fractures from happening." "This medication will help to increase bone mineral density." "My child's risk for fractures will hopefully be decreased as by taking this medication."

"This medication will cure my child of this disorder."

While visiting a friend, the nurse sees an 18-month-old toddler pull a scalding cup of coffee off a table onto himself. Which should be the nurse's priority action? A.Pour cool water over the skin area where the coffee spilled. B.Remove his shirt and apply burn ointment. C.Wrap him in a blanket and rush him to the nearest hospital. D.Apply butter to soothe the injured skin.

A.Pour cool water over the skin area where the coffee spilled. (Rationale: Cooling a burn almost automatically prevents further damage.)

Sage is 4 years old and sustained a burn that required hospitalization when her 10-year-old brother attempted to cook a meal while their mother was in the living room watching television. The nurse is preparing Sage for discharge from the hospital. Based on the evidence presented, the most effective advice the nurse could give to the mother to prevent future unintentional injuries is to: Discuss that it is difficult to supervise children's activities when they are out of sight. Inform her that a 10-year-old is not old enough to cook. Suggest in the future that she keep the volume on the television low, so that she can hear what the children are doing. Ask her if she has working smoke detectors and a fire extinguisher in the home.

Discuss that it is difficult to supervise children's activities when they are out of sight. (Based on Damashek and Corlis (2017) study, visual and proximity in combination are predictive in preventing injuries)

During the physical assessment of a 2½-month-old infant, the nurse suspects the child may have hydrocephalus. Which sign or symptom was observed? Dramatic increase in head circumference Posterior fontanel (fontanelle) is closed Vertical nystagmus Pupil of one eye dilated and reactive

Dramatic increase in head circumference

The nurse is observing a 3-year-old boy who is sitting and playing in the waiting area of his pediatrician's office. The nurse calls the boy and his mother back for the boy's appointment. The boy rolls onto his stomach and pushes himself to his knees. Then he presses his hands against his ankles, knees, and thighs, walking up the front of his body, to stand. Which condition should the nurse suspect in this client? Duchenne muscular dystrophy Facioscapulohumeral muscular dystrophy Juvenile arthritis Congenital myotonic dystrophy

Duchenne muscular dystrophy

A child is being prepared for discharge after sustaining a simple contusion of the eye. Which advice would the nurse expect to include in the discharge instructions? Inform the parents to call their pediatrician if the bruising persists for more than 2 days. Encourage the parents to apply ice to the area for 20 minutes at a time for the first 24 hours. Tell the parents that although the condition is frightening, no intervention is needed. Teach the parents how to apply ophthalmologic antibiotic ointment properly.

Encourage the parents to apply ice to the area for 20 minutes at a time for the first 24 hours.

A 10-year-old girl has been referred for evaluation due to difficulties integrating with her peers at her new school. The counselor believes she is at risk for situational low self-esteem due to problematic relationships with both family members and peers. What is the best approach? Engage the girl in dialogue regarding feelings about self/personal appearance. Explore the girl's feelings about changes in her body with the onset of puberty. Introduce the concept of accepting differences to reduce conflict. Remind her of the importance of good hygiene for better appearance.

Engage the girl in dialogue regarding feelings about self/personal appearance.

**A nurse witnesses a child get hit by a car while riding a bike. The child is lying motionless in the street. What action should the nurse take next? Check for visible injuries. Assess the level of consciousness. Ensure a safe environment. Check the vital signs.

Ensure a safe environment.

The nurse is caring for a child with a fractured femur in traction. Which action will the nurse complete while caring for this client? Remove traction weights once per shift for 30 minutes and then replace them. Plan to add additional weights as the fracture heals, usually once per day. Have the unlicensed assistive personnel remove the weights daily and encourage the child to move around in bed. Ensure traction weights are hanging freely, not touching the bed or floor.

Ensure traction weights are hanging freely, not touching the bed or floor.

The nurse is caring for a young child whose parents have been charged with physical abuse. Which child reaction is noted as a result of the parental behavior? Cries frequently and stares at the nurse Fretful and shrinks away when approached Aggressive and kicks and fights during the assessment Despondent and does not respond to questions

Fretful and shrinks away when approached

A 1-year-old child below 5% on the growth chart has been admitted to the hospital. The nursing diagnosis for this child is Imbalanced nutrition, less than body requirements, related to inadequate intake secondary to emotional deprivation. Which nursing intervention would be most effective for this child? Discourage the parents from visiting their child. Have one consistent nurse feed and care for the child. Maintain strict intake and output plus calorie count. Contact child protective services to report abuse.

Have one consistent nurse feed and care for the child.

A pregnant client with multiple bruises in various stages of healing comes to the clinic for treatment. She appears withdrawn and quiet when the nurse approaches her. Her partner accompanies her to the exam room and begins to answer for the client. There is minimal eye contact from the client to the nurse. Which action will the nurse complete next? Review the client's chart for previous signs of violence. Assess the client for intimate partner violence. Have the client's partner leave the room. Report the findings to the local authorities.

Have the client's partner leave the room.

Jeffrey is prescribed crutches to take weight off his affected leg. What teaching point should the nurse include in his health edu? His crutches should be at least 6 in. longer than he is tall. He should lean forward at a 45-degree angle while walking. He should bear weight on his arms to avoid pressure on his axillae. It is unsafe to walk downstairs with crutches; walking upstairs is acceptable

He should bear weight on his arms to avoid pressure on his axillae. (brachial plexus risk)

Sulfadiazine (Silvadene) cream is often used to treat burns. The nurse should explain what to the child before applying this drug? A.It will cause some discomfort when applied. B.It helps to keep the burn eschar soft. C.It sometimes causes mild but annoying itching. D.It may stain the bed linen brown.

It helps to keep the burn eschar soft. (Rationale: Sulfadiazine reduces the possibility of infection; it keeps the burn eschar soft and prevents cracking and bleeding.)

A nurse is providing instructions to the parent of a toddler regarding the prevention of burn injuries. Which instruction is of the highest priority? Keep pan handles away from the edge of the stove. Instruct the toddler about the consequences of burns. Keep coffee cups on the counter above the child's reach. Cool hot liquids before giving them to the child.

Keep coffee cups on the counter above the child's reach.

A nurse is educating a parent about caring for a newborn baby. What should the nurse teach the client as a precautionary measure to protect the infant from burns? Keep hot substances away from the baby. Keep hot substances on the table. Keep the infant away from the kitchen. Monitor the activities of the infant closely.

Keep hot substances away from the baby.

In examining the vision of a 9-year-old girl, the nurse notices that she frequently reaches either too far or not far enough when attempting to take an object from the nurse's hand. Which condition does the nurse suspect? Lack of accommodation Diplopia Refractive error Lack of depth perception (stereopsis)

Lack of depth perception (stereopsis)

The health care provider has recently informed parents that their child has an intellectual disability. The parents express the need for information and help with the important decisions they need to make concerning care of their child. What is an appropriate nursing diagnosis for this situation? Ineffective family coping related to having a child with an intellectual disability Parental knowledge deficit related to health care needs for a child with an intellectual disability Ineffective family process related to having a child with an intellectual disability Anxiety related to health care needs for a child with an intellectual disability

Parental knowledge deficit related to health care needs for a child with an intellectual disability

**A pregnant woman comes to the clinic with a head injury. She tells the nurse that her partner came home drunk and she made him angry by not having dinner ready. He lashed out, she got in the way, and her head hit the corner on the table. What action should the nurse take in this situation? Provide the client with contact information for a 24-hour shelter and social worker on discharge. Call the police and have the social worker find a place for the client to stay until she gives birth. Have the client call the police and obtain a restraining order against the partner. Do not discharge the client until she makes arrangements to stay at a friend's home.

Provide the client with contact information for a 24-hour shelter and social worker on discharge.

The nurse is caring for a comatose school-age child receiving gastrostomy tube feedings. The nurse aspirates 15 ml of stomach contents prior to administering a feeding. What is the appropriate action by the nurse? Discard the stomach contents and continue with the feedings as prescribed. Replace the stomach contents and hold the feeding. Replace the stomach contents and continue with the feedings as prescribed. Discard the stomach contents and notify the health care provider of the aspiration amount.

Replace the stomach contents and continue with the feedings as prescribed.

If Hillary had been maltreated as an infant, she might have experienced abusive head trauma (shaken baby syndrome). Which finding is common with this syndrome and would indicate a baby should be evaluated for medical and safety reasons? A baby is fearful of strangers. Retinal hemorrhages develop. A baby develops Crohn disease. A major bone has been broken.

Retinal hemorrhages develop.

**A nurse is assessing a little boy who has been diagnosed with Tourette syndrome. Which finding would the nurse expect to see? Toe walking Spinning and hand-flapping Lack of eye contact Speaks sudden, fast phrases out of context

Speaks sudden, fast phrases out of context

The nurse is discussing types of treatment used when working with children who have orthopedic disorders. Which form of treatment covers the lower part of the body, usually from the waist down, and either one or both legs while leaving the feet open? Stockinette Spica cast Internal fixation device External fixation device

Spica cast

The nurse is assessing a child who has been injured. What assessment finding would support the need to initiate a notification to the abuse registry so that child protection specialists can investigate? There is bruising to various parts of the body after reported fall from a swing. The child has a greenstick fracture. The child and parent have conflicting stories on what caused the injury. The child and both parents' descriptions of the accident are the same.

The child and parent have conflicting stories on what caused the injury.

What is an example of impaired adaptive functioning in an 8-year-old girl with a developmental disorder? The child cannot properly dress herself. The child cannot correctly copy a sentence. The child's vision is fine but she is a poor reader. The child cannot correctly copy a phone number.

The child cannot properly dress herself.

Which sign or symptom suggests that a 5-year-old child who does not maintain eye contact or speak may have autism spectrum disorder (ASD)? The child has a long face and prominent jaw. The child has a slight decrease in head circumference. The child is highly active and inattentive. The child constantly pats his or her legs.

The child constantly pats his or her legs.

The nurse is assisting with a physical exam on a child who has been admitted with a diagnosis of possible child abuse (child maltreatment). Which finding might alert the nurse to this possibility that the child may have been abused? The child has bruises on the knees and elbows. The child is hyperactive and angry. The child has a burn that has not been treated. The child has a fractured bone.

The child has a burn that has not been treated.

What finding would suggest that a 5-year-old boy might have a developmental disorder? The child is not able to follow directions. The child knows what a dog and a cat sound like. The child has trouble with R, L, and Y sounds. The child must be supervised when brushing his teeth.

The child is not able to follow directions.

The nurse is observing a child walk down stairs using a swing-through gait. What action by the child is correct? The child places the crutches on the lower step before placing the good foot down between the crutches. The child tries to walk without the crutches. Both crutches are placed on the lower step, and then the good foot is placed on the step below the crutches. One crutch is placed on the lower step, and then the good foot is placed next to the crutch.

The child places the crutches on the lower step before placing the good foot down between the crutches.

The nurse is working with school-aged children who are having enuresis or encopresis. What will most likely be the first step in this child's treatment? The child will be taken to a therapist. The child will have a complete physical exam. The child will be given medications. The child will be given a strict daily schedule.

The child will have a complete physical exam.

The nurse is caring for a child diagnosed with Duchenne muscular dystrophy and notes the presence of a Gower sign on the assessment form. What action by the child would support this assessment? a short heel cord caused by walking on the toes meeting motor milestones such as sitting, walking, and standing but at a later age than the average child when on the floor, rising to the knees and pressing the hands against the ankles, knees, and thighs to stand the presence of a waddling gait and difficulty climbing stairs

when on the floor, rising to the knees and pressing the hands against the ankles, knees, and thighs to stand

An 11-year-old boy was raised in a home where his father beat his mother on a regular basis. Which statement is true regarding children being raised in a home where they have witnessed intimate partner violence? Female children are more likely to experience depression. They are at increased risk for being abused. They have higher rates of schizophrenia. It has little impact on child functioning.

They are at increased risk for being abused.

The nurse is caring for an 8-month-old infant in Bryant traction for developmental dysplasia of the hip (DDH) and is monitoring for complications. Which assessment finding most concerns the nurse? a weak pedal pulse mild fussiness decreased oral intake temperature 100.2°F (37.9°C)

a weak pedal pulse

**The nurse is working with a child diagnosed with encopresis. After a complete medical workup has been done, no organic cause has been found for the disorder. What follow-up will the nurse expect? put on a high-calorie, high-protein diet started on methylphenidate administered antidiarrheal medications referred for counseling

referred for counseling

A mother is telling the school nurse about her concerns regarding her 13-year-old daughter, who is experiencing headaches. Her grades have dropped, and she is sleeping late and going to bed early every night. The nurse advises the mother that the first priority should be to: call for an appointment with a psychologist. schedule an immediate history and physical examination. ask the school psychologist to do psychometric testing. discuss the situation with her teacher.

schedule an immediate history and physical examination.

The type of traction in which a pin, wire, tongs, or other device is surgically inserted through a bone is: Russell traction. skin traction. skeletal traction. Buck extension traction.

skeletal traction.

A 10-year-old boy who was in a car wreck has been brought to the emergency room for evaluation. He appears to have suffered abdominal trauma due to his seat belt. He has tenderness in the left upper quadrant of the abdomen, especially on deep inspiration. Given these circumstances, the nurse should suspect injury to which of the following organs? pancreas spleen stomach liver

spleen

The charge nurse is observing a student nurse perform skeletal traction pin care. What action by the student nurse would indicate a need for intervention by the charge nurse? mixing hydrogen peroxide with sterile water to make half-strength hydrogen peroxide placing sterile cotton gauze squares around the ends of the pins unhooking a weight while providing pin care using latex free sterile gloves

unhooking a weight while providing pin care

Which statement by a parent would best indicate that she understands the precautions required for her son after the insertion of myringotomy tubes? A."I will keep him away from all children to prevent infections." B."I will be certain he takes showers, not tub baths." C."I will be certain he does not swim with the tubes in place." D."I will not shampoo his hair until the tubes come out."

"I will be certain he does not swim with the tubes in place." (Rationale: Myringotomy tubes would allow water to enter the middle ear and lead to infection.)

While caring for a child who will be undergoing a lumbar puncture, the nurse explains the procedure to the infant's mother. Which statement by the mother would indicate a need for further education? "I will cradle her in my arms after the procedure for at least 30 minutes." "My child may have a headache after the procedure. If she does, she can have something for the pain." "I need to encourage my child to drink at least 1 glass of water after the procedure." "During the test, the health care provider will most likely take 3 tubes of spinal fluid to test for several things."

"I will cradle her in my arms after the procedure for at least 30 minutes."

Tasha, 3 years old, is scheduled for a full neurologic examination. What explanation would best prepare her for this? "You'll need to answer questions carefully so you can pass this test." "I'll be asking you to move in different ways, almost like a game." "I need to find out how healthy or unhealthy your brain seems to be." "Seizures can be caused by a brain tumor, so that needs to be ruled out."

"I'll be asking you to move in different ways, almost like a game."

The parents of an 8-year-old child report that the child's teachers noted the child is having problems seeing the board in school but state they do not understand this since the child is able to read from the computer with no difficulty. Which response from the nurse is most appropriate? "These reports are consistent with hyperopia." "This may signal your child is having difficulty paying attention rather than a visual disorder." "What you are describing may be what is called myopia." "Your child will need to be evaluated for an accommodation disorder."

"What you are describing may be what is called myopia."

In completing a neurologic assessment on a preschool-aged client, the student nurse plans to assess for stereognosis. Which technique demonstrates the proper way to assess for stereognosis? Ask the child to close the eyes and extend a hand. The nurse will then trace 2 different shapes on the hand. Ask the child if the shapes traced were the same or different. As the child has the eyes closed, ask the child to extend the hands in front. The nurse will then extend one of the child's fingers up or down. Ask the child if the finger moved up or down. Ask the child to perform a complex motor skill such as folding a piece of paper and placing in an envelope. Ask the child to close the eyes and hold out a hand; place a key in the hand. Then ask the child to identify the object.

Ask the child to close the eyes and hold out a hand; place a key in the hand. Then ask the child to identify the object.

To detect complications as early as possible in a child with meningitis who's receiving IV fluids, monitoring for which condition should be the nurse's priority? Cardiogenic shock Cerebral edema Renal failure Left-sided heart failure

Cerebral edema

**A panicked mother calls the health care provider's office and reports that her 5-year-old has a high fever and just had a seizure. The mother asks the nurse what she should do. Which is the nurse's best response? Report to the emergency room for medical evaluation. Administer oral acetaminophen per package directions. Immerse the child in a bathtub of tepid water. Remove any heavy clothing and cover with a thin sheet.

Report to the emergency room for medical evaluation.

Glaucoma can occur in children following surgery for cataracts. Because Carla had surgery for congenital cataracts as an infant, she is being followed by a pediatric ophthalmologist. What assessment finding from the ophthalmologist's documentation would best reveal that Carla is developing glaucoma? Assessment for migraine headaches Carla's ability to identify colors Results of eye pressure assessment Results of temporal palpation

Results of eye pressure assessment

In caring for the child with meningitis, the nurse recognizes that which nursing diagnosis would be most important to include in this child's plan of care? Risk for injury related to seizure activity Delayed growth and development related to physical restrictions Risk for acute pain related to surgical procedure Ineffective airway clearance related to history of seizures

Risk for injury related to seizure activity

The nurse is preparing discharge education for the caregivers of a child with a seizure disorder. Which goal of treatment is priority for this client? The caregivers will be prepared to care for the child at home. The child will remain free from injury during a seizure. The family will understand seizure precautions. The child will have an understanding of the disorder.

The child will remain free from injury during a seizure.

The nurse is educating the parents of a 7-year-old girl with epilepsy about managing treatment of the disorder at home. Which intervention is most effective for eliminating breakthrough seizures? Treating the child as though she did not have epilepsy Placing the child on her side on the floor Instructing her teacher how to respond to a seizure Understanding the side effects of medications

Understanding the side effects of medications

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

Use his name before touching him.

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

Vomiting Photophobia Complaints of stiff neck

The nurse is caring for a 12-month-old infant diagnosed with Haemophilus influenzae meningitis. Which clinical manifestation would likely have been noted in this child? high-pitched cry and nuchal rigidity shaking the head and pulling the ear body stiffening and loss of consciousness severe vomiting and confusion

high-pitched cry and nuchal rigidity

The mother of a 6-month-old states that she does not understand how her child has contracted botulism. What is the best response by the nurse? "I'm sure this is very upsetting to you. It can be quite scary to see your child so sick." "Is your child not up to date with his vaccines? There is a vaccine that could have prevented this." "There is nothing you could have done to prevent your child from contracting this disease." "Botulism is caused by contaminated food. Honey is a common source."

"Botulism is caused by contaminated food. Honey is a common source."

An otherwise healthy 18-month-old child with a history of febrile seizures is in the well-child clinic. Which statement by the father would indicate to the nurse that additional teaching should be done? "I have ibuprofen available in case it's needed." "My child will likely outgrow these seizures by age 5." "The most likely time for a seizure is when the fever is rising." "I always keep phenobarbital with me in case of a fever."

"I always keep phenobarbital with me in case of a fever."

Based on this study, if Tasha is found to have recurrent seizures, which statement by her mother at a healthcare visit would concern a nurse the most? "I forgot to give Tasha her medicine twice last week; I have to try harder." "I feel really sad when children call Tasha names because of her seizures." "I don't like having to miss work due to Tasha's clinic visits." "I think Tasha's medicine is giving her headaches; maybe she needs glasses."

"I forgot to give Tasha her medicine twice last week; I have to try harder."

The nurse is caring for a child who has suffered a febrile seizure. While speaking with the child's parents, which statement by a parent indicates a need for further education? "I hate to think that I will need to be worried about my child having seizures for the rest of his life." "When he gets his next set of immunizations, I need to make sure I give him some ibuprofen so he doesn't spike a fever." "The next time he has a fever, I need to make sure I read the dosage on the acetaminophen bottle carefully." "I need to set an alarm to wake up and check his temperature during the night when he is sick."

"I hate to think that I will need to be worried about my child having seizures for the rest of his life."

A 7-year-old client has been complaining of headache, coughing, and an aching chest. The care provider makes a diagnosis of a viral infection. The child's mother tells the nurse that when she first said she had a headache, the child's father gave her half of an adult aspirin. The mother has heard of Reye syndrome and asks the nurse if her child could get this. Which statement would be the best response by the nurse? "This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome." "This is a serious problem. Aspirin is likely to cause Reye syndrome, and she should be admitted to the hospital for observation as a precaution." "This is unlikely to be a problem. Half an aspirin is not enough to cause harm. Reye syndrome generally only develops from prolonged use of aspirin in connection with a virus." "This might or might not be a problem. Watch your daughter for signs of nasal discharge, sneezing, itching of the nose, or dark circles under the eyes. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome."

"This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome."

A school-age child with external otitis media wonders how she got the illness. What information would the nurse discuss with her as a common cause? A.Swimming B.Use of ear plugs C.Wearing sunglasses that are too tight Excessive use of cotton swabs

A.Swimming (Rationale: Swimming or the presence of a foreign body are leading causes of "swimmer's ear." Secondary infections may also occur.)

Tasha's diagnostic workup will include a lumbar puncture. When collaborating with the physician to perform this procedure, what nursing action should the nurse prioritize? Explain to Tasha that her back will be washed with a cold liquid. Apply EMLA cream to Tasha's lumbar region 5 to 10 minutes before the procedure. Reassure Tasha that the procedure will not hurt. Help Tasha into a prone position on the procedure tabl

Explain to Tasha that her back will be washed with a cold liquid.

A nurse is talking with the parents of a child who has had a febrile seizure. The nurse would integrate an understanding of what information into the discussion? The child's risk for epilepsy is now increased. The child's risk for cognitive problems is greatly increased. Structural damage occurs with febrile seizure. Febrile seizures are benign in nature.

Febrile seizures are benign in nature.

The nurse is preparing a room for a child being admitted with meningitis. What is the appropriate action by the nurse? Ensure that lights and televisions work properly to provide stimulation while the child is hospitalized. Gather appropriate equipment and signage for respiratory isolation precautions. Provide information regarding policies of the unit's playroom for the parents to review. Place multiple pillows in the room to assist with propping the child's head up. SUBMIT ANSWER

Gather appropriate equipment and signage for respiratory isolation precautions.

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

Indications of increased intracranial pressure

A 6-month-old infant is admitted with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. Which intervention should the nurse take initially? Palpate the child's fontanels (fontanelles). Encourage the mother to hold and comfort the infant. Educate the family about preventing bacterial meningitis. Institute droplet precautions in addition to standard precautions.

Institute droplet precautions in addition to standard precautions.

The nurse is caring for a child who has conductive hearing loss. What is true regarding this type of hearing loss? It is caused by maternal rubella. It is often undetected until the child goes to school. It is caused by chronic otitis media or another infection. It is generally severe and unresponsive to medical treatment.

It is caused by chronic otitis media or another infection. (In conductive hearing loss, middle ear structures fail to carry soundwaves to the inner ear. This type of impairment most often results fromchronic serious otitis media or other infection.)

The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure? Brief, sudden contracture of a muscle or muscle group Muscle tone maintained and child frozen in position Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention Sudden, momentary loss of muscle tone, with a brief loss of consciousness

Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention

A young preschool-age child with impaired visual acuity can be treated with glasses. The parents are reluctant to agree. The nurse explains that: because your preschooler is not old enough to learn to read, it would be acceptable to delay their use until kindergarten. by treating the child now, the child will be well-adjusted to wearing glasses by kindergarten. with impaired vision, children have difficulty interacting with their environment and meeting developmental milestones. today, eye glasses are attractive and relatively unbreakable. Replacement insurance is inexpensive should they be lost or broken.

with impaired vision, children have difficulty interacting with their environment and meeting developmental milestones.