part 4

60) A nurse is teaching the parents of a toddler who has cognitive impairment about toilet training Which of the following instructions should the nurse include in the teaching? a) "Scold your child when they have a toileting accident." b) "Award your child with a sticker when they sit on the potty chair." c) "Play your child's favorite song while teaching them to use the potty chair" d) Teach multiple steps of the skill at the same time"

b) "Award your child with a sticker when they sit on the potty chair."

6) A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching?

b) "Brush the child's teeth after giving the medication."

35) A nurse is planning n educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include

b) "Choose a waterproof sunscreen with a minimum SPF of 15."

37) A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthritis. Which if the following instructions should the nurse include in the teaching?

b) "Encourage the child to perform independent self-care."

33) A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching

b) "I should wear sandals as much as possible."

12) A nurse in an emergency department is caring for a school-age child who has sustained a minor superficial burn from fireworks on their forearm. Which of the following actions should the nurse take? a) Administer the tetanus toxoid vaccine if more than 1 year since the prior dose. b) Apply an antimicrobial ointment to the affected area. c) Leave the burn area open to air. d) Place an ice pack on the affected area.

b) Apply an antimicrobial ointment to the affected area.

57) A nurse is caring for a toddler who has acute otitis media and a temperature of 40 C (104 F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature? a) Apply a cooling blanket to the toddler. b) Dress the toddler in minimal clothing. c) Give the toddler a tepid bath d) Administer diphenhydramine to the toddler.

b) Dress the toddler in minimal clothing.

24) A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider?

b) Presence of strabismus

55) A nurse is caring for a 10-year-old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus?

b) Sodium 155 mEq/L

5) A nurse is admitting an infant who has intussusception. Which of the following findings should the nurse expect? (Select all that apply.) a) Steatorrhea b) Vomiting c) Lethargy d) Constipation e) Weight gain

b) Vomiting c) Lethargy

8. A nurse is performing a physical assessment on a 6-month-old infant. Which of the following reflexes should the nurse expect to find?

b. Babinski

1. A nurse in the emergency department is caring for a 2-year-old child who was found by his parents crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse? a. Remove the child's contaminated clothing b. Check the child's respiratory status. e. Administer an antidote to the child d. Establish IV access for the child.

b. Check the child's respiratory status.

10. A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in temporary loss of vision. Which of the following interventions should the nurse include in the plan of care?

b. Explain sounds the child is hearing.

34. A nurse is preparing to administer a liquid medication to an infant. Which of the following actions should the nurse take?

b. Give the medication at the side of the infant's mouth.

33. A nurse is assessing a 9-month-old infant during a well-child visit. Which of the following findings indicates that the infant has a developmental delay?

b. Inability to vocalize vowel sounds

5. A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should inform the client that he should receive which of the following immunizations prior to moving into a campus dormitory?

b. Meningococcal polysaccharide

11. A nurse is assessing a 3-year-old child who is 1 day postoperative following a tonsillectomy. Which of the following methods should the nurse use to determine if the child is experiencing pain?

b. Use the FACES scale.

49) A nurse is providing discharge teaching to the parent of an 18-month-old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching?

c) "I will monitor my child's number of wet diapers."

30) A nurse is providing discharge teaching to the guardian of a school-age child who has undergone a tonsillectomy. Which of the following statements by the guardian indicates an understanding the teaching?

c) "I will notify the doctor if I notice that my child is swallowing frequently."

A guardian calls the clinic nurse after his child has developed symptoms of varicella and asks when his child will no longer be contagious. Which of the following responses should the nurse make?

c) "Six days after lesions appear if they are crusted."

58) A nurse is teaching a school-age child and their parent about postoperative care following cardiac catheterization Which of the following instructions should the nurse include? a) "Stay home from school for 1 week following the procedure b) Follow a diet that is low in liber for 1 week c) "Wait 3 days before taking a tub bath." d) "Apply a pressure dressing to the site for days.

c) "Wait 3 days before taking a tub bath."

56) A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan?

d) Increase fat content in the child's diet to 40% of total calories.

38) A nurse is creating a plan of care for a child who has varicella. Which of the following interventions should the nurse include?

d) Initiate airborne precautions for the child

31) A community health nurse is assessing an 18-month-old toddler in a community day care. Which of the following findings should the nurse identify as a potential indication of physical neglect?

d) Poor personal hygiene

0) A nurse is caring for a preschooler who has congestive heart failure. The nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider? a) Furosemide b) Captopril c) Regular insulin d) Potassium chloride

d) Potassium chloride

45) A nurse is planning care for a school-age child who has tunneled central venous access device. Which of the following interventions should the nurse include in the plan?

d) Use a semipermeable transparent dressing to cover the site.

31. A nurse is teaching the parent of a 12-month-old infant about nutrition. Which of the following statements by the parent indicates a need for further teaching?

d. "My infant drinks at least 2 quarts of skim milk each day."

23. A nurse in an emergency department is caring for an 8-year old who is up-to-date with current immunization recommendations and has a deep puncture injury. Which of the following should the nurse anticipate administering?

d. Adult tetanus booster (Td)

1. A nurse is collecting date from a school-age child. The nurse should identify that which of the following findings is a manifestation of physical abuse? a) Multiple dental caries b) Malnutrition c) Recurrent urinary tract infections d. Bruises at various stages of healing

d. Bruises at various stages of healing

39. A murse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom Which of the following activities would be appropriate for the child a. Cutting figures from colored paper b Drawing stick figures using cravons Riding a tricycle d. Building towers of blocks

d. Building towers of blocks

29. A nurse is caring for an adolescent who is receiving pain medication via a PCA pump. When the nurse assess the client's pain at 0800, the client describes the pain as a 3 on a scale of 1 to 10. At 100, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hr. Which of the following actions should the nurse take?

d. Reinforce teaching with the client about how to push the button to deliver the med.

23) A nurse is preparing to administer ibuprofen 5 mg/kg every 6 hr PRN for a temperatures above 38.0 C (100.5 F) to an infant who weighs 17.6 lb. Available is ibuprofen oral suspension 100mg/5mL. How many mL should the nurse administer to the infant per dose?

i) 2 mL

A nurse is assessing a school-age child who has an acute spinal cord injury following a sports injury 1 week ago. Identify the area the nurse should tap to elicit the bicep reflect.

i) Correct answer is A

54) A nurse in an emergency department is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? (Select all that apply.)

vi) Increased temperature Xerophthalmia ix) Bradycardia x) Cervical lymphadenopathy

26. A nurse is assessing a 6-year-old child at a well-child visit. Which of the following findings requires further assessment by the nurse?

a. Presence of sparse, fine pubic hair

27. A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? (Select all that apply.)

a. The child views death as similar to sleep. b. The child is interested in what happens to his body after death. e. The child thinks death is a punishment.

16. A nurse is planning to collect a specimen from a male infant using a urine collection bag. Which of the following actions should the nurse take?

a. Wash and dry the infant's genitalia and perineum thoroughly.

52) A nurse is providing anticipatory guidance to the parent of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include?

d) Expresses likes and dislikes

26) A nurse is planning developmental activities for a newly admitted 10-year-old child who has neutropenia. Which of the following actions should the nurse plan to take?

a) Provide the child with a book about adventure

7. A nurse is teaching the parent of a toddler about home safety. Which of the following statements by the parent indicates an understanding of the teaching

a. "I lock my medications in the medicine cabinet."

37. A nurse is caring for a child who has a bacterial endocarditis. The child is scheduled to receive moderate term antibiotic therapy and requires a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include when teaching the child's parent?

a. "The PICC line will last several weeks with proper care."

3. A nurse is caring for a toddler and is preparing to administer 0.9% sodium chloride 100 mL IV to infuse over 4 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.

25 gtt

21. A nurse is providing teaching to the parents of a 4-year-old child about fine motor development. Which of the following tasks should the nurse include in the teaching as an expected finding for this age group?

a. Copies a circle

15. A nurse at a pediatric clinic is assessing a 5-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider?

a. Head lags when pulled from a lying to a sitting position

51) A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions?

d) For 24 hr following initiation of antimicrobial therapy

18. A nurse is planning care for a 10-month-old infant who has suspected failure to thrive (FTT). Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

a. Observe the parents' actions when feeding the child. b. Maintain a detailed record of food and fluid intake

7. A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of rheumatic fever. Which of the following statements by the guardian indicates an understanding of the teaching?

"My child might have a period of irregular movement of the extremities."

27) A nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take?

a) Have the adolescent sign a consent form for treatment

59) A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider? a) Nasal flaring b) WBC count 11,300-mm3 c) Diarrhea d) Abdominal distension

a) Nasal flaring

41) A nurse is caring for a school-age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema?

a) Palpate the dorsum of the child's feet

2. A nurse is teaching a parent of a 12-month old child about development during the toddler years. Which of the following statements should the nurse include? a. "Your child should be referring to himself using the appropriate pronoun by 18 months b. "A toddler's interest in looking at pictures occurs at 20 months of age." c. "A toddler should have daytime control of his bowel and bladder by 24 months of age." "Your child should be able to scribble spontaneously using a crayon at the age of 15 months."

"Your child should be able to scribble spontaneously using a crayon at the age of 15 months."

A nurse is providing discharge teaching to the parent of a school-age child who has moderate persistant asthma. Which of the following instructions should the nurse include? a) "You should give your child their salmeterol inhaler every 4 hours when they are having an acute episode of wheezing." b) "You should monitor your child's weight weekly while they are receiving inhaled corticosteroid therapy." c) "Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy." d) "When using the peak expiratory flow meter, record your child's average of three readings."

) "Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy."

29) A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation?

) An 8-month-old infant who is not yet making babbling sounds

34) A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect?

) Deep respirations of 32/min

A nurse assessing a school-age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

) Difficulty concentrating

21) A charge nurse is preparing to make a room assignment for a newly admitted school- age child. Which of the following considerations is the nurses priority?

) Disease process

28) A nurse is assessing an 8-year-old child who has early indications of shock. After establishing an airway and stabilizing the childs respirations, which of the following actions should the nurse take next

) Initiate IV access

11) A nurse is planning an educational program for school-age children and their parents about bicycle safety. Which of the following information should the nurse plan to include? a) The child should be able to stand on the balls of their feet when sitting on the bike. b) The child should ride their bike 2 feet to the side of other bike riders. c) The child should wear dark-colored clothing with a fluorescent stripe when riding at night. d) The child should ride the bike facing traffic when it is necessary to ride in the street

) The child should be able to stand on the balls of their feet when sitting on the bike.

6. A nurse is teaching the parent of an infant about food allergens. Which of the following foods should the nurse include as being the most common food allergy in children?

. Cow's milk

17. A nurse in a pediatric clinic is caring for a 3-year-old child who has a blood lead level of 3 mcg/dL. When teaching the toddler's parents about the correlation of nutrition with lead poisoning, which of the following information is appropriate for the nurse to include in the teaching?

. Ensure the child's dietary intake of calcium and iron is adequate.

24. A nurse is providing teaching about promoting sleep with the parent of a 3-year-old toddler. Which of the following information should the nurse include?

. Follow a nightly routine and established bedtime

30. A nurse is assessing a 12-month-old male infant's vital signs during a well-child visit. The infant is in the 90th percentile of height. Which of the following findings should the nurse report to the provider?

. Heart rate 175/min

4. A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take?

. Minimize physical contact with the child initially.

22. A nurse is providing teaching to the parents of a 4-year-old child about fine motor development. Which of the following tasks should the nurse include in the teaching as an expected finding for this age group?

. Plastic stethoscope

25. A nurse is planning to implement relaxation strategies with a young child prior to a painful procedure. Which of the following actions should the nurse take?

. Rock the child in long rhythmic movements

32. A nurse is assisting a provider during a femoral venipuncture on a toddler. The nurse should place the child in which of the following positions?

. Supine

19. A nurse is assessing a 7-year-old child's psychosocial development. Which of the following findings should the nurse recognize as requiring further evaluation?

. The child complains daily about going to school.

A nurse is assisting with the care of a child who is postoperative and received a transfusion during a surgical procedure. Which of the following findings indicates the child is havig a hemolytic reaction?

Chills and flank pain

3. A nurse is reinforcing teaching about sudden infant death syndrome (SIDS) with the parent of a 1-month-old infant. Which of the following statements by the parent indicates an understanding of the teaching?

I will allow my baby to have a pacifier while sleeping.

A nurse is preparing a toddler for suturing of a minor facial laceration. The nurse should place the toddler in which of the following restraints?

Mummy restraint

42) A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have hypercryanotic spell. Which of the following actions should the nurse take?

a) Place the infant in a knee-chest position.

A nurse is collecting date from a child during a well-child visit. The nurse should recognize that which of the following findings places the child at a higher risk for abuse?

The child was born at 30 weeks of gestation.

A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by parent indicates an understanding the teaching?

a) "Mononucleosis is caused by an infection with the Epstein-Barr virus."

50) A nurse is teaching the guardian of a 6-month-old infant about teething. Which of the following statements should the nurse make?

a) "Your baby might pull at their ears when they are teething."

8. A nurse is collecting data from an infant during a well-child visit. Which of the following sites should the nurse use when obtaining the infant's heart rate?

a) Apical

48) A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include?

a) Avoid palpating the abdomen when bathing the child before surgery

53) A nurse is admitting a 4-month-old infant who has heart failure. Which of the following findings is the nurses priority?

a) Episodes of vomiting

A nurse is reviewing the laboratory results of a school-age child who is 1 week postoperative following an open fracture repair. Which of the following findings should the nurse identify as an indication of a potential complication?

a) Erythrocyte sedimentation rate 18 mm/hr

22) A nurse is assessing the pain level of a 3-year-old toddler. Which of the following pain assessment scales should the nurse use?

a) FACES

13) A nurse in a providers office is caring for a school-age child who has varicella. The parents asks the nurse when their child will no longer be contagious. Which of the following responses should the nurse make? a) "When your child no longer has an increased temperature." b) "Three days after you first noticed the rash appear on your child." c) "When your child's lesions are crusted, usually 6 days after they appear." d) "Two to three weeks, when your child's lesions completely disappear."

c) "When your child's lesions are crusted, usually 6 days after they appear."

A nurse is caring for a 1-month-old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize the infants pain?

c) Allow the mother to breastfeed while the sample is being obtained.

25) A school nurse is caring for a child following tonic-clonic seizure. Which of the following actions should the nurse take first?

c) Check the child's respiratory rate

47) A nurse is caring for a newly admitted school-age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to prescribe?

c) Recombinant growth hormone

20) A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication?

c) Serum potassium level 4.1 mEq/L

44) A nurse in an emergency department is assessing a 3-month-old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration?

c) Sunken anterior fontanel

43) A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron?

c) ½ cup raisins

20. A nurse is providing education to the parent of a toddler who is about to receive her first dose of the MMR (measles, mumps and rubella) immunization. Which of the following statements by the parent indicates an understanding of the teaching?

c. "I can give my child acetaminophen for discomfort associated with the immunization."

36. A nurse in the emergency department is caring for a 12-year-old child who has ingested bleach. Which of the following statements by the nurse indicated an understanding of this ingestion?

c. "Injury by a corrosive liquid is more extensive than by a corrosive solid."

40. A nurse is assessing a 30-month-old toddler during a well-child visit. Which of the following findings requires further assessment by the nurse?

c. Birth weight is tripled

38. A nurse is providing anticipatory guidance about accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance? a. Give the toddler milk. b. Go to an emergency department. c. Call the poison control center. d. Induce vomiting Rationale: According to evidence-based practice, the nurse should instruct the parents to first call the poison control center, which will then identify what further actions the parents should take.

c. Call the poison control center

9. A nurse is preparing to administer recommended immunizations to a 2-month-old infant. Which of the following immunizations should the nurse plan to administer?

c. Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV)

12. A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings indicates the need for further assessment?

c. Legs remain crossed and extended when supine

35. A nurse on a pediatric unit is reviewing the health record of a client who is demonstrating increasing levels of stress after admission. The nurse should identify which of the following findings as a risk factor for a stress-related reaction to hospitalization?

c. Male gender

13. A nurse is observing a mother who is playing peek-a-boo with her 8-month-old child. The mother asks if this game has any developmental significance. The nurse should inform the mother that peek-a-boo helps develop which of the following concepts in the child?

c. Object permanence

28. A nurse is teaching the parent of an infant about home safety. Which of the following information should the nurse include?

c. Position the car seat so it is rear-facing. d. Secure a safety gate at the top and bottom of the stairs. e. Maintain the water heater temperature at 49° C (120° F).

14. A nurse is caring for a 15-month-old toddler who requires droplet precautions. Which of the following actions should the nurse take?

c. Wear a mask when assisting the toddler with meals.

17) A nurse is providing discharge teaching to the parents of a 3-month old infant following a cheiloplasty. Which of the following instructions should the nurse include?

d) "Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days."

40) A school nurse is providing an in-service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching?

d) "I will teach challenging academic subjects to students who have ADHD in the morning."

A nurse is reinforcing teaching with an adolescent who has an inflamed nonperforated appendix and is scheduled for a laparoscopic assisted appendectomy. Which of the following instructions should the nurse include in the teaching? a) "You can begin drinking fluids again 2 days after your surgery. by "You will need to ask for pain medication for the first 24 hours after surgery. e) You will leave your vital signs monitored every 8 hours after surgery d) "You will sit in your chair at least twice a day after surgery.

d) "You will sit in your chair at least twice a day after surgery.

A nurse is discussion organ donation with the parents of a school-age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first?

d) Explore the parents' feelings and wishes regarding organ donation.