Lippincots qa

19. Which development is necessary for toilet training readiness for a 2-year-old? Select all that apply. ■ 1. Adequate neuromuscular development for sphincter control. ■ 2. Appropriate chronological age. ■ 3. Ability to communicate the need to use the toilet. ■ 4. Desire to please the parents. ■ 5. Ability to play with other 2-year-olds.

1, 3, 4. Readiness for toilet training is based on neurological, psychological, and physical developmental readiness. The nurse can introduce concepts of readiness for toilet training and encour- age parents to look for adaptive and psychomo- tor signs such as the ability to walk well, balance, climb, sit in a chair, dress oneself, please the parent, and communicate awareness of the need to urinate or defecate. Chronological age is not an indicator for toilet training. Two-year-olds engage in parallel play, which is not an indicator of readiness for toilet training. CN: Health promotion and maintenance; CL: Apply

32. The parents of a preschooler ask the nurse how to handle their child's temper tantrums. Which of the following should the nurse include in the teaching plan? Select all that apply. ■ 1. Putting the child in "time-out." ■ 2. Telling the child to go to his bedroom. ■ 3. Ignoring the child. ■ 4. Putting the child to bed. ■ 5. Spanking the child. ■ 6. Trying to reason with the child.

1, 3. Some parents fi nd that putting the child in time-out until control is regained is very effective. Others fi nd that ignoring the behaviors works just as well with their child. Both suggestions are appropri- ate to include in the teaching plan. Sending the child to his bedroom means the child is being punished for having a tantrum. Spanking the child is never an option. Attempting to reason with a child having a temper tantrum does not work because the child is out of control. A more appropriate time to discuss it with the child is when the child regains control. CN: Health promotion and maintenance; CL: Create

1. After reading the vaccine information sheets, the parent of a 2-month-old infant is hesitant to consent to the recommended vaccinations. The nurse should fi rst ask the parent: ■ 1. "Did you know that vaccinations are required by law for school entry?" ■ 2. "What personal beliefs or safety concerns do you have about vaccinations?" ■ 3. "Would you prefer that fewer vaccines are given at a time?" ■ 4. "Can you please sign this vaccine waiver form?"

1. 2. By trying to determine the source of parents' concerns, the nurse is able to acknowledge their feelings and provide the most appropriate information. This approach increases the likelihood parents will listen to the health care provider's views. Exemptions for vaccines vary by state and many parents feel legal requirements for vaccinations take away parental rights. The number of vaccinations given at one time may not be the issue. Waivers are used only if clients refuse vaccination after a discussion of risks and benefits. CN: Health promotion and maintenance; CL: Synthesize

67. A parent asks why it is recommended that the second dose of the measles, mumps, and rubella (MMR) vaccine be given at 4 to 6 years of age? The nurse should explain to the parent that the second dose is given at this age for what reason? ■ 1. If the child reaches puberty and becomes pregnant when receiving the vaccine, the risks to the fetus are high. ■ 2. The chance of contracting the disease is much lower at this age. ■ 3. The dangers associated with a strong reaction to the vaccine are increased at this age. ■ 4. A serious complication from the vaccine is swelling of the joints.

1. After receiving the MMR vaccine, the per- son develops a mild form of the disease, stimulating the body to develop immunity. Administration to a pregnant adolescent early in pregnancy puts the fetus at risk for deformity or spontaneous abor- tion. Some authorities recommend withholding the immunization for rubella until after puberty because a woman does not always know when she is preg- nant and a fetus could be placed in jeopardy. How- ever, the risk of contracting the disease is not lower at this age. There is no difference in the reaction to the vaccine at this age or in an older child. Swell- ing of the joints is a rare complication of the rubella vaccine. CN: Pharmacological and parenteral therapies; CL: Apply

16. A mother states that she thinks her 9-month- old "is developing slowly." When assessing the infant's development, the nurse is also concerned because the infant should be demonstrating which of the following characteristics? ■ 1. Vocalizing single syllables. ■ 2. Standing alone. ■ 3. Building a tower of two cubes. ■ 4. Drinking from a cup with little spilling.

1. Normally, a 9-month-old infant should have been voicing single syllables since 6 months of age. Absence of this fi nding would be a cause for concern. An infant usually is able to stand alone at about 10 months of age. An infant usually is able to build a tower of two cubes at about 15 months of age. An infant usually is able to drink from a cup with little spilling at about 15 months of age. CN: Health promotion and maintenance; CL: Analyze

10. The parents of a 9-month-old bring the infant to the clinic for a regular checkup. The infant has received no immunizations. Which of the following would be appropriate for the nurse to administer at this visit? ■ 1. Diphtheria, tetanus, and acellular pertussis (DTaP); Haemophilus infl uenzae type B (Hib); inactivated poliomyelitis vaccine (IPV); and purifi ed protein derivative (PPD). ■ 2. DTaP; Hib; oral polio vaccine (OPV); and measles, mumps, and rubella (MMR). ■ 3. PPD, MMR, hepatitis B (hepB), and OPV. ■ 4. HepB, IPV, Hib, and varicella.

1. The American Academy of Pediatrics recommends that infants who are delayed in receiv- ing their immunizations or have not started their series by 9 months of age begin with DTaP, Hib, IPV, and PPD. OPV is not used because cases of polio have been reported with use of the vaccine. MMR and varicella vaccines are not administered until 12 months of age. CN: Health promotion and maintenance; CL: Synthesize

65. A mother has heard that several children have been diagnosed with mononucleosis. She asks the nurse what precautions should be taken to prevent this from occurring in her child. The nurse should instruct the mother to: ■ 1. Take no particular precautionary measures. ■ 2. Sterilize the child's eating utensils before they are reused. ■ 3. Wash the child's linens separately in hot, soapy water. ■ 4. Wear masks when providing direct personal care.

1. The cause of infectious mononucleosis is thought to be the Epstein-Barr virus. No precaution- ary measures are recommended for clients with mononucleosis. The virus is believed to be spread only by direct intimate contact. CN: Physiological adaptation; CL: Synthesize

55. A parent asks the nurse about head lice (pediculosis capitis) infestation during a visit to the clinic. Which of the following symptoms should the nurse tell the parent is most common in a child infected with head lice? ■ 1. Itching of the scalp. ■ 2. Scaling of the scalp. ■ 3. Serous weeping on the scalp surface. ■ 4. Pinpoint hemorrhagic spots on the scalp surface.

1. The most common characteristic of head lice infestation (pediculosis capitis) is severe itching. The head is the most common site of lice infestation. If the child scratches, scaling may occur. Itching also occurs when lice infest other parts of the body. Scratch marks are almost always found when lice are present. Weeping on the scalp surface may be an indication of an infection or other dermatologic condition. Hemorrhagic spots are not a symptom of head lice, but may be caused by scratch marks. CN: Physiological adaptation; CL: Analyze

2. Which of the following is appropriate language development for an 8-month-old? The child should be: ■ 1. Saying "dada" and "mama" specifi cally ("dada" to father and "mama" to mother). ■ 2. Saying three other words besides "mama" and "dada." ■ 3. Saying "dada" and "mama" nonspecifi cally. ■ 4. Saying "ball" when parents point to a ball.

2. 3. It is important for the nurse to assist par- ents in assessing speech development in their child so that developmental delays can be identifi ed early. According to the Denver Developmental Screening Examination, at 8 months of age, the child should say "mama" and "dada" nonspecifi cally and imi- tate speech sounds. A child cannot say "dada" or "mama" specifi cally or use more than three words until they are about 12 months of age. A child cannot respond to specifi c commands or point to objects when requested until about 17 months of age. CN: Health promotion and maintenance; CL: Apply

70. A 13-month-old has a febrile seizure one month after the administration of the chicken pox vaccine. The nurse should: ■ 1. Recognize that the events are unrelated. ■ 2. Report the event through the Vaccine Adverse Event Reporting System. ■ 3. Explain to the parents that this is a rare but acceptable risk. ■ 4. Report the incident through the vaccine manufacturer's hotline.

2. Any unusual event that occurs after the administration of a vaccination should be reported. Reporting the incident through the Vaccine Adverse Event Reporting System (VAERS), a joint program from the FDA and CDC, helps to identify any new safety concerns. A high fever, with or without a sei- zure, that occurs within 6 weeks of vaccination may have been caused by the vaccine. A febrile seizure is considered a moderate reaction that warrants cau- tion with future chicken pox vaccination. Reporting the incident to the manufacturer does not help build the same body of knowledge as reporting the prob- lem through the national surveillance system. CN: Safety and infection control; CL: Synthesize

31. The mother of a preschooler reports that her child creates a scene every night at bedtime. The nurse and the mother decide that the best course of action would be to do which of the following? ■ 1. Allow the child to stay up later one or two nights a week. ■ 2. Establish a set bedtime and follow a routine. ■ 3. Encourage active play before bedtime. ■ 4. Give the child a cookie if bedtime is pleasant.

2. Bedtime is often a problem with preschool- ers. Recommendations for reducing conflicts at bedtime include establishing a set bedtime; having a dependable routine, such as story reading; and con- veying the expectation that the child will comply. Allowing the child to stay up late one or two nights interferes with establishing the needed bedtime ritu- als. Excitement, such as active play, just before bed- time should be avoided because it stimulates the child, making it diffi cult for the child to calm down and pre- pare for sleep. Using food such as a cookie as a reward if bedtime is pleasant should be avoided because it places too much importance on food. Other rewards, such as stickers, could be used as an alternative. CN: Health promotion and maintenance; CL: Synthesize

46. The nurse is teaching an adolescent with asthma how to use an inhaler. In which order should the nurse instruct the client to follow the steps from first to last? 1. Inhale through an open mouth. 2. Breathe out through the mouth. 3. Hold the breath for 5 to 10 seconds. 4. Press the canister to release the medication.

2. Breathe out through the mouth. 1. Inhale through an open mouth. 4. Press the canister to release the medication. 3. Hold the breath for 5 to 10 seconds. When dispensing medication from an inhaler, the client should fi rst breathe out through the mouth. Next the client inhales through an open mouth and then presses the canister to dispense the medica- tion while continuing to inhale and holds the breath for 5 to 10 seconds. The client can then exhale and breathe normally. CN: Pharmacological and parenteral therapies; CL: Apply

13. The nurse notes that an infant stares at an object placed in her hand and takes it to her mouth, coos and gurgles when talked to, and sustains part of her own weight when held in a standing position. The nurse correctly interprets these fi ndings as characteristic of an infant at which of the following ages? ■ 1. 2 months. ■ 2. 4 months. ■ 3. 7 months. ■ 4. 9 months.

2. Holding the head erect when sitting, star- ing at an object placed in the hand, taking the object to the mouth, cooing and gurgling, and sustaining part of her body weight when in a standing position are behaviors characteristic of a 4-month old infant. A 2-month-old typically vocalizes, follows objects to the midline, and smiles. A 7-month-old typically is able to sit without support, turns toward the voice, and transfers object from hand to hand. Usually, a 9-month-old can crawl, stand while holding on, and initiate speech sounds. CN: Health promotion and maintenance; CL: Analyze

66. A father asks the nurse how he would know if his child had developed mononucleosis. The nurse explains that in addition to fatigue, which of the following would be most common? ■ 1. Liver tenderness. ■ 2. Enlarged lymph glands. ■ 3. Persistent nonproductive cough. ■ 4. A blush-like generalized skin rash.

2. Mononucleosis usually has an insidious onset, with fatigue and the inability to maintain usual activity levels as the most common symptoms. The lymph nodes are typically enlarged, and the spleen also may be enlarged. Fever and a sore throat often accompany mononucleosis. A persistent non- productive cough can follow an upper respiratory tract infection. A blush-like generalized skin rash is more characteristic of rubella. CN: Physiological adaptation; CL: Analyze

24. A 2-year-old child brought to the clinic by her parents is uncooperative when the nurse tries to look in her ears. Which of the following should the nurse try fi rst? ■ 1. Ask another nurse to assist. ■ 2. Allow a parent to assist. ■ 3. Wait until the child calms down. ■ 4. Restrain the child's arms.

2. Parents can be asked to assist when their child becomes uncooperative during a procedure. Most commonly, the child's diffi culty in cooperating is caused by fear. In most situations, the child will feel more secure with a parent present. Other meth- ods, such as asking another nurse to assist or wait- ing until the child calms down, may be necessary, but obtaining a parent's assistance is the recom- mended fi rst action. Restraints should be used only as a last resort, after all other attempts have been made to encourage cooperation. CN: Health promotion and maintenance; CL: Synthesize

54. Parents of a 15-year-old state that he is moody and rude. The nurse should advise his parents to: ■ 1. Restrict his activities. ■ 2. Discuss their feelings with their child. ■ 3. Obtain family counseling. ■ 4. Talk to other parents of adolescents.

2. Parents need to discuss with their adoles- cent how they perceive his behavior and how they feel about it. Moodiness is characteristic of adoles- cents. The adolescent may have a reason for or not be aware of his behavior. Restricting the adolescent's activities will not change his mood or the way he responds to others. It may increase his unacceptable responses. Counseling may not be needed at this time if the parents are open to communicating and listening to the adolescent. Talking to other parents may be of some help, but what is helpful to others may not be helpful to their child. CN: Health promotion and maintenance; CL: Synthesize

30. The mother of a 4-year-old expresses concern that her child may be hyperactive. She describes the child as always in motion, constantly dropping and spilling things. Which of the following actions would be appropriate at this time? ■ 1. Determine whether there have been any changes at home. ■ 2. Explain that this is not unusual behavior. ■ 3. Explore the possibility that the child is being abused. ■ 4. Suggest that the child be seen by a pediatric neurologist.

2. Preschool-age children have been described as powerhouses of gross motor activity who seem to have endless energy. A limitation of their motor ability is that in moving as quickly as they do, they are not always able to judge distances, nor are they able to estimate the amount of strength and balance needed for activities. As a result, they have frequent mishaps. This level of activity typi- cally is not associated with changes at home. How- ever, if the behavior intensifi es, a referral to a pediat- ric neurologist would be appropriate. Children who have been abused usually demonstrate withdrawn behaviors, not endless energy. CN: Health promotion and maintenance; CL: Synthesize

11. To assess the development of a 1-month-old, the nurse asks the parent if the infant is able to: ■ 1. Smile and laugh out loud. ■ 2. Roll from back to side. ■ 3. Hold a rattle briefl y. ■ 4. Turn the head from side to side.

4. A 1-month-old infant is usually able to lift the head and turn it from side-to-side from a prone position. The full-term infant with no complica- tions has probably been able to do this since birth. Smiling and laughing is expected behavior at 2 to 3 months. Rolling from back to side and holding a rattle are characteristics of a 4-month-old. CN: Health promotion and maintenance; CL: Analyze

69. A parent brings a 5-year-old child to a vac- cination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. To determine the current evidence for best practices for scheduling missed vaccinations the nurse should: ■ 1. Ask the primary care provider. ■ 2. Check the website at the Center for Disease Control and Prevention (CDC). ■ 3. Read the vaccine manufacturer's insert. ■ 4. Contact the pharmacist.

2. The CDC is the federal body that is ulti- mately responsible for vaccination recommenda- tions for adults and children. A division of the CDC, the Advisory Committee on Immunization Practices, reviews vaccination evidence and updates recom- mendation on a yearly basis. The CDC publishes current vaccination catch-up schedules that are readily available on their website. The lack of vacci- nations is a strong indicator that the child probably does not have a primary care provider. If consulted, the pharmacist would most likely have to review the CDC guidelines that are equally available to the nurse. Reading the manufacturer's inserts for multi- ple vaccines would be time consuming and synthe- sis of the information could possibly lead to errors. CN: Management of care; CL: Apply

59. A mother asks the nurse, "How did my children get pinworms?" The nurse explains that pinworms are most commonly spread by which of the following when contaminated? ■ 1. Food. ■ 2. Hands. ■ 3. Animals. ■ 4. Toilet seats.

2. The adult pinworm emerges from the rec- tum and colon at night onto the perianal area to lay its eggs. Itching and scratching introduces the eggs to the hands, from where they can easily reinfect the child or infect others. Nightclothes and bed linens can be sources of infection. The eggs can also be transmitted by dust in the home. Although transmis- sion through contaminated food and water supplies is possible, it is rare. Contaminated animals can spread histoplasmosis and salmonella. The spread of infections by toilet seats has not been supported by research. CN: Physiological adaptation; CL: Apply

34. After having a blood sample drawn, a 5-year- old child insists that the site be covered with a ban- dage. When the parent tries to remove the bandage before leaving the offi ce, the child screams that all the blood will come out. The nurse encourages the parent to leave the bandage in place and tells the parent that the child: ■ 1. Fears another procedure. ■ 2. Does not understand body integrity. ■ 3. Is expressing pain. ■ 4. Is attempting to regain control.

2. The preschool-age child does not have an accurate concept of skin integrity and can view med- ical and surgical treatments as hostile invasions that can destroy or damage the body. The child does not understand that exsanguinations will not occur from the injection site. Here, the child is verbalizing a fear consistent with the developmental age. The child would most likely verbalize concerns of not wanting another procedure or exhibit other symptoms associ- ated with pain if those were the underlying issues. If control was the main issue, the child would try to control more than just the bandage removal. CN: Psychosocial adaptation; CL: Analyze

51. Which of the following actions initiated by the parents of an 8-month-old indicates they need further teaching about preventing childhood accidents? ■ 1. Placing a fi re screen in front of the fi replace. ■ 2. Placing a car seat in a front-seat, front-facing position. ■ 3. Inspecting toys for loose parts. ■ 4. Placing toxic substances out of reach or in a locked cabinet.

2. The recommended safety-seat arrange- ment for infants up to 20 lb and less than 1 year old is rear-facing with shoulder restraints. The middle of the back seat is considered the safest area of the car. Burns are a major cause of childhood accidents, and using fi re screens in front of fi replaces can help prevent children from getting too close to a fi re in a fi replace. Toys that contain loose parts or plastic eyes that can be swallowed or aspirated by small children should be avoided. Parents should inspect all toys for these parts before giving one to a child. Poisonings are most commonly caused by improper storage of a toxic substance. Keeping toxic substances in a child-proof container in a locked cabinet and continually observing the child's activi- ties can prevent most poisonings. CN: Safety and infection control; CL: Evaluate

28. When planning a 15-month-old toddler's daily diet with the parents, which of the following amounts of milk should the nurse include? ■ 1. 1⁄2 to 1 cup. ■ 2. 2 to 3 cups. ■ 3. 3 to 4 cups. ■ 4. 4 to 5 cups.

2. Toddlers around the age of 15 months need 2 to 3 cups of milk per day to supply necessary nutrients such as calcium. A daily intake of more than 3 cups of milk may interfere with the ingestion of other necessary nutrients. CN: Health promotion and maintenance; CL: Apply

27. When assessing for pain in a toddler, which of the following methods should be the most appro- priate? ■ 1. Ask the child about the pain. ■ 2. Observe the child for restlessness. ■ 3. Use a numeric pain scale. ■ 4. Assess for changes in vital signs.

2. Toddlers usually express pain through such behaviors as restlessness, facial grimaces, irritability, and crying. It is not particularly help- ful to ask toddlers about pain. In most instances, they would be unable to understand or describe the nature and location of their pain because of their lack of verbal and cognitive skills. However, preschool and older children have the verbal and cognitive skills to be able to respond appropriately. Numeric pain scales are more appropriate for chil- dren who are of school age or older. Changes in vital signs do occur as a result of pain, but behavioral changes usually are noticed fi rst. CN: Physiological adaptation; CL: Analyze

14. An 8-month-old infant is seen in the well- child clinic for a routine checkup. The nurse should expect the infant to be able to do which of the fol- lowing? Select all that apply. ■ 1. Say "mama" and "dada" with specifi c meaning. ■ 2. Feed self with a spoon. ■ 3. Play peek-a-boo. ■ 4. Walk independently. ■ 5. Stack two blocks. ■ 6. Transfer object from hand to hand.

3, 6. Typical abilities demonstrated by 8-month-old infants include playing peek-a-boo and transferring objects from one hand to another. The ability to say "dada" and "mama" is more typical of 10-month-old infants. Infants usually are at least 12 months old when they achieve the ability to walk independently. Infants who are 15 months old com- monly can feed themselves with a spoon and stack two blocks. CN: Health promotion and maintenance; CL: Analyze

23. When assessing a 2-year-old child brought by his mother to the clinic for a routine checkup, which of the following should the nurse expect the child to be able to do? ■ 1. Ride a tricycle. ■ 2. Tie his shoelaces. ■ 3. Kick a ball forward. ■ 4. Use blunt scissors.

3. A 2-year-old child usually can kick a ball forward. Riding a tricycle is characteristic of a 3-year-old child. Tying shoelaces is a behavior to be expected of a 5-year-old child. Using blunt scissors is characteristic of a 3-year-old child. CN: Health promotion and maintenance; CL: Analyze

20. A mother of a toilet-trained 3-year-old expresses concern over her child's bedwetting while hospitalized. The nurse should tell the mother: ■ 1. "He was too immature to be toilet trained. In a few months he should be old enough." ■ 2. "Children are afraid in the hospital and fre- quently wet their bed." ■ 3. "It's very common for children to regress when they're in the hospital." ■ 4. "This is normal. He probably received too much fluid the night before."

3. A child will regress to a behavior used in an earlier stage of development in order to cope with a perceived threatening situation. Readiness for toilet training should be based on neurologi- cal, physical, and psychological development, not the age of the child. Children are afraid of hospi- talization but the bedwetting is a compensatory mechanism done to regress to a previous stage of development that is more comfortable and secure for the child. Telling the mother that bedwetting is related to fl uid intake does not provide an adequate explanation for the underlying regression to an ear- lier stage of development. CN: Psychosocial adaptation; CL: Synthesize

61. A mother calls the clinic to talk to the nurse. The mother states that a physician described her daughter as having 20/60 vision and she asks the nurse what this means. The nurse responds based on the interpretation that the child is experiencing which of the following? ■ 1. A loss of approximately one-third of her visual acuity. ■ 2. Ability to see at 60 feet what she should see at 20 feet. ■ 3. Ability to see at 20 feet what she should see at 60 feet. ■ 4. Visual acuity three times better than average.

3. A child with 20/60 vision sees at 20 feet what those with 20/20 vision see at 60 feet. A visual acuity of 20/200 is considered to be the boundary of legal blindness.

22. A mother brings her 18-month-old to the clinic because the child "eats ashes, crayons, and paper." Which of the following information about the toddler should the nurse assess fi rst? ■ 1. Evidence of eruption of large teeth. ■ 2. Amount of attention from the mother. ■ 3. Any changes in the home environment. ■ 4. Intake of a soft, low-roughage diet.

3. A craving to eat nonfood substances is known as pica. Toddlers use oral gratifi cation as a means to cope with anxiety. Therefore, the nurse should fi rst assess whether the child is experienc- ing any change in the home environment that could cause anxiety. Teething or the eruption of large teeth and the amount of attention from the mother are unlikely causes of pica. Nutritional defi cien- cies, especially iron defi ciency, were once thought to cause pica, but research has not substantiated this theory. A soft, low-roughage diet is an unlikely cause. CN: Physiological adaptation; CL: Analyze

53. A nurse is assessing the growth and development of a 14-year-old boy. He reports that his 13-year-old sister is 2 inches taller than he is. The nurse should advise the boy that the growth spurt in adolescent boys, compared with the growth spurt of adolescent girls: ■ 1. Occurs at the same time. ■ 2. Occurs 2 years earlier. ■ 3. Occurs 2 years later. ■ 4. Occurs 1 year earlier.

3. Adolescent boys lag about 2 years behind adolescent girls in growth. Most girls are 1 to 2 inches taller than boys at the beginning of adoles- cence but tend to stop growing approximately 2 to 3 years after menarche with the closure of the epiphy- seal lines of the long bones. CN: Health promotion and maintenance; CL: Apply

29. To encourage autonomy in a 4-year-old, the nurse should instruct the mother to: ■ 1. Discourage the child's choice of clothing. ■ 2. Button the child's coat and blouse. ■ 3. Praise the child's attempts to dress herself. ■ 4. Tell the child when the combination of clothes is not appropriate.

3. At age 4, the child should be learning to dress without supervision. A child will feel more autonomous if allowed to try to take on tasks herself. Such attempts should be encouraged to increase self- esteem. Allowing choices encourages the child's capac- ity to control her behavior. Continued dependency may cause the child to doubt her own abilities. Telling the child that a combination of clothes is not appropri- ate may cause the child to doubt her abilities. Feelings of guilt can develop from not being able to accomplish what the child feels the adult expects of her. CN: Health promotion and maintenance; CL: Synthesize

17. A 2-year-old tells his mother he is afraid to go to sleep because "the monsters will get him." The nurse should tell his mother to: ■ 1. Allow him to sleep with his parents in their bed whenever he is afraid. ■ 2. Increase his activity before he goes to bed, so he eventually falls asleep from being tired. ■ 3. Read a story to him before bedtime and allow him to have a cuddly animal or a blanket. ■ 4. Allow him to stay up an hour later with the family until he falls asleep.

3. Behavior problems related to sleep and rest are common in young children. Consistent ritu- als around bedtime help to create an easier transi- tion from waking to sleep. Allowing a child to sleep with his parents commonly creates more problems for the family and child and does not alleviate the problem or foster autonomy. Increasing activity before bedtime does not alleviate the separation anxiety in the toddler and causes further anxiety. Allowing him to stay up later than his normal time for bed will increase his anxiety, make it more diffi - cult for him to fall asleep, and do nothing to lessen his fear. CN: Psychosocial adaptation; CL: Synthesize

8. A parent brings a 4-month-old to the clinic for a regular well visit and expresses concern that the infant is not developing appropriately. Which findings in the infant would indicate the need for further developmental screening? ■ 1. Has no interest in peek-a-boo games. ■ 2. Does not turn front to back. ■ 3. Does not babble. ■ 4. Continues to have head lag.

3. By the end of 3 months infants should babble. Lack of babbling suggests a language delay and warrants further investigation. Infants typically would begin playing peek-a-boo around 7 months. The ability to roll front to back typically occurs at 5 months. Head lag is expected to resolve by 5 months. CN: Health promotion and maintenance; CL: Analyze

33. After teaching a group of parents of pre- schoolers attending a well-child clinic about oral hygiene and tooth brushing, the nurse determines that the teaching has been successful when the parents state that children can begin to brush their teeth without help at which of the following ages? ■ 1. 3 years. ■ 2. 5 years. ■ 3. 7 years. ■ 4. 9 years.

3. Children younger than 7 years of age do not have the manual dexterity needed for tooth brushing. Therefore, parents need to help with this task until that time. CN: Health promotion and maintenance; CL: Evaluate

35. The family of a 5-year-old, only child has just moved to a rural setting where the father has started a dental practice. At the well-child visit, the father expresses concern that his child seems prone to minor accidents such as, skinning his elbow and knees or falling off his scooter. The nurse tells the father: ■ 1. "Only children use accidents as a way to seek parental attention." ■ 2. "Children who live in the suburbs typically have more accidents." ■ 3. "Children frequently have more accidents when families experience change." ■ 4. "We see a relationship between accidents and parental education."

3. Family changes and stresses (e.g., moving, having company, taking a vacation, adding a new member) can distract parents and contribute to acci- dents. Only children typically receive more atten- tion than those with siblings. Thus, the risk would be less. Families who live in the suburbs frequently are more affl uent and, therefore, better able to main- tain a home less conducive to accidents. A parent's formal education is unrelated to accidents. CN: Health promotion and maintenance; CL: Synthesize

64. When discussing the onset of adolescence with parents, the nurse explains that it occurs at which of the following times? ■ 1. Same age for both boys and girls. ■ 2. 1 to 2 years earlier in boys than in girls. ■ 3. 1 to 2 years earlier in girls than in boys. ■ 4. 3 to 4 years later in boys than in girls.

3. Girls experience the onset of adolescence about 1 to 2 years earlier than boys. The reason for this is not understood. CN: Health promotion and maintenance; CL: Apply

50. Several high-school seniors are referred to the school nurse because of suspected alcohol misuse. When the nurse assesses the situation, what would be most important to determine? ■ 1. What they know about the legal implications of drinking. ■ 2. The type of alcohol they usually drink. ■ 3. The reasons they choose to use alcohol. ■ 4. When and with whom they use alcohol.

3. Information about why adolescents choose to use alcohol or other drugs can be used to deter- mine whether they are becoming responsible users or problem users. The senior students likely know the legal implications of drinking, and the nurse will establish a more effective relationship with the students by understanding motivations for use. The type of alcohol and when and with whom they are using it are not the fi rst data to obtain when assess- ing the situation. CN: Health promotion and maintenance; CL: Analyze

56. A parent asks, "Can I get head lice too?" The nurse indicates that adults can also be infested with head lice but that pediculosis is more common among school children, primarily for which of the following reasons? ■ 1. An immunity to pediculosis usually is estab- lished by adulthood. ■ 2. School-age children tend to be more neglect- ful of frequent handwashing. ■ 3. Pediculosis usually is spread by close contact with infested children. ■ 4. The skin of adults is more capable of resisting the invasion of lice.

3. Lice are spread by close personal con- tact and by contact with infested clothing, bed and bathroom linens, and combs and brushes. Lice are more common in school-age children than in adults because of the close contact in school and the com- mon practice of sharing possessions. Lice are not commonly spread by hand contact. There is no immunity conferred by having head lice. Adults can have head lice, particularly if they come in close con- tact with their children's infested clothing or linens. CN: Physiological adaptation; CL: Apply

36. When developing the teaching plan about illness for the mother of a preschooler, which of the following should the nurse include about how a preschooler perceives illness? ■ 1. A necessary part of life. ■ 2. A test of self-worth. ■ 3. A punishment for wrongdoing. ■ 4. The will of God.

3. Preschool-age children may view illness as punishment for their fantasies. At this age children do not have the cognitive ability to separate fantasies from reality and may expect to be punished for their "evil thoughts." Viewing illness as a necessary part of life requires a higher level of cognition than preschoolers possess. This view is seen in children of middle school age and older. Perceiving illness as a test of self-worth or as the will of God is more characteristic of adults. CN: Health promotion and maintenance; CL: Apply

57. After teaching the parents about the cause of ringworm of the scalp (tinea capitis), which of the following, if stated by the father, indicates success- ful teaching? ■ 1. "It results from overexposure to the sun." ■ 2. "It's caused by infestation with a mite." ■ 3. "It's a fungal infection of the scalp." ■ 4. "It's an allergic reaction."

3. Ringworm of the scalp is caused by a fun- gus of the dermatophyte group of the species. Over- exposure to the sun would result in sunburn. Mites, such as chiggers or ticks, produce bites on the skin, resulting in infl ammation. An allergic reaction com- monly is manifested by hives, rash, or anaphylaxis. CN: Physiological adaptation; CL: Evaluate

52. The mother of a 2-year-old is concerned because the child's right eye seems to turn in toward his nose when he is tired. The nurse should: ■ 1. Assure the mother that this is a normal event when the child is tired. ■ 2. Advise the mother to continue to watch his eyes closely and if the problem persists to call the clinic. ■ 3. Test the child with the cover-uncover test and refer the mother and child to an ophthalmolo- gist if the test is abnormal. ■ 4. Explain to the mother that the child will probably outgrow the weakness and she need not be concerned.

3. Strabismus is diagnosed through observa- tion and use of the corneal light refl ex test. The cov- er-uncover test will reveal movement of the affected eye when the unaffected eye is covered, indicating abnormal fi xation of the affected eye. The child should be referred to an ophthalmologist as soon as possible so that the correct vision in the affected eye can be restored. It is never normal for one eye to turn inward or outward even if the child is tired. If this condition is not corrected early, blindness can result in the unaffected eye due to the brain sup- pressing the double vision. Thus, telling the mother to watch the child and call later with concerns is not an appropriate response. The child will not grow out of this type of condition and may need surgery, an eye patch, daily exercises, or a combination of these interventions. CN: Health promotion and maintenance; CL: Synthesize

3. The nurse should refer the parents of an 8-month-old child to a health care provider if the child is unable to: ■ 1. Stand momentarily without holding onto furniture. ■ 2. Stand alone well for long periods of time. ■ 3. Stoop to recover an object. ■ 4. Sit without support for long periods of time.

4. According to the Denver Developmental Screening Examination, a child of 8 months should sit without support for long periods of time. An 8-month-old child does not have the ability to stand without hanging on to a stationary object for sup- port. His muscles are not developed enough to sup- port all his weight without assistance. His balance has not developed to the point that he can stand and stoop over to reach an object. CN: Health promotion and maintenance; CL: Synthesize

12. The mother of a 6-month-old states that she started her infant on 2% milk. The nurse should fi rst ask the mother: ■ 1. "Do you think your baby will be fi ne with this milk?" ■ 2. "Is it possible for you to switch your baby to whole milk?" ■ 3. "Can you tell me more about the reason you switched your baby to 2% milk?" ■ 4. "You cannot switch to 2% milk right now. Did your pediatrician tell you to do this?"

3. The American Academy of Pediatrics recommends that infants remain on iron fortifi ed formula or breast milk until 1 year of age. The nurse needs to fi rst assess if the mother switched the baby prematurely to due to lack of information or lack of resources. Then appropriate teaching or referrals may be determined. At 1 year of age the infant may be switched to whole milk, which has a higher fat content than 2%. The higher fat content is needed for brain growth. Demanding clients change behav- iors without addressing the cause is unlikely to produce desired results. CN: Health promotion and maintenance; CL: Analyze

60. A mother tells the nurse that one of her chil- dren has chickenpox and asks what she should do to care for that child. When teaching the mother, the nurse should instruct the mother to help her child prevent: ■ 1. Acid-base imbalance. ■ 2. Malnutrition. ■ 3. Skin infection. ■ 4. Respiratory infection.

3. The care of a child with chickenpox focuses primarily on preventing infection in the lesions. The lesions cause severe itching, and organisms are ordinarily introduced into the lesion through scratching. Acid-base imbalance rarely occurs with chickenpox. Malnutrition is a chronic problem associated with the ingestion of an inadequate diet over a long period. It is not associated with chickenpox. Secondary infection in the lesions, not the respiratory tract, is most common. CN: Physiological adaptation; CL: Synthesize

6. Which of the following structures should be closed by the time the child is 2 months old? *pic ■ 1. A. ■ 2. B. ■ 3. C. ■ 4. D.

3. The posterior fontanel should be closed by age 2 months. The anterior fontanel and sagittal and frontal sutures should be closed by age 18 months. CN: Health promotion and maintenance; CL: Apply

68. An 18-year-old high school senior wishes to obtain birth control through her parents' insurance but does not want the information disclosed. The nurse tells the client that under the Health Informa- tion Portability and Accountability Act (HIPAA) parents: ■ 1. Have the right to review a minor's medical records until high school graduation. ■ 2. Have the right to review a minor's medical record if they are responsible for the payment. ■ 3. May not view the medical record, but may learn of the visit through the insurance bill. ■ 4. May not view the minor's medical record or the insurance bill.

3. Under HIPAA, 18-year-olds have the right to medical privacy and their medical records may not be disclosed to their parents without their permission. However, the adolescent must be made aware of the fact that information is sent to third party payers for the purpose of reimbursement. Those payers send the primary insurer, in this case the parent, a statement of benefi ts. HIPAA protects the right to medical privacy of all 18-year-olds regardless of their educational status. Even if parents are responsible for payment, they may not view the client's chart without the consent of the adolescent. CN: Management of care; CL: Apply

5. A 10-month-old looks for objects that have been removed from his view. The nurse should instruct the parents that: ■ 1. Neuromuscular development enables the child to reach out and grasp objects. ■ 2. The child's curiosity has increased. ■ 3. The child understands the permanence of objects even though the child cannot see them. ■ 4. The child is now able to transfer objects from hand to hand.

3. Understanding object permanence means that the child is aware of the existence of objects that are covered or displaced. Neuromuscular devel- opment, curiosity, and the ability to transfer objects are not associated with the principle of object permanence. Although, at 10 months, neuromuscu- lar development is suffi cient to grasp objects and a child's curiosity has increased, neither are related to the thought process involved in object permanence. CN: Health promotion and maintenance; CL: Apply

9. The nurse assesses a 6-month-old for vaccination readiness. Which fi nding would most likely indicate the need to delay administering the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine? ■ 1. A family history of sudden infant death syndrome (SIDS). ■ 2. A fever of 38.5 °C following the 4-month vaccinations. ■ 3. An acute bilateral ear infection. ■ 4. Living with a family member who is immunosuppressed.

3. Vaccination in the presence of a mod- erate to severe infection, with or without fever, increases the risk of injury and decreases the chance of mounting good immunity. There is currently no evidence to suggest vaccines raise the risk of SIDS. A mild temperature may be expected with the DTaP. A fever of greater than 40.5° within 48 hours of vac- cination would warrant caution. The DTaP is not a live vaccine. No special precautions are needed regarding immunosuppressed family members. CN: Reduction of risk potential; CL: Synthesize

37. To determine if a blood pressure reading is normal, the nurse must know which information about the child? Select all that apply. ■ 1. Age. ■ 2. Body mass index (BMI). ■ 3. Gender. ■ 4. Height. ■ 5. Occipital frontal circumference (OFC). ■ 6. Weight.

37. 1, 3, 4. Blood pressures percentiles for children are referenced by the age, sex, and height. Measurements at or above the 95th percentile are considered indicative of hypertension. Weight and elevated BMI contributes to hypertension but are not used to defi ne it. The OFC is not routinely measured in children over 2 years of age. CN: Health promotion and maintenance; CL: Analyze

38. A nurse is assessing the growth and develop- ment of a 10-year-old. What is the expected behavior of this child? ■ 1. Enjoys physical demonstrations of affection. ■ 2. Is selfi sh and insensitive to the welfare of others. ■ 3. Is uncooperative in play and school. ■ 4. Has a strong sense of justice and fair play.

38. 4. School-age children are concerned about justice and fair play. They become upset when they think someone is not playing fair. Physical affection makes them embarrassed and uncomfortable. They are concerned about others and are cooperative in play and school. CN: Health promotion and maintenance; CL: Analyze

39. To assess a 9-year-old's social development, the nurse asks the parent if the child: ■ 1. Thinks independently. ■ 2. Is able to organize and plan. ■ 3. Has a best friend. ■ 4. Enjoys active play.

39. 3. During the school-age years children learn to socialize with children of the same age. The "best friend" stage, which occurs around age 9 or 10 years of age, is important in providing a foundation for self-esteem and later relationships. Thinking inde- pendently, organizing, and planning are cognitive skills. Active play relates to motor skills. CN: Health promotion and maintenance; CL: Analyze

71. The school nurse is invited to attend a meet- ing with several parents who express frustration with the amount of time their adolescents spend in front of the mirror and the length of time it takes them to get dressed. The nurse explains that this behavior indicates: ■ 1. An abnormal narcissism. ■ 2. A method of procrastination. ■ 3. A way of testing the parents' limit-setting. ■ 4. A result of developing self-concept.

4. An adolescent's body is undergoing rapid changes. Adolescence is a time of integrating these rapidly occurring physical changes into the self- concept to achieve the developmental task of a posi- tive self-identity. Thus, most adolescents spend much time worrying about their personal appearance. This behavior is not abnormal narcissism, a method of procrastination, or a way of testing the parents' limits. CN: Health promotion and maintenance; CL: Analyze

58. Griseofulvin (Grisactin) was ordered to treat a child's ringworm of the scalp. The nurse instructs the parents to use the medication for several weeks for which of the following reasons? ■ 1. A sensitivity to the drug is less likely if it is used over a period of time. ■ 2. Fewer side effects occur as the body slowly adjusts to a new substance over time. ■ 3. Fewer allergic reactions occur if the drug is maintained at the same level long-term. ■ 4. The growth of the causative organism into new cells is prevented with long-term use.

4. Griseofulvin is an antifungal agent that acts by binding to the keratin that is deposited in the skin, hair, and nails as they grow. This keratin is then resistant to the fungus. But as the keratin is normally shed, the fungus enters new, uninfected cells unless drug therapy continues. Long-term administration of griseofulvin does not prevent sen- sitivity or allergic reactions. As the body adjusts to a new substance over time, side effects are variable and do not necessarily decrease. CN: Pharmacological and parenteral therapies; CL: Apply

21. A nurse working in the nursery identifies a goal for a mother of a newborn to demonstrate positive attachment behaviors upon discharge. Which intervention would be least effective in accomplishing this goal? ■ 1. Provide opportunities for the mother to hold and examine the newborn. ■ 2. Engage the mother in the newborn's care. ■ 3. Create an environment that fosters privacy for the mother and newborn. ■ 4. Identify strategies to prevent difficulties in parenting.

4. Identifying ways to prevent diffi culties in parenting would be helpful in reducing the inci- dence of child abuse and reducing the stress of child rearing. However, it would not help to develop positive attachment behaviors. Providing opportuni- ties for the mother to hold and examine the new- born and help with care helps establish a positive emotional bond between the mother and newborn. Providing time for the mother to be alone with the infant further allows the mother and newborn to bond. CN: Psychosocial adaptation; CL: Synthesize

25. When observing the parent instilling pre- scribed ear drops ordered twice a day for a toddler, the nurse decides that the teaching about position- ing of the pinna for instillation of the drops is effec- tive when the parent pulls the toddler's pinna in which of the following directions? ■ 1. Up and forward. ■ 2. Up and backward. ■ 3. Down and forward. ■ 4. Down and backward.

4. In a child younger than 3 years of age, the pinna is pulled back and down, because the audi- tory canals are almost straight in children. In an adult, the pinna is pulled up and backward because the auditory canals are directed inward, forward, and down. CN: Pharmacological and parenteral therapies; CL: Evaluate

4. The nurse is teaching the parents of an 8-month-old about what the child should eat. The nurse should include which of the following points in the teaching plan? ■ 1. Items from all four food groups should be introduced to the infant by the time the child is 10 months old. ■ 2. Solid foods should not be introduced until the infant is 10 months old. ■ 3. Iron defi ciency rarely develops before 12 months of age, so iron-fortifi ed cereals should not be introduced until the infant is 12 months old. ■ 4. The infant's diet can be changed from for- mula to whole milk when the infant is 12 months old.

4. Infants should be kept on formula or breast milk until 1 year of age. The protein in cow's milk is harder to digest than that found in formula. The infant cannot digest fats well, so some foods from the four food groups are not necessary in his diet during infancy. Solids are introduced into the infant's diet around 4 to 6 months, after the extrusion refl ex has diminished and when the child will accept new tex- tures. Iron defi ciency develops in term infants between 4 to 6 months when the prenatal iron stores are depleted. Fortifi ed cereals can be added to the infant's diet at 4 to 6 months to prevent iron defi ciency anemia. CN: Health promotion and maintenance; CL: Create

7. The nurse is discharging an 8-month-old who weighs 15 lb from the hospital. The parents have put the child in the back seat of the car with the car seat facing the front. The nurse should: ■ 1. Ask the parents to wait while obtaining the correct car seat. ■ 2. Complete the discharge with the child sitting facing the front seat. ■ 3. Give the parents a manual on proper car seat placement. ■ 4. Explain the need for the rear-facing posi- tion and request assistance from a car seat technician.

4. Proper car seat placement for a child younger than 1 year or weighing less than 20 lb is facing the rear of the car. Without specialized train- ing, nurses may not understand how to correctly use all brands of car seats. Families who need help installing car seats should be referred to persons who have had specialized training. The car seat is not in question and does not need to be replaced. Keeping the infant in an incorrect position while completing the discharge reinforces the incor- rect placement. The parents are unlikely to read a manual, especially since the child is 8 months old and it is very likely that they have been using this position since birth. Additionally, the manual may not be specifi c for their brand of car seat. CN: Safety and infection control; CL: Synthesize

15. The parent of a 9-month-old infant is con- cerned that the infant's front soft spot is still open. The nurse should tell the parent: ■ 1. "I will measure your baby's head to see if it is a normal size." ■ 2. "Your infant will need to be referred for more testing." ■ 3. "You should contact your physician immediately." ■ 4. "This is normal because this soft spot usually closes between 12 and 18 months."

4. The anterior fontanel, commonly known as the soft spot, closes between 12 to 18 months in most infants. The nurse normally measures an infant's occipital frontal circumference at each well-child visit. This action alone does not relieve the parent's concerns. Referrals would be indicated for premature or delayed closures of the fontanel especially if there were other abnormal fi ndings. Closure of the anterior fontanel by 12 months can only be expected to occur in approximately a third of all infants. CN: Health promotion and maintenance; CL: Synthesize

26. The mother asks the nurse for advice about discipline for her 18-month-old. Which of the fol- lowing should the nurse suggest that the mother use? ■ 1. Structured interactions. ■ 2. Spanking. ■ 3. Reasoning. ■ 4. Time out.

4. Time out is the most appropriate discipline for toddlers. It helps to remove them from the situa- tion and allows them to regain control. Structuring interactions with 3-year-olds helps minimize unac- ceptable behavior. This approach involves setting clear and reasonable rules and calling attention to unacceptable behavior as soon as it occurs. Physical punishment, such as spanking, does cause a dra- matic decrease in a behavior but has serious negative effects. However, slapping a child's hand is effective when the child refuses to listen to verbal commands. Reasoning is more appropriate for older children, such as preschoolers and those older, especially when moral issues are involved. Unfortunately, rea- soning combined with scolding often takes the form of shame or criticism and children take such remarks seriously, believing that they are "bad." CN: Health promotion and maintenance; CL: Synthesize

18. A 2-year-old always puts his teddy bear at the head of his bed before he goes to sleep. The parents ask the nurse if this behavior is normal. The nurse should explain to the parents that toddlers use ritualistic patterns to: ■ 1. Establish a sense of identity. ■ 2. Establish control over adults in their environment. ■ 3. Establish sequenced patterns of learning behavior. ■ 4. Establish a sense of security.

4. Toddlers establish ritualistic patterns to feel secure, despite inconsistencies in their envi- ronment. Establishing a sense of identity is the developmental task of the adolescent. The tod- dler's developmental task is to use rituals and rou- tines to help in making autonomy easier to accom- plish. Ritualistic patterns do involve patterns of behavior but they are not utilized to develop learning behaviors. CN: Psychosocial adaptation; CL: Apply

40. A 10-year-old child proudly tells the nurse that brushing and fl ossing her teeth is her responsi- bility. The nurse interprets this statement as indicat- ing which of the following about the child? ■ 1. She is too young to be given this responsibility. ■ 2. She is most likely capable of this responsibility. ■ 3. She should have assumed this responsibility much sooner. ■ 4. She is probably just exaggerating the responsibility.

40. 2. Children are capable of mastering the skills required for fl ossing when they reach 9 years of age. At this age, many children are able to assume responsibility for personal hygiene. She is not too young to assume this responsibility and she should not have been expected to assume this responsibility much earlier. It is not likely that she is exaggerating; this is an expected behavior at this age. CN: Health promotion and maintenance; CL: Analyze

41. The mother tells the nurse that her 8-year- old child is continually telling jokes and riddles to the point of driving the other family members crazy. The nurse should explain this behavior is a sign of? ■ 1. Inadequate parental attention. ■ 2. Mastery of language ambiguities. ■ 3. Inappropriate peer infl uence. ■ 4. Excessive television watching.

41. 2. School-age children delight in riddles and jokes. Mastery of the ambiguities of language and of sentence structure allows the school-age child to manipulate words, and telling riddles and jokes is a way of practicing this skill. Children who suf- fer from inadequate attention from parents tend to demonstrate abnormal behavior. Peer infl uence is less important to school-age children, and while the child may learn the joke from a friend, he is telling the joke to master language. Watching television does not infl uence the extent of joke telling. CN: Health promotion and maintenance; CL: Analyze

42. The mother asks the nurse about her 9-year- old child's apparent need for between-meal snacks, especially after school. When developing a sound nutritional plan for the child with the mother, the nurse should advise the mother: ■ 1. The child does not need to eat between-meal snacks. ■ 2. The child should eat the snacks the mother thinks are appropriate. ■ 3. The child should help with preparing his or her own snacks. ■ 4. The child will instinctively select nutritional snacks.

42. 3. Snacks are necessary for school-age chil- dren because of their high energy level. School-age children are in a stage of cognitive development in which they can learn to categorize or classify and can also learn cause and effect. By preparing their own snacks, children can learn the basics of nutrition (such as what carbohydrates are and what happens when they are eaten). The mother and child should make the decision about appropriate foods together. School-age children learn to make decisions based on information, not instinct. Some knowledge of nutrition is needed to make appropri- ate choices. CN: Health promotion and maintenance; CL: Synthesize

43. A nurse compares a child's height and weight with standard growth charts and fi nds the child to be in the 50th percentile for height and in the 45th percentile for weight. The nurse interprets these fi ndings as indicating that the child is: ■ 1. Average height and weight. ■ 2. Overweight for height. ■ 3. Underweight for height. ■ 4. Abnormal in height.

43. 1. The values of height and weight percen- tiles are usually similar for an individual child. Measurements between the 5th and 95th percentiles are considered normal. Marked discrepancies iden- tify overweight or underweight children. CN: Health promotion and maintenance; CL: Analyze

44. The nurse is assessing an 11-year-old female, using the Tanner Staging of Puberty. Which of the following indicates preadolescent development of the breasts? *Pic

44. 3. This fi gure indicates elevation of the papilla, without breast buds, considered Stage 1 and typical of a preadolescent. Figure 1 shows stage 2, breast bud enlargement; there is elevation of the breast and the diameter of the areola has increased. Figure 2 shows stage 3, enlargement of the breast and areola. Figure 4 shows stage 4, in which there is projection of areola and papilla to form a secondary mound above the level of the breast. CN: Physiological adaptation; CL: Analyze

45. The parents of a 12-year-old girl ask why their non-sexually active daughter should receive the human papillomavirus (HPV) vaccine. The nurse should tell the parents: ■ 1. "The vaccine is most effective against cervi- cal cancer if given before becoming sexually active." ■ 2. "Parents are never sure when their child might become sexually active." ■ 3. "HPV is most common is teens and women in their late twenties." ■ 4. "If your daughter is sexually assaulted, she may be exposed to HPV."

45. 1. Vaccines are preventative in nature and ideally given before exposure. Focusing on the benefi ts of cancer prevention is most appropriate, as opposed to discussing with parents the poten- tial that their child may become sexually active without their knowledge. It is true HPV is most common in adolescents and women in their late twenties, but parents still may not perceive that their child is at risk. Discussing the possibility of exposure through assault raises fears and does not focus on prevention. CN: Health promotion and maintenance; CL: Apply

47. Initiation of which of the following immu- nizations is recommended prior to the adolescent entering college? ■ 1. Diphtheria, tetanus, and acellular pertussis (DTaP). ■ 2. Varicella. ■ 3. Meningococcal. ■ 4. Pneumococcal conjugate vaccine (PCV).

47. 3. Meningococcal vaccine should be admin- istered before the adolescent enters college because outbreaks of this type of meningitis are likely when people live in close association, such as in college dorms. DTaP, varicella, and PCV are given as boost- ers or initial doses before the child enters preschool or kindergarten. CN: Health promotion and maintenance; CL: Apply

48. The school nurse develops a plan with an adolescent to provide relief of dysmenorrhea to aid in her development of which of the following? ■ 1. Positive peer relations. ■ 2. Positive self-identity. ■ 3. A sense of autonomy. ■ 4. A sense of independence.

48. 2. Relieving dysmenorrhea in adolescence is crucial for the female's development of positive self- identity, of which positive body image and sexual identity are important components. Menstruation should not be viewed as painful and debilitating. Positive peer relations and a sense of independence would develop with a positive self-identity. Sense of autonomy, according to Erikson, is the developmen- tal task of toddlers that, if successfully mastered, leads to a sense of self-control. CN: Physiological adaptation; CL: Apply

49. An adolescent tells the school nurse that she would like to use tampons during her period. The nurse should fi rst: ■ 1. Assess her usual menstrual fl ow pattern. ■ 2. Determine whether she is sexually active. ■ 3. Provide information about preventing toxic shock syndrome. ■ 4. Refer her to a specialist in adolescent gynecology.

49. 3. The nurse should provide the adoles- cent with information about toxic shock syndrome because of the identifi ed relationship between tam- pon use and the syndrome's development. Addition- ally, about 95% of cases of toxic shock syndrome occur during menses. Most adolescent females can use tampons safely if they change them frequently. Using tampons is not related to menstrual fl ow or sexual activity. There is no need to refer the girl to a gynecologist; a nurse can provide health teaching about tampon use. CN: Reduction of risk potential; CL: Synthesize

62. After teaching a group of parents about tem- per tantrums, the nurse knows the teaching has been effective when one of the parents states which of the following? ■ 1. "I will ignore the temper tantrum." ■ 2. "I should pick up the child during the tantrum." ■ 3. "I'll talk to my daughter during the tantrum." ■ 4. "I should put my child in time out."

62. 1. Children who have temper tantrums should be ignored as long as they are safe. They should not receive either positive or negative reinforcement to avoid perpetuating the behavior. Temper tantrums are a toddler's way of achieving independence.

63. The nurse discusses the eating habits of school-age children with their parents, explaining that these habits are most infl uenced by: ■ 1. Food preferences of their peers. ■ 2. Smell and appearance of foods offered. ■ 3. Examples provided by parents at mealtimes. ■ 4. Parental encouragement to eat nutritious foods.

63. 3. Although children may be infl uenced by their peers and smell and appearance of foods may be important, children are most likely to be infl uenced by the example and atmosphere pro- vided by their parents. Coaxing and badgering a child to eat most likely will aggravate poor eating habits. CN: Health promotion and maintenance; CL: Apply