PEX2

The nurse is measuring an abdominal girth on a child with abdominal distension. Identify the area on the child's abdomen where the tape measure should be placed for an accurate abdominal girth. 1. Just above the umbilicus, around the largest circumference of the abdomen 2. Below the umbilicus 3. Just below the sternum 4. Just above the pubic bone

Answer: 1 Explanation: 1. An abdominal girth should be taken around the largest circumference of the abdomen, in this case, just above the umbilicus. The circumference below the umbilicus or just below the sternum would not be an accurate abdominal girth. 2. An abdominal girth should be taken around the largest circumference of the abdomen, in this case, just above the umbilicus. The circumference below the umbilicus or just below the sternum would not be an accurate abdominal girth. 3. An abdominal girth should be taken around the largest circumference of the abdomen, in this case, just above the umbilicus. The circumference below the umbilicus or just below the sternum would not be an accurate abdominal girth. 4. An abdominal girth should be taken around the largest circumference of the abdomen, in this case, just above the umbilicus. The circumference below the umbilicus or just below the sternum would not be an accurate abdominal girth.

An adolescent client has a long leg cast secondary to a fractured femur. Which action by the nurse would effectively facilitate the adolescent's return to school? 1. Meet with teachers and administrators at the school to make sure entrances and classrooms are wheelchair accessible. 2. Develop an individualized health plan (IHP) that focuses on long-term needs of the adolescent. 3. Prior to the student's return to school, meet with all of the other students to emphasize the special needs of the injured teen. 4. Meet with parents of the injured student to encourage homebound schooling until a short leg cast is applied.

Answer: 1 Explanation: 1. An adolescent with a long leg cast secondary to a fractured femur will be dependent on a wheelchair for mobility. It is essential that the environment be wheelchair accessible prior to the adolescent's return to school. While an IHP might be developed, short-term needs would be the focus. It is not necessary to meet all of the students to discuss the adolescent's needs. There is no reason to encourage the adolescent to stay at home for schooling if he is ready to return. 2. An adolescent with a long leg cast secondary to a fractured femur will be dependent on a wheelchair for mobility. It is essential that the environment be wheelchair accessible prior to the adolescent's return to school. While an IHP might be developed, short-term needs would be the focus. It is not necessary to meet all of the students to discuss the adolescent's needs. There is no reason to encourage the adolescent to stay at home for schooling if he is ready to return. 3. An adolescent with a long leg cast secondary to a fractured femur will be dependent on a wheelchair for mobility. It is essential that the environment be wheelchair accessible prior to the adolescent's return to school. While an IHP might be developed, short-term needs would be the focus. It is not necessary to meet all of the students to discuss the adolescent's needs. There is no reason to encourage the adolescent to stay at home for schooling if he is ready to return. 4. An adolescent with a long leg cast secondary to a fractured femur will be dependent on a wheelchair for mobility. It is essential that the environment be wheelchair accessible prior to the adolescent's return to school. While an IHP might be developed, short-term needs would be the focus. It is not necessary to meet all of the students to discuss the adolescent's needs. There is no reason to encourage the adolescent to stay at home for schooling if he is ready to return.

A mother of a 2-year-old child becomes very anxious when the child has a temper tantrum in the medical office. Which response by the nurse is the most appropriate? 1. "What do you usually do or say during a temper tantrum?" 2. "Let's ignore this behavior; it will stop sooner or later." 3. "Pick up and cuddle your child now, please." 4. "This is definitely a temper tantrum; I know exactly what you are feeling right now."

Answer: 1 Explanation: 1. Asking the mother to describe her usual behavior via an open-ended question will encourage the mother to talk about home management and will lead the nurse to assist the mother in making a plan of care for temper tantrums. Ignoring the behavior, instructing the mother to cuddle the child, or sympathizing with the mother ("I know exactly what you are feeling") are not effective ways to problem solve for temper tantrums. 2. Asking the mother to describe her usual behavior via an open-ended question will encourage the mother to talk about home management and will lead the nurse to assist the mother in making a plan of care for temper tantrums. Ignoring the behavior, instructing the mother to cuddle the child, or sympathizing with the mother ("I know exactly what you are feeling") are not effective ways to problem solve for temper tantrums. 3. Asking the mother to describe her usual behavior via an open-ended question will encourage the mother to talk about home management and will lead the nurse to assist the mother in making a plan of care for temper tantrums. Ignoring the behavior, instructing the mother to cuddle the child, or sympathizing with the mother ("I know exactly what you are feeling") are not effective ways to problem solve for temper tantrums. 4. Asking the mother to describe her usual behavior via an open-ended question will encourage the mother to talk about home management and will lead the nurse to assist the mother in making a plan of care for temper tantrums. Ignoring the behavior, instructing the mother to cuddle the child, or sympathizing with the mother ("I know exactly what you are feeling") are not effective ways to problem solve for temper tantrums.

When examining a 7-year-old, which action by the nurse would be most appropriate? 1. Allow the child to participate in the exam. 2. Ask the parent what kind of food the child likes to eat. 3. Ask the child whether he plays outside for at least 30 minutes a day. 4. Allow the child to decide whether he is ready for his next immunization.

Answer: 1 Explanation: 1. At this age, children have logical thought, and are learning about their bodies. Participating in the physical exam is appropriate for this age. The child can answer the question about food intake himself. Asking whether he plays outside for 30 minutes is fine, but children at this age need at least 60 minutes of activity, so the question will not gather appropriate information. It is not the child's decision whether he is ready for immunization, so do not ask this question. 2. At this age, children have logical thought, and are learning about their bodies. Participating in the physical exam is appropriate for this age. The child can answer the question about food intake himself. Asking whether he plays outside for 30 minutes is fine, but children at this age need at least 60 minutes of activity, so the question will not gather appropriate information. It is not the child's decision whether he is ready for immunization, so do not ask this question. 3. At this age, children have logical thought, and are learning about their bodies. Participating in the physical exam is appropriate for this age. The child can answer the question about food intake himself. Asking whether he plays outside for 30 minutes is fine, but children at this age need at least 60 minutes of activity, so the question will not gather appropriate information. It is not the child's decision whether he is ready for immunization, so do not ask this question. 4. At this age, children have logical thought, and are learning about their bodies. Participating in the physical exam is appropriate for this age. The child can answer the question about food intake himself. Asking whether he plays outside for 30 minutes is fine, but children at this age need at least 60 minutes of activity, so the question will not gather appropriate information. It is not the child's decision whether he is ready for immunization, so do not ask this question.

Which of these strategies would be most effective for a teachable moment during a routine office visit for the parents of a 6-year-old child? 1. Select one topic and present a brief amount of information on the topic. 2. Review all 6-year-old anticipatory guidelines with the parents. 3. Review 7-year-old anticipatory guidelines with the parents. 4. Discuss signs of malnutrition with the parents.

Answer: 1 Explanation: 1. Children and families often learn best when presented with small bits of information. Do not give too much information to the parents at one time; therefore, selecting one topic and presenting information is appropriate. It is not appropriate to discuss malnutrition with these parents, since nothing in the stem of the question indicates that the child has a problem with nutrition. 2. Children and families often learn best when presented with small bits of information. Do not give too much information to the parents at one time; therefore, selecting one topic and presenting information is appropriate. It is not appropriate to discuss malnutrition with these parents, since nothing in the stem of the question indicates that the child has a problem with nutrition. 3. Children and families often learn best when presented with small bits of information. Do not give too much information to the parents at one time; therefore, selecting one topic and presenting information is appropriate. It is not appropriate to discuss malnutrition with these parents, since nothing in the stem of the question indicates that the child has a problem with nutrition. 4. Children and families often learn best when presented with small bits of information. Do not give too much information to the parents at one time; therefore, selecting one topic and presenting information is appropriate. It is not appropriate to discuss malnutrition with these parents, since nothing in the stem of the question indicates that the child has a problem with nutrition.

The nurse working in the clinic includes an adolescent history in every client intake interview. Which issue should the nurse address when the parents are not present? 1. Possible domestic violence 2. Teen job responsibilities 3. Activities that are done as a family 4. The adolescent's role in the family

Answer: 1 Explanation: 1. If domestic violence is suspected, it would only be appropriate to ask these questions when the teenager is alone with the nurse or healthcare provider. 2. If domestic violence is suspected, it would only be appropriate to ask these questions when the teenager is alone with the nurse or healthcare provider. 3. If domestic violence is suspected, it would only be appropriate to ask these questions when the teenager is alone with the nurse or healthcare provider. 4. If domestic violence is suspected, it would only be appropriate to ask these questions when the teenager is alone with the nurse or healthcare provider.

The nurse is teaching a new mother developmental expectations. Which activity should the nurse expect a newborn to do within the first month of life? 1. Bring hands to eyes and mouth 2. Push up with hands, moving chest up 3. Keep hands in a relaxed position 4. Roll over from back to abdomen

Answer: 1 Explanation: 1. Newborns at one month of age can bring hands to their eyes and mouths, move their heads from side to side when lying on their abdomens, and attempt to lift their heads only when prone. Newborn hands are kept in tight fist position, and the newborn cannot roll over until 4 months of age. 2. Newborns at one month of age can bring hands to their eyes and mouths, move their heads from side to side when lying on their abdomens, and attempt to lift their heads only when prone. Newborn hands are kept in tight fist position, and the newborn cannot roll over until 4 months of age. 3. Newborns at one month of age can bring hands to their eyes and mouths, move their heads from side to side when lying on their abdomens, and attempt to lift their heads only when prone. Newborn hands are kept in tight fist position, and the newborn cannot roll over until 4 months of age. 4. Newborns at one month of age can bring hands to their eyes and mouths, move their heads from side to side when lying on their abdomens, and attempt to lift their heads only when prone. Newborn hands are kept in tight fist position, and the newborn cannot roll over until 4 months of age.

A mother who is bottle feeding her newborn asks to be discharged 24 hours post-delivery, because she also has twin 2-year-old children at home. When should the nurse schedule the first office visit for this newborn? 1. Within 48 hours of discharge 2. Within 1 week of discharge 3. Within 2 weeks of discharge 4. When the infant is 1-month old

Answer: 1 Explanation: 1. Newborns discharged before 48 hours old should be seen within 48 hours of discharge. Waiting 1 or 2 weeks after discharge of a 24-hour-old infant increases the chance that several common newborn conditions can go undiagnosed (e.g., jaundice, failure to gain weight). Waiting one month is too long for any infant who is discharged at 24 hours old. 2. Newborns discharged before 48 hours old should be seen within 48 hours of discharge. Waiting 1 or 2 weeks after discharge of a 24-hour-old infant increases the chance that several common newborn conditions can go undiagnosed (e.g., jaundice, failure to gain weight). Waiting one month is too long for any infant who is discharged at 24 hours old. 3. Newborns discharged before 48 hours old should be seen within 48 hours of discharge. Waiting 1 or 2 weeks after discharge of a 24-hour-old infant increases the chance that several common newborn conditions can go undiagnosed (e.g., jaundice, failure to gain weight). Waiting one month is too long for any infant who is discharged at 24 hours old. 4. Newborns discharged before 48 hours old should be seen within 48 hours of discharge. Waiting 1 or 2 weeks after discharge of a 24-hour-old infant increases the chance that several common newborn conditions can go undiagnosed (e.g., jaundice, failure to gain weight). Waiting one month is too long for any infant who is discharged at 24 hours old.

A child who is dependent on a ventilator is being discharged from the hospital. Prior to discharge, the home-health nurse discusses development of an emergency plan of care with the family. Which is the most essential part of the plan? 1. Acquisition of a backup generator 2. Designation of an emergency shelter site 3. Provision for an alternate heating source if power is lost 4. Notifying the power company that the child is on life support

Answer: 1 Explanation: 1. Prior to discharge to home, it is essential that the family acquire a generator so that the child's life support will continue to function effectively should power be lost. While all other actions are very important, it is most essential that the ventilator has power to continue to function at all times. 2. Prior to discharge to home, it is essential that the family acquire a generator so that the child's life support will continue to function effectively should power be lost. While all other actions are very important, it is most essential that the ventilator has power to continue to function at all times. 3. Prior to discharge to home, it is essential that the family acquire a generator so that the child's life support will continue to function effectively should power be lost. While all other actions are very important, it is most essential that the ventilator has power to continue to function at all times. 4. Prior to discharge to home, it is essential that the family acquire a generator so that the child's life support will continue to function effectively should power be lost. While all other actions are very important, it is most essential that the ventilator has power to continue to function at all times.

A parent says to a nurse, "How do you know when my child needs these screening tests the doctor just mentioned?" Which response by the nurse is the most appropriate? 1. "Screening tests are administered at the ages when a child is most likely to develop a condition." 2. "Screening tests are done in the newborn nursery and from these results, additional screening tests are ordered throughout the first two years of life." 3. "Screening tests are most often done when the doctor suspects something is wrong with the child." 4. "Screening tests are done at each office visit."

Answer: 1 Explanation: 1. Screening tests administered at ages when a child is most likely to develop a condition provide a good basis for health promotion. The remaining answers all provide incorrect information to the parent. Abnormal newborn screening tests require immediate follow-up. Screening tests are done to detect the possibility of problems, not when a problem is suspected; at that point, a child needs diagnostic testing. Screening tests are not done at each office visit. 2. Screening tests administered at ages when a child is most likely to develop a condition provide a good basis for health promotion. The remaining answers all provide incorrect information to the parent. Abnormal newborn screening tests require immediate follow-up. Screening tests are done to detect the possibility of problems, not when a problem is suspected; at that point, a child needs diagnostic testing. Screening tests are not done at each office visit. 3. Screening tests administered at ages when a child is most likely to develop a condition provide a good basis for health promotion. The remaining answers all provide incorrect information to the parent. Abnormal newborn screening tests require immediate follow-up. Screening tests are done to detect the possibility of problems, not when a problem is suspected; at that point, a child needs diagnostic testing. Screening tests are not done at each office visit. 4. Screening tests administered at ages when a child is most likely to develop a condition provide a good basis for health promotion. The remaining answers all provide incorrect information to the parent. Abnormal newborn screening tests require immediate follow-up. Screening tests are done to detect the possibility of problems, not when a problem is suspected; at that point, a child needs diagnostic testing. Screening tests are not done at each office visit.

Which of these measures used by a nurse will help relieve parental anxiety related to the changing appetite in the toddler who is gaining weight along the 50th percentile? 1. Discussing the growth of the toddler as compared to the growth chart 2. Suggesting ways to have the toddler eat higher calorie foods 3. Instructing the mother to feed the toddler alone without any distractions such as TV or music 4. Teaching the mother to avoid disciplining the toddler within one-half hour of eating

Answer: 1 Explanation: 1. Showing the parents the growth pattern of the child as compared to the normal growth chart will help relieve parental anxiety related to eating less food during the toddler years. Toddlers who are at the 50th percentile do not need additional high-calorie foods. Toddlers eat to their personal needs and there is no reason to restrict watching TV or other environmental stimuli during meals. There is no reason to relate timing of discipline and eating. 2. Showing the parents the growth pattern of the child as compared to the normal growth chart will help relieve parental anxiety related to eating less food during the toddler years. Toddlers who are at the 50th percentile do not need additional high-calorie foods. Toddlers eat to their personal needs and there is no reason to restrict watching TV or other environmental stimuli during meals. There is no reason to relate timing of discipline and eating. 3. Showing the parents the growth pattern of the child as compared to the normal growth chart will help relieve parental anxiety related to eating less food during the toddler years. Toddlers who are at the 50th percentile do not need additional high-calorie foods. Toddlers eat to their personal needs and there is no reason to restrict watching TV or other environmental stimuli during meals. There is no reason to relate timing of discipline and eating. 4. Showing the parents the growth pattern of the child as compared to the normal growth chart will help relieve parental anxiety related to eating less food during the toddler years. Toddlers who are at the 50th percentile do not need additional high-calorie foods. Toddlers eat to their personal needs and there is no reason to restrict watching TV or other environmental stimuli during meals. There is no reason to relate timing of discipline and eating.

While inspecting a 5-year-old child's ears, the nurse notes that the right pinna protrudes outward and that there is a mass behind the right ear. In light of these findings, which vital-sign parameter would the nurse assess on priority? 1. Temperature 2. Heart rate 3. Respirations 4. Blood pressure

Answer: 1 Explanation: 1. Swelling behind an ear could indicate mastoiditis, and the presence of a fever would indicate a higher index of suspicion for this. There could also be changes in other vital-sign parameters, but they would not be specific for the presence of infection. 2. Swelling behind an ear could indicate mastoiditis, and the presence of a fever would indicate a higher index of suspicion for this. There could also be changes in other vital-sign parameters, but they would not be specific for the presence of infection. 3. Swelling behind an ear could indicate mastoiditis, and the presence of a fever would indicate a higher index of suspicion for this. There could also be changes in other vital-sign parameters, but they would not be specific for the presence of infection. 4. Swelling behind an ear could indicate mastoiditis, and the presence of a fever would indicate a higher index of suspicion for this. There could also be changes in other vital-sign parameters, but they would not be specific for the presence of infection.

An adolescent reports the following: "I get up at 6 a.m., I attend early-morning band classes three times each week, I play sports for 2 hours each day after school, and homework takes me 3 hours each night. I always feel tired." Which question by the nurse is most appropriate based on this information? 1. "How many hours of sleep do you get each night?" 2. "Do you consume foods high in iron?" 3. "Do you think you are doing too much?" 4. "Have you considered talking with your teachers about decreasing your homework, since you have so many extracurricular activities?"

Answer: 1 Explanation: 1. The data in this scenario reveals very little time for sleep; therefore, the history should focus on sleep patterns. 2. The data in this scenario reveals very little time for sleep; therefore, the history should focus on sleep patterns. 3. The data in this scenario reveals very little time for sleep; therefore, the history should focus on sleep patterns. 4. The data in this scenario reveals very little time for sleep; therefore, the history should focus on sleep patterns

An adolescent is accompanied by the mother for an annual physical examination. The nurse is aware of privacy issues related to the adolescent. While the mother is in the room, the nurse should avoid which questions? Select all that apply. 1. Sexual activity 2. Cigarette smoking 3. School performance 4. Use of alcohol 5. Car seatbelt use

Answer: 1, 2, 4 Explanation: 1. The nurse must maintain the nurse—client relationship, which is between the nurse and the adolescent, and the nurse must maintain confidentiality. Therefore, the nurse cannot ask any personal questions while the mother is in the room, such as those related to sexual activity, drug and alcohol use, and smoking cigarettes. The nurse can ask general questions about seatbelt use and academic performance without breaching confidentiality. 2. The nurse must maintain the nurse—client relationship, which is between the nurse and the adolescent, and the nurse must maintain confidentiality. Therefore, the nurse cannot ask any personal questions while the mother is in the room, such as those related to sexual activity, drug and alcohol use, and smoking cigarettes. The nurse can ask general questions about seatbelt use and academic performance without breaching confidentiality. 3. The nurse must maintain the nurse—client relationship, which is between the nurse and the adolescent, and the nurse must maintain confidentiality. Therefore, the nurse cannot ask any personal questions while the mother is in the room, such as those related to sexual activity, drug and alcohol use, and smoking cigarettes. The nurse can ask general questions about seatbelt use and academic performance without breaching confidentiality. 4. The nurse must maintain the nurse—client relationship, which is between the nurse and the adolescent, and the nurse must maintain confidentiality. Therefore, the nurse cannot ask any personal questions while the mother is in the room, such as those related to sexual activity, drug and alcohol use, and smoking cigarettes. The nurse can ask general questions about seatbelt use and academic performance without breaching confidentiality. 5. The nurse must maintain the nurse—client relationship, which is between the nurse and the adolescent, and the nurse must maintain confidentiality. Therefore, the nurse cannot ask any personal questions while the mother is in the room, such as those related to sexual activity, drug and alcohol use, and smoking cigarettes. The nurse can ask general questions about seatbelt use and academic performance without breaching confidentiality.

Which would be an acceptable community-health diagnosis? 1. Risk for Injury Related to Lack of Safe Bicycle Paths in High-Traffic Areas 2. Ineffective Family Coping Related to Lack of Time Together 3. Alterations in Nutrition Related to Use of Fast Food Restaurants 4. Ineffective Communication Related to Lack of Community Newsletter

Answer: 1 Explanation: 1. The lack of safe bicycle paths in high-traffic areas is a community hazard affecting a large population of people. Ineffective family coping is appropriate for one family; alterations in nutrition and ineffective communication are not appropriate for the community as a whole. 2. The lack of safe bicycle paths in high-traffic areas is a community hazard affecting a large population of people. Ineffective family coping is appropriate for one family; alterations in nutrition and ineffective communication are not appropriate for the community as a whole. 3. The lack of safe bicycle paths in high-traffic areas is a community hazard affecting a large population of people. Ineffective family coping is appropriate for one family; alterations in nutrition and ineffective communication are not appropriate for the community as a whole. 4. The lack of safe bicycle paths in high-traffic areas is a community hazard affecting a large population of people. Ineffective family coping is appropriate for one family; alterations in nutrition and ineffective communication are not appropriate for the community as a whole.

A nurse is assessing an 11-month-old infant and notes that the infant's height and weight are at the 5th percentile on the growth chart. Family history reveals that the infant's two siblings are at the 50th percentile for height and at the 75th percentile for weight. Psychosocial history reveals that the parents are separated and are planning to divorce. Which of these nursing diagnoses takes priority? 1. Alteration in Growth Pattern Related to Parental Anxiety 2. Alteration in Growth Pattern Secondary to Familial Short Stature 3. Nutritional Intake: Excessive Secondary to Maternal Feeding Patterns 4. At Risk for Constitutional Growth Delay Related to Decreased Appetite

Answer: 1 Explanation: 1. The scenario reveals parental anxiety due to marital problems. The most appropriate nursing diagnosis is alteration in growth patterns related to parental anxiety. There is no data that indicates familial short stature. Since height and weight are at the 5th percentile, there is no indication of increased nutritional intake. This infant is not at risk for constitutional growth delay. 2. The scenario reveals parental anxiety due to marital problems. The most appropriate nursing diagnosis is alteration in growth patterns related to parental anxiety. There is no data that indicates familial short stature. Since height and weight are at the 5th percentile, there is no indication of increased nutritional intake. This infant is not at risk for constitutional growth delay. 3. The scenario reveals parental anxiety due to marital problems. The most appropriate nursing diagnosis is alteration in growth patterns related to parental anxiety. There is no data that indicates familial short stature. Since height and weight are at the 5th percentile, there is no indication of increased nutritional intake. This infant is not at risk for constitutional growth delay. 4. The scenario reveals parental anxiety due to marital problems. The most appropriate nursing diagnosis is alteration in growth patterns related to parental anxiety. There is no data that indicates familial short stature. Since height and weight are at the 5th percentile, there is no indication of increased nutritional intake. This infant is not at risk for constitutional growth delay.

A parent questions how her toddler plays with other toddlers. Which response by the nurse displays the best description of the differences in play between the toddler and the preschool-age child? 1. Toddlers play side by side, while preschool-age children play cooperatively. 2. Toddlers play house and imitate adult roles, while preschool-age children become the Mom or Dad while playing house. 3. Toddlers play cooperatively, while preschool-age children play interactive games. 4. There are no differences between toddlers and preschool-age children because both groups play cooperatively.

Answer: 1 Explanation: 1. Toddlers will play side by side with another child, but they do not interact with the child during play. Preschoolers play cooperatively with other children. 2. Toddlers will play side by side with another child, but they do not interact with the child during play. Preschoolers play cooperatively with other children. 3. Toddlers will play side by side with another child, but they do not interact with the child during play. Preschoolers play cooperatively with other children. 4. Toddlers will play side by side with another child, but they do not interact with the child during play. Preschoolers play cooperatively with other children.

The clinic administrator has asked each nurse to classify the nursing activities as a beginning step of clinic reorganization. Which of these strategies can be identified as health promotion and health maintenance? Select all that apply. 1. Administration of the flu vaccine for infants from 6 months to 23 months old 2. Daily feeding schedules for infants 3. Instruction to adolescents on how to use dental floss 4. Treatment for a child with a diagnosis of acute otitis media

Answer: 1, 2, 3 Explanation: 1. Administering flu vaccines, discussion of feeding schedules, and instructions to adolescents are all health-promotion and health-maintenance topics. Treatment of an acute ear infection (otitis media) would not be a topic for health promotion and health maintenance since it is an acute illness. 2. Administering flu vaccines, discussion of feeding schedules, and instructions to adolescents are all health-promotion and health-maintenance topics. Treatment of an acute ear infection (otitis media) would not be a topic for health promotion and health maintenance since it is an acute illness. 3. Administering flu vaccines, discussion of feeding schedules, and instructions to adolescents are all health-promotion and health-maintenance topics. Treatment of an acute ear infection (otitis media) would not be a topic for health promotion and health maintenance since it is an acute illness. 4. Administering flu vaccines, discussion of feeding schedules, and instructions to adolescents are all health-promotion and health-maintenance topics. Treatment of an acute ear infection (otitis media) would not be a topic for health promotion and health maintenance since it is an acute illness.

The nurse educator is teaching a group of students about the key concepts of a medical home during the developmental years of the pediatric client. Which items should the educator include in the teaching session? Select all that apply. 1. Financial accessibility 2. Consistent, ongoing care 3. Coordination of care 4. No individualization of care 5. A paternalistic view of care

Answer: 1, 2, 3 Explanation: 1. All children need a medical home, where accessible, continuous, and coordinated health supervision is provided during the developmental years. Accessibility refers to both financial and geographic access; continuous indicates that the care is ongoing with consistent care providers; coordination refers to the need for communication among health professionals to provide for the needs of the child. Care is individualized and is not paternalistic. 2. All children need a medical home, where accessible, continuous, and coordinated health supervision is provided during the developmental years. Accessibility refers to both financial and geographic access; continuous indicates that the care is ongoing with consistent care providers; coordination refers to the need for communication among health professionals to provide for the needs of the child. Care is individualized and is not paternalistic. 3. All children need a medical home, where accessible, continuous, and coordinated health supervision is provided during the developmental years. Accessibility refers to both financial and geographic access; continuous indicates that the care is ongoing with consistent care providers; coordination refers to the need for communication among health professionals to provide for the needs of the child. Care is individualized and is not paternalistic. 4. All children need a medical home, where accessible, continuous, and coordinated health supervision is provided during the developmental years. Accessibility refers to both financial and geographic access; continuous indicates that the care is ongoing with consistent care providers; coordination refers to the need for communication among health professionals to provide for the needs of the child. Care is individualized and is not paternalistic. 5. All children need a medical home, where accessible, continuous, and coordinated health supervision is provided during the developmental years. Accessibility refers to both financial and geographic access; continuous indicates that the care is ongoing with consistent care providers; coordination refers to the need for communication among health professionals to provide for the needs of the child. Care is individualized and is not paternalistic.

The school health nurse recognizes that children who display certain characteristics are at risk for poor school performance. The nurse will, therefore, observe each school-age child for which characteristics? Select all that apply. 1. Decreased ability to perform visual tracking. 2. Decreased auditory stimulation. 3. Decreased muscle tone. 4. Multiple dental caries. 5. Chronic tonsillitis.

Answer: 1, 2, 3 Explanation: 1. Children with vision, hearing, and muscle tone problems are at risk for poor school performance, since most school activities involve listening, seeing, and kinetic activity. School performance most likely would not be affected by dental caries and chronic tonsillitis. 2. Children with vision, hearing, and muscle tone problems are at risk for poor school performance, since most school activities involve listening, seeing, and kinetic activity. School performance most likely would not be affected by dental caries and chronic tonsillitis. 3. Children with vision, hearing, and muscle tone problems are at risk for poor school performance, since most school activities involve listening, seeing, and kinetic activity. School performance most likely would not be affected by dental caries and chronic tonsillitis. 4. Children with vision, hearing, and muscle tone problems are at risk for poor school performance, since most school activities involve listening, seeing, and kinetic activity. School performance most likely would not be affected by dental caries and chronic tonsillitis. 5. Children with vision, hearing, and muscle tone problems are at risk for poor school performance, since most school activities involve listening, seeing, and kinetic activity. School performance most likely would not be affected by dental caries and chronic tonsillitis.

The nurse is planning care for a preschool-age child and family. In order to assess the family, what should the nurse plan to do during each health supervision visit? Select all that apply. 1. Discuss the child's developmental status 2. Observe interactions among the family members 3. Discuss concerns with the parents 4. Administer age appropriate vaccinations 5. Record height and weight

Answer: 1, 2, 3 Explanation: 1. In order to assess the child and family, the nurse would plan to discuss the child's developmental status, observe interactions among the family members, and discuss any concerns with the parents. Administering age appropriate vaccinations and recording height and weight are appropriate interventions, but are not included during the family assessment process. 2. In order to assess the child and family, the nurse would plan to discuss the child's developmental status, observe interactions among the family members, and discuss any concerns with the parents. Administering age appropriate vaccinations and recording height and weight are appropriate interventions, but are not included during the family assessment process. 3. In order to assess the child and family, the nurse would plan to discuss the child's developmental status, observe interactions among the family members, and discuss any concerns with the parents. Administering age appropriate vaccinations and recording height and weight are appropriate interventions, but are not included during the family assessment process. 4. In order to assess the child and family, the nurse would plan to discuss the child's developmental status, observe interactions among the family members, and discuss any concerns with the parents. Administering age appropriate vaccinations and recording height and weight are appropriate interventions, but are not included during the family assessment process. 5. In order to assess the child and family, the nurse would plan to discuss the child's developmental status, observe interactions among the family members, and discuss any concerns with the parents. Administering age appropriate vaccinations and recording height and weight are appropriate interventions, but are not included during the family assessment process.

The nurse is assessing an infant client during a health supervision visit. Which assessment findings are considered normal variations for this client? Select all that apply. 1. Sucking pads in the mouth 2. A rounded chest 3. Hearing breath sounds over the entire chest 4. Pubertal development 5. Knock-knees

Answer: 1, 2, 3 Explanation: 1. Normal variations for the infant client include sucking pads in the mouth, a rounded chest, and hearing breath sounds over the entire chest. Pubertal development and knock-knees are not normal variations for the infant client. 2. Normal variations for the infant client include sucking pads in the mouth, a rounded chest, and hearing breath sounds over the entire chest. Pubertal development and knock-knees are not normal variations for the infant client. 3. Normal variations for the infant client include sucking pads in the mouth, a rounded chest, and hearing breath sounds over the entire chest. Pubertal development and knock-knees are not normal variations for the infant client. 4. Normal variations for the infant client include sucking pads in the mouth, a rounded chest, and hearing breath sounds over the entire chest. Pubertal development and knock-knees are not normal variations for the infant client. 5. Normal variations for the infant client include sucking pads in the mouth, a rounded chest, and hearing breath sounds over the entire chest. Pubertal development and knock-knees are not normal variations for the infant client.

The school nurse performs screenings on all students in the middle school. In addition, the nurse will perform selected screenings on individual school-age children. When planning the screenings for the year, which screenings will the nurse include for all school-age children? Select all that apply. 1. Hearing 2. Height and weight 3. Blood-pressure measurement 4. Hepatitis B profile serology 5. Chest x-ray

Answer: 1, 2, 3 Explanation: 1. Routine screening for school-age children include hearing, checking for height and weight, and blood-pressure measurements. The hepatitis B profile is only needed once, prior to administration of hepatitis B vaccine; however, this is not a required screening for all school-age children. A chest x-ray is not a routine screening test for school-age children. 2. Routine screening for school-age children include hearing, checking for height and weight, and blood-pressure measurements. The hepatitis B profile is only needed once, prior to administration of hepatitis B vaccine; however, this is not a required screening for all school-age children. A chest x-ray is not a routine screening test for school-age children. 3. Routine screening for school-age children include hearing, checking for height and weight, and blood-pressure measurements. The hepatitis B profile is only needed once, prior to administration of hepatitis B vaccine; however, this is not a required screening for all school-age children. A chest x-ray is not a routine screening test for school-age children. 4. Routine screening for school-age children include hearing, checking for height and weight, and blood-pressure measurements. The hepatitis B profile is only needed once, prior to administration of hepatitis B vaccine; however, this is not a required screening for all school-age children. A chest x-ray is not a routine screening test for school-age children. 5. Routine screening for school-age children include hearing, checking for height and weight, and blood-pressure measurements. The hepatitis B profile is only needed once, prior to administration of hepatitis B vaccine; however, this is not a required screening for all school-age children. A chest x-ray is not a routine screening test for school-age children

A nursery nurse is planning care for the newborns currently in the newborn nursery. Which activities does the nurse plan for the first 48 hours of life? Select all that apply. 1. Monitor feeding behaviors 2. Perform a hearing screening 3. Perform a heel stick to obtain blood for the newborn screen 4. Monitor the mother as she performs the first newborn bath to remove blood and amniotic fluids 5. Administer folic-acid injection to the infant to prevent bleeding

Answer: 1, 2, 3 Explanation: 1. The nurse should assess feeding behaviors of the infant whether the infant is breastfed or bottle-fed. A hearing screening is performed on all newborn infants prior to discharge. The newborn screen is performed prior to infant discharge from the newborn unit. The nurse, not the mother, performs the first bath to remove blood and amniotic fluids. Vitamin K is administered, not folic acid. 2. The nurse should assess feeding behaviors of the infant whether the infant is breastfed or bottle-fed. A hearing screening is performed on all newborn infants prior to discharge. The newborn screen is performed prior to infant discharge from the newborn unit. The nurse, not the mother, performs the first bath to remove blood and amniotic fluids. Vitamin K is administered, not folic acid. 3. The nurse should assess feeding behaviors of the infant whether the infant is breastfed or bottle-fed. A hearing screening is performed on all newborn infants prior to discharge. The newborn screen is performed prior to infant discharge from the newborn unit. The nurse, not the mother, performs the first bath to remove blood and amniotic fluids. Vitamin K is administered, not folic acid. 4. The nurse should assess feeding behaviors of the infant whether the infant is breastfed or bottle-fed. A hearing screening is performed on all newborn infants prior to discharge. The newborn screen is performed prior to infant discharge from the newborn unit. The nurse, not the mother, performs the first bath to remove blood and amniotic fluids. Vitamin K is administered, not folic acid. 5. The nurse should assess feeding behaviors of the infant whether the infant is breastfed or bottle-fed. A hearing screening is performed on all newborn infants prior to discharge. The newborn screen is performed prior to infant discharge from the newborn unit. The nurse, not the mother, performs the first bath to remove blood and amniotic fluids. Vitamin K is administered, not folic acid.

The nurse in the newborn nursery is admitting a neonate. To determine the health and development of the newborn, what will the nurse include in the assessment? Select all that apply. 1. Head circumference 2. Body length 3. Weight 4. Length of pregnancy 5. Hearing screens

Answer: 1, 2, 3, 4 Explanation: 1. The nurse should assess almost all of these parameters to determine the health of the newborn. However, hearing screens are typically done after the first 12 hours after birth and are not part of newborn assessment. 2. The nurse should assess almost all of these parameters to determine the health of the newborn. However, hearing screens are typically done after the first 12 hours after birth and are not part of newborn assessment. 3. The nurse should assess almost all of these parameters to determine the health of the newborn. However, hearing screens are typically done after the first 12 hours after birth and are not part of newborn assessment. 4. The nurse should assess almost all of these parameters to determine the health of the newborn. However, hearing screens are typically done after the first 12 hours after birth and are not part of newborn assessment. 5. The nurse should assess almost all of these parameters to determine the health of the newborn. However, hearing screens are typically done after the first 12 hours after birth and are not part of newborn assessment.

The nurse is creating a teaching care plan for the toddler and family. Which nursing diagnoses are normally used at each healthcare visit for this age group? Select all that apply. 1. Knowledge deficit related to growth patterns 2. Risk for injury related to developmental skills 3. Risk for exposure to infectious diseases related to childcare environment 4. Knowledge deficit related to toys that encourage development 5. Risk for loneliness related to lack of siblings

Answer: 1, 2, 3, 4 Explanation: 1. The toddler is assessed for height, weight, BMI, head circumference, growth and nutrition, verbal skills, gross and fine motor movement, appropriate toys for developmental age. 2. The toddler is assessed for height, weight, BMI, head circumference, growth and nutrition, verbal skills, gross and fine motor movement, appropriate toys for developmental age. 3. The toddler is assessed for height, weight, BMI, head circumference, growth and nutrition, verbal skills, gross and fine motor movement, appropriate toys for developmental age. 4. The toddler is assessed for height, weight, BMI, head circumference, growth and nutrition, verbal skills, gross and fine motor movement, appropriate toys for developmental age. 5. The toddler is assessed for height, weight, BMI, head circumference, growth and nutrition, verbal skills, gross and fine motor movement, appropriate toys for developmental age.

The nurse manager is assisting the organization to open a healthcare center. What items must the manager include in pediatric inventory? Select all that apply. 1. Preprinted drug dosage chart 2. Oxygen face masks 3. Pediatric chairs and litters 4. Length-based resuscitation tape 5. Oral and NG airways and laryngoscope blades

Answer: 1, 2, 4, 5 Explanation: 1. Essential equipment: child/neonate sized, proper weight dosage medications, smaller bags of IV fluids and special IV tubing, pediatric external defibrillator, pediatric oxygen masks/oral/NG airways and laryngoscope blades, length based resuscitation tapes and preprinted dosage chart to quickly identify equipment sizes and drug dosages by the length or weight of the child, essential emergency pediatric drugs and equipment. 2. Essential equipment: be child/neonate sized, proper weight dosage medications, smaller bags of IV fluids and special IV tubing, pediatric external defibrillator, pediatric oxygen masks/oral/NG airways and laryngoscope blades, length based resuscitation tapes and preprinted dosage chart to quickly identify equipment sizes and drug dosages by the length or weight of the child, essential emergency pediatric drugs and equipment. 3. Essential equipment: child/neonate sized, proper weight dosage medications, smaller bags of IV fluids and special IV tubing, pediatric external defibrillator, pediatric oxygen masks/oral/NG airways and laryngoscope blades, length based resuscitation tapes and preprinted dosage chart to quickly identify equipment sizes and drug dosages by the length or weight of the child, essential emergency pediatric drugs and equipment. Pediatric chairs and litters would be nice, but not essential. 4. Essential equipment: child/neonate sized, proper weight dosage medications, smaller bags of IV fluids and special IV tubing, pediatric external defibrillator, pediatric oxygen masks/oral/NG airways and laryngoscope blades, length based resuscitation tapes and preprinted dosage chart to quickly identify equipment sizes and drug dosages by the length or weight of the child, essential emergency pediatric drugs and equipment. 5. Essential equipment: child/neonate sized, proper weight dosage medications, smaller bags of IV fluids and special IV tubing, pediatric external defibrillator, pediatric oxygen masks/oral/NG airways and laryngoscope blades, length based resuscitation tapes and preprinted dosage chart to quickly identify equipment sizes and drug dosages by the length or weight of the child, essential emergency pediatric drugs and equipment.

The school nurse is teaching a class about safety. The nurse will teach the children that they should wear protective athletic gear when participating in selected activities. Which of these activities require protective athletic gear? Select all that apply. 1. Skateboarding 2. Playing football 3. Swimming 4. Playing lacrosse 5. Performing acrobatic tricks

Answer: 1, 2, 4 Explanation: 1. Any sport that includes body contact requires a child to wear protective equipment. These include skateboarding, football, and lacrosse. Swimming and acrobatics do not have any requirements for protective equipment. 2. Any sport that includes body contact requires a child to wear protective equipment. These include skateboarding, football, and lacrosse. Swimming and acrobatics do not have any requirements for protective equipment. 3. Any sport that includes body contact requires a child to wear protective equipment. These include skateboarding, football, and lacrosse. Swimming and acrobatics do not have any requirements for protective equipment. 4. Any sport that includes body contact requires a child to wear protective equipment. These include skateboarding, football, and lacrosse. Swimming and acrobatics do not have any requirements for protective equipment. 5. Any sport that includes body contact requires a child to wear protective equipment. These include skateboarding, football, and lacrosse. Swimming and acrobatics do not have any requirements for protective equipment.

Which nursing assessment activities should be included for the child and family at each health-supervision visit? Select all that apply. 1. Interview to obtain an updated health history 2. Performing an age-appropriate development assessment 3. Monitoring parents' ability to pay for services 4. Performing age-appropriate screening examinations 5. Physical assessment for genetic abnormalities

Answer: 1, 2, 4 Explanation: 1. The interview, the developmental assessment, and age-appropriate screenings are all included in the nursing assessment of a child and family during each health-supervision visit. A nurse would not assess the parents' financial status at each health-supervision visit. Physical assessments for genetic abnormalities would be done based on history and physical findings, not at each routine visit. 2. The interview, the developmental assessment, and age-appropriate screenings are all included in the nursing assessment of a child and family during each health-supervision visit. A nurse would not assess the parents' financial status at each health-supervision visit. Physical assessments for genetic abnormalities would be done based on history and physical findings, not at each routine visit. 3. The interview, the developmental assessment, and age-appropriate screenings are all included in the nursing assessment of a child and family during each health-supervision visit. A nurse would not assess the parents' financial status at each health-supervision visit. Physical assessments for genetic abnormalities would be done based on history and physical findings, not at each routine visit. 4. The interview, the developmental assessment, and age-appropriate screenings are all included in the nursing assessment of a child and family during each health-supervision visit. A nurse would not assess the parents' financial status at each health-supervision visit. Physical assessments for genetic abnormalities would be done based on history and physical findings, not at each routine visit. 5. The interview, the developmental assessment, and age-appropriate screenings are all included in the nursing assessment of a child and family during each health-supervision visit. A nurse would not assess the parents' financial status at each health-supervision visit. Physical assessments for genetic abnormalities would be done based on history and physical findings, not at each routine visit

The nurse is asked to teach injury prevention measures to a classroom of 4-year-old preschoolers. Which teaching points are most appropriate at this age? Select all that apply. 1. Stop, drop and roll if clothes catch fire 2. Never go into the road alone. 3. Acceptable places for climbing 4. Safe meeting place outside the house in case of fire 5. Car seat safety

Answer: 1, 2, 4, 5 Explanation: 1. Acceptable places to climb should be introduced in the toddler years when children are learning to walk, climb, and explore. It is not a topic for a preschool class. All the other topics are appropriate for this age. 2. Acceptable places to climb should be introduced in the toddler years when children are learning to walk, climb, and explore. It is not a topic for a preschool class. All the other topics are appropriate for this age. 3. Acceptable places to climb should be introduced in the toddler years when children are learning to walk, climb, and explore. It is not a topic for a preschool class. All the other topics are appropriate for this age. 4. Acceptable places to climb should be introduced in the toddler years when children are learning to walk, climb, and explore. It is not a topic for a preschool class. All the other topics are appropriate for this age. 5. Acceptable places to climb should be introduced in the toddler years when children are learning to walk, climb, and explore. It is not a topic for a preschool class. All the other topics are appropriate for this age.

A follow-up visit for a newborn client is scheduled with the pediatric nurse practitioner 3 days after discharge. What will the nurse include in the assessment during the scheduled visit for this newborn? Select all that apply. 1. Feeding pattern 2. Jaundice 3. Length 4. Vision screen 5. Sleep pattern

Answer: 1, 2, 5 Explanation: 1. Feeding pattern, sleep pattern, and jaundice assessment would be appropriate 3 days after discharge. It would not be necessary to do a length or vision screen at this age. 2. Feeding pattern, sleep pattern, and jaundice assessment would be appropriate 3 days after discharge. It would not be necessary to do a length or vision screen at this age. 3. Feeding pattern, sleep pattern, and jaundice assessment would be appropriate 3 days after discharge. It would not be necessary to do a length or vision screen at this age. 4. Feeding pattern, sleep pattern, and jaundice assessment would be appropriate 3 days after discharge. It would not be necessary to do a length or vision screen at this age. 5. Feeding pattern, sleep pattern, and jaundice assessment would be appropriate 3 days after discharge. It would not be necessary to do a length or vision screen at this age. Page Ref: 156

The nurse is preparing to complete a health surveillance appointment with a school-age client and parents. Which observations would necessitate the need for further assessment by the nurse? Select all that apply. 1. Client who does not make eye contact 2. Client with visible bruises in various stages of healing 3. Client holding a video game talking with parent 4. Client playing a card game with sibling 5. Client who appears red in the face while walking to exam room

Answer: 1, 2, 5 Explanation: 1. Nursing assessment begins with the first encounter with the client and the family. The nurse would want to further explore a client who does not make eye contact, who has bruises in various stages of healing, and a client who appears red in the face while walking to the exam room. All of these items may be clues to emotional issues, physical violence, and health related issues, such as hypertension. A client who is holding a video game and talking to the parent and a client who is playing a card game with a sibling are not observations that are abnormal for the school-age client. 2. Nursing assessment begins with the first encounter with the client and the family. The nurse would want to further explore a client who does not make eye contact, who has bruises in various stages of healing, and a client who appears red in the face while walking to the exam room. All of these items may be clues to emotional issues, physical violence, and health related issues, such as hypertension. A client who is holding a video game and talking to the parent and a client who is playing a card game with a sibling are not observations that are abnormal for the school-age client. 3. Nursing assessment begins with the first encounter with the client and the family. The nurse would want to further explore a client who does not make eye contact, who has bruises in various stages of healing, and a client who appears red in the face while walking to the exam room. All of these items may be clues to emotional issues, physical violence, and health related issues, such as hypertension. A client who is holding a video game and talking to the parent and a client who is playing a card game with a sibling are not observations that are abnormal for the school-age client. 4. Nursing assessment begins with the first encounter with the client and the family. The nurse would want to further explore a client who does not make eye contact, who has bruises in various stages of healing, and a client who appears red in the face while walking to the exam room. All of these items may be clues to emotional issues, physical violence, and health related issues, such as hypertension. A client who is holding a video game and talking to the parent and a client who is playing a card game with a sibling are not observations that are abnormal for the school-age client. 5. Nursing assessment begins with the first encounter with the client and the family. The nurse would want to further explore a client who does not make eye contact, who has bruises in various stages of healing, and a client who appears red in the face while walking to the exam room. All of these items may be clues to emotional issues, physical violence, and health related issues, such as hypertension. A client who is holding a video game and talking to the parent and a client who is playing a card game with a sibling are not observations that are abnormal for the school-age client.

When reviewing the adolescent health record, which immunizations should the nurse encourage? Select all that apply. 1. Varicella 2. Human papillomavirus 3. HIV 4. Cholesterol 5. Hepatitis B

Answer: 1, 2, 5 Explanation: 1. When identifying immunizations needed by the adolescent some of the questions to ask would be: When was the last tetanus-diphtheria (Td) booster? Was a second measles-mumps-rubella administered? Is hepatitis A common in your state? Has the youth had hepatitis B vaccine? Did the youth have a documented history of varicella disease? Has the youth received meningococcal vaccine? Have the adolescent female and male received the human papillomavirus vaccine? Has the youth received the annual influenza vaccine? 2. When identifying immunizations needed by the adolescent some of the questions to ask would be: When was the last tetanus-diphtheria (Td) booster? Was a second measles-mumps-rubella administered? Is hepatitis A common in your state? Has the youth had hepatitis B vaccine? Did the youth have a documented history of varicella disease? Has the youth received meningococcal vaccine? Have the adolescent female and male received the human papillomavirus vaccine? Has the youth received the annual influenza vaccine? 3. When identifying immunizations needed by the adolescent some of the questions to ask would be: When was the last tetanus-diphtheria (Td) booster? Was a second measles-mumps-rubella administered? Is hepatitis A common in your state? Has the youth had hepatitis B vaccine? Did the youth have a documented history of varicella disease? Has the youth received meningococcal vaccine? Have the adolescent female and male received the human papillomavirus vaccine? Has the youth received the annual influenza vaccine? HIV is not needed unless the adolescent is sexually active with same sex partner or many partners or has symptoms. 4. When identifying immunizations needed by the adolescent some of the questions to ask would be: When was the last tetanus-diphtheria (Td) booster? Was a second measles-mumps-rubella administered? Is hepatitis A common in your state? Has the youth had hepatitis B vaccine? Did the youth have a documented history of varicella disease? Has the youth received meningococcal vaccine? Have the adolescent female and male received the human papillomavirus vaccine? Has the youth received the annual influenza vaccine? Cholesterol is not needed unless the adolescent eats a high fat diet or there is a family history of high cholesterol. 5. When identifying immunizations needed by the adolescent some of the questions to ask would be: When was the last tetanus-diphtheria (Td) booster? Was a second measles-mumps-rubella administered? Is hepatitis A common in your state? Has the youth had hepatitis B vaccine? Did the youth have a documented history of varicella disease? Has the youth received meningococcal vaccine? Have the adolescent female and male received the human papillomavirus vaccine? Has the youth received the annual influenza vaccine?

The nurse working with a family has observed that the older children have a large number of dental caries and plans to provide the mother with information to prevent the development of dental caries in her new infant. Which interventions will prevent the development of dental caries in the infant? Select all that apply. 1. Avoiding nursing or giving the infant a bottle at bedtime 2. Giving foods high in sugar only at breakfast time 3. Using a soft moist gauze for cleaning 4. Using a topical anesthetic daily beginning as soon as the first tooth begins to erupt

Answer: 1, 3 Explanation: 1. The only interventions that will assist in the prevention of dental caries listed in this question are wiping the gums with a soft, moist gauze and avoiding putting the infant to bed with a bottle. Foods high in sugar should be avoided in the infant period. Topical anesthetic should not be applied daily. 2. The only interventions that will assist in the prevention of dental caries listed in this question are wiping the gums with a soft, moist gauze and avoiding putting the infant to bed with a bottle. Foods high in sugar should be avoided in the infant period. Topical anesthetic should not be applied daily. 3. The only interventions that will assist in the prevention of dental caries listed in this question are wiping the gums with a soft, moist gauze and avoiding putting the infant to bed with a bottle. Foods high in sugar should be avoided in the infant period. Topical anesthetic should not be applied daily. 4. The only interventions that will assist in the prevention of dental caries listed in this question are wiping the gums with a soft, moist gauze and avoiding putting the infant to bed with a bottle. Foods high in sugar should be avoided in the infant period. Topical anesthetic should not be applied daily.

The nurse is teaching a mother of a 2-month-old that she will begin to introduce certain foods to the diet between 4 and 6 months. The nurse should recommend what foods? Select all that apply. 1. Vegetables 2. Pasta 3. Rice cereal 4. Fruits 5. Soups

Answer: 1, 3, 4 Explanation: 1. Reinforce proper introduction of new foods, to include rice cereal, vegetables, and fruits. Discuss any unusual food reactions observed. Pasta and soups are not advised at this time. 2. Reinforce proper introduction of new foods, to include rice cereal, vegetables, and fruits. Discuss any unusual food reactions observed. Pasta and soups are not advised at this time. 3. Reinforce proper introduction of new foods, to include rice cereal, vegetables, and fruits. Discuss any unusual food reactions observed. Pasta and soups are not advised at this time. 4. Reinforce proper introduction of new foods, to include rice cereal, vegetables, and fruits. Discuss any unusual food reactions observed. Pasta and soups are not advised at this time. 5. Reinforce proper introduction of new foods, to include rice cereal, vegetables, and fruits. Discuss any unusual food reactions observed. Pasta and soups are not advised at this time.

Which of these aspects of developmental health supervision should be included in each healthcare visit of young children? Select all that apply. 1. Assessment 2. Discipline 3. Education 4. Intervention 5. Toilet training

Answer: 1, 3, 4 Explanation: 1. The main recommendations for developmental health supervision of young children include assessment, education, intervention, and care coordination. This standard framework should be used as guidelines for each healthcare visit. Discipline and toilet training, while important to the care of children, are age specific and not part of the main developmental plans. 2. The main recommendations for developmental health supervision of young children include assessment, education, intervention, and care coordination. This standard framework should be used as guidelines for each healthcare visit. Discipline and toilet training, while important to the care of children, are age specific and not part of the main developmental plans. 3. The main recommendations for developmental health supervision of young children include assessment, education, intervention, and care coordination. This standard framework should be used as guidelines for each healthcare visit. Discipline and toilet training, while important to the care of children, are age specific and not part of the main developmental plans. 4. The main recommendations for developmental health supervision of young children include assessment, education, intervention, and care coordination. This standard framework should be used as guidelines for each healthcare visit. Discipline and toilet training, while important to the care of children, are age specific and not part of the main developmental plans. 5. The main recommendations for developmental health supervision of young children include assessment, education, intervention, and care coordination. This standard framework should be used as guidelines for each healthcare visit. Discipline and toilet training, while important to the care of children, are age specific and not part of the main developmental plans

A 7-year-old child presents to the clinic with an exacerbation of asthma symptoms. On physical examination, the nurse would expect which assessment findings? Select all that apply. 1. Wheezing 2. Increased tactile fremitus 3. Decreased vocal resonance 4. Decreased tactile fremitus 5. Bronchophony

Answer: 1, 3, 4 Explanation: 1. Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition present in asthma exacerbations. The air trapping in the lungs that occurs in asthma causes a decrease in the sensation of vibrations felt, not an increase in tactile fremitus, which is indicative of pneumonia. Bronchophony is an increase in the intensity and clarity of transmitted sounds. This is also indicative of pneumonia but not asthma, which causes a decrease in vocal resonance. 2. Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition present in asthma exacerbations. The air trapping in the lungs that occurs in asthma causes a decrease in the sensation of vibrations felt, not an increase in tactile fremitus, which is indicative of pneumonia. Bronchophony is an increase in the intensity and clarity of transmitted sounds. This is also indicative of pneumonia but not asthma, which causes a decrease in vocal resonance. 3. Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition present in asthma exacerbations. The air trapping in the lungs that occurs in asthma causes a decrease in the sensation of vibrations felt, not an increase in tactile fremitus, which is indicative of pneumonia. Bronchophony is an increase in the intensity and clarity of transmitted sounds. This is also indicative of pneumonia but not asthma, which causes a decrease in vocal resonance. 4. Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition present in asthma exacerbations. The air trapping in the lungs that occurs in asthma causes a decrease in the sensation of vibrations felt, not an increase in tactile fremitus, which is indicative of pneumonia. Bronchophony is an increase in the intensity and clarity of transmitted sounds. This is also indicative of pneumonia but not asthma, which causes a decrease in vocal resonance. 5. Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition present in asthma exacerbations. The air trapping in the lungs that occurs in asthma causes a decrease in the sensation of vibrations felt, not an increase in tactile fremitus, which is indicative of pneumonia. Bronchophony is an increase in the intensity and clarity of transmitted sounds. This is also indicative of pneumonia but not asthma, which causes a decrease in vocal resonance.

The nurse is teaching the adolescent and family about sleep hygiene. What behaviors should the nurse suggest? Select all that apply. 1. Avoid naps in the late afternoon and evening 2. Sleep 12 hours a day 3. Avoid caffeine, tea, coffee, carbonated beverages and energy drinks for several hours before sleep. 4. Avoid setting an alarm clock 5. Go to bed and get up at the same time each day, including weekends

Answer: 1, 3, 5 Explanation: 1. General information about sleep includes no drinks or food with stimulants, go to bed and get up at the same time each day, including weekends, and avoid naps in the late afternoon and evening. 2. General information about sleep includes no drinks or food with stimulants, go to bed and get up at the same time each day, including weekends, and avoid naps in the late afternoon and evening. Sleeping 12 hours is not required—sleep is not made up if it is lost. 3. General information about sleep includes no drinks or food with stimulants, go to bed and get up at the same time each day, including weekends, and avoid naps in the late afternoon and evening. 4. General information about sleep includes no drinks or food with stimulants, go to bed and get up at the same time each day, including weekends, and avoid naps in the late afternoon and evening. Avoiding setting an alarm clock does not help the adolescent get and maintain good restful sleep. 5. General information about sleep includes no drinks or food with stimulants, go to bed and get up at the same time each day, including weekends, and avoid naps in the late afternoon and evening.

The nurse is conducting a health surveillance visit with a 6-month-old infant. Which methods are appropriate to monitor the infant's growth pattern since birth? Select all that apply. 1. Weight the infant twice and average together 2. Measure the infant's height 3. Measure the infant's head circumference 4. Determine the infant's body mass index 5. Plot the infant's growth on appropriate chart

Answer: 1, 3, 5 Explanation: 1. In order to determine the infant's growth pattern, the nurse will obtain two weights and average them together, measure the infant's head circumference, and obtain the infant's length, not height. After the measurements have been obtained the nurse will plot the measurements on the appropriate growth chart and monitor the infant's growth pattern. Body mass index is not determined during infancy. 2. In order to determine the infant's growth pattern, the nurse will obtain two weights and average them together, measure the infant's head circumference, and obtain the infant's length, not height. After the measurements have been obtained the nurse will plot the measurements on the appropriate growth chart and monitor the infant's growth pattern. Body mass index is not determined during infancy. 3. In order to determine the infant's growth pattern, the nurse will obtain two weights and average them together, measure the infant's head circumference, and obtain the infant's length, not height. After the measurements have been obtained the nurse will plot the measurements on the appropriate growth chart and monitor the infant's growth pattern. Body mass index is not determined during infancy. 4. In order to determine the infant's growth pattern, the nurse will obtain two weights and average them together, measure the infant's head circumference, and obtain the infant's length, not height. After the measurements have been obtained the nurse will plot the measurements on the appropriate growth chart and monitor the infant's growth pattern. Body mass index is not determined during infancy. 5. In order to determine the infant's growth pattern, the nurse will obtain two weights and average them together, measure the infant's head circumference, and obtain the infant's length, not height. After the measurements have been obtained the nurse will plot the measurements on the appropriate growth chart and monitor the infant's growth pattern. Body mass index is not determined during infancy.

The school nurse plans, develops, manages, and evaluates healthcare services to all children while they are in the educational setting. With which healthcare providers will the nurse be collaborating? Select all that apply. 1. School physician 2. Teachers 3. Cafeteria staff 4. Primary physician 5. Bus driver

Answer: 1, 4 Explanation: 1. Partnering with the school physician consultant to discuss and update standing orders for the care of children; these standing orders usually address urgent and emergency care potentially needed by students. 2. The school nurse may need to educate the teachers, cafeteria staff, and bus drivers regarding detecting complications and alerting emergency personnel. 3. The school nurse may need to educate the teachers, cafeteria staff, and bus drivers regarding detecting complications and alerting emergency personnel. 4. Communicating with the child's primary healthcare provider or pediatric specialist about a child's specific health condition that needs to be effectively managed in the school setting. 5. The school nurse may need to educate the teachers, cafeteria staff, and bus drivers regarding detecting complications and alerting emergency personnel.

Match the Development surveillance questionnaire with its description. A. Denver II B. Ages and stages questionnaire C. Child development inventory D. Parents evaluation of developmental status E. Prescreening developmental questionnaire 1. Questionnaire of specific ages, 10 to 15 items in each area: fine motor, gross motor, communication, adaptive, personal, and social skills. 2. Consists of 10 questions for parent to answer in interview, based on research regarding parents' concerns. 3. Consists of 60, yes-no descriptions for three separate instruments to identify child with developmental difficulties. 4. Consists of observation of child in 4 domains; personal, social, fine-motor-adaptive, language, and gross motor. 5. Helps identify children who need Denver II assessment.

Answer: 1/B, 2/D, 3/C, 4/A, 5/E 1. Ages and stages questionnaire 2. Parents evaluation of developmental status 3. Child development inventory 4. Denver II 5. Prescreening developmental questionnaire

The nurse must assess each of the 2-year-olds listed below. Which one should be evaluated first? 1. A child with a temperature of 101 degrees F 2. A child who has stridor 3. A child who has absent Babinski sign 4. A child who has a pot belly appearance

Answer: 2 Explanation: 1. A child with stridor is at risk for airway compromise; a child with a temperature of 101 degrees F, while sick, is not as ill as the child with stridor; and the child with an absent Babinski sign and the pot-bellied child are normal. 2. A child with stridor is at risk for airway compromise; a child with a temperature of 101 degrees F, while sick, is not as ill as the child with stridor; and the child with an absent Babinski sign and the pot-bellied child are normal. 3. A child with stridor is at risk for airway compromise; a child with a temperature of 101 degrees F, while sick, is not as ill as the child with stridor; and the child with an absent Babinski sign and the pot-bellied child are normal. 4. A child with stridor is at risk for airway compromise; a child with a temperature of 101 degrees F, while sick, is not as ill as the child with stridor; and the child with an absent Babinski sign and the pot-bellied child are normal.

A nurse assesses the height and weight measurements on an infant and documents these measurements at the 75th percentile. The nurse notes that the previous measurements two months ago were at the 25th percentile. Which interpretation by the nurse is the most accurate? 1. The infant is not gaining enough weight. 2. The infant has gained a significant amount of weight. 3. The previous measurements were most likely inaccurate. 4. These measurements are most likely inaccurate.

Answer: 2 Explanation: 1. A comparison of these two sets of measurements shows that the infant has crossed two percentiles going from the 25th to the 75th percentile and therefore has gained a significant amount of weight. There is neither indication that the previous measurements are inaccurate nor that the current measurement is inaccurate. 2. A comparison of these two sets of measurements shows that the infant has crossed two percentiles going from the 25th to the 75th percentile and therefore has gained a significant amount of weight. There is neither indication that the previous measurements are inaccurate nor that the current measurement is inaccurate. 3. A comparison of these two sets of measurements shows that the infant has crossed two percentiles going from the 25th to the 75th percentile and therefore has gained a significant amount of weight. There is neither indication that the previous measurements are inaccurate nor that the current measurement is inaccurate. 4. A comparison of these two sets of measurements shows that the infant has crossed two percentiles going from the 25th to the 75th percentile and therefore has gained a significant amount of weight. There is neither indication that the previous measurements are inaccurate nor that the current measurement is inaccurate.

A mother brings a child to the pediatric office for a sick visit. Which action by the nurse is the most appropriate? 1. Focus exclusively on the reported illness. 2. Review health-promotion and health-maintenance activities. 3. Ask the mother to leave the room after obtaining the history. 4. Obtain a comprehensive history, including sociodemographic data.

Answer: 2 Explanation: 1. A nurse should use every opportunity during an office visit to review health-promotion and health-maintenance activities. Focusing exclusively on the reported illnesses ignores the opportunity to use health-promotion strategies. There is not enough data in this scenario to determine whether the mother should be asked to leave the room. There is not enough information to indicate that a comprehensive history should be taken at this visit. 2. A nurse should use every opportunity during an office visit to review health-promotion and health-maintenance activities. Focusing exclusively on the reported illnesses ignores the opportunity to use health-promotion strategies. There is not enough data in this scenario to determine whether the mother should be asked to leave the room. There is not enough information to indicate that a comprehensive history should be taken at this visit. 3. A nurse should use every opportunity during an office visit to review health-promotion and health-maintenance activities. Focusing exclusively on the reported illnesses ignores the opportunity to use health-promotion strategies. There is not enough data in this scenario to determine whether the mother should be asked to leave the room. There is not enough information to indicate that a comprehensive history should be taken at this visit. 4. A nurse should use every opportunity during an office visit to review health-promotion and health-maintenance activities. Focusing exclusively on the reported illnesses ignores the opportunity to use health-promotion strategies. There is not enough data in this scenario to determine whether the mother should be asked to leave the room. There is not enough information to indicate that a comprehensive history should be taken at this visit.

The nurse notes a history of a grade III heart murmur in a small infant. When assessing the heart, the nurse would expect to: 1. Auscultate a quiet but easily heard murmur. 2. Auscultate a moderately loud murmur without a palpable thrill. 3. Auscultate a very loud murmur with easily palpable thrill. 4. Listen without a stethoscope and hear a murmur at chest wall.

Answer: 2 Explanation: 1. A quiet but easily heard murmur is a grade II. A moderately loud murmur without palpable thrill is a grade III. A very loud murmur with easily palpable thrill is a grade V. A murmur heard at the chest wall without the aid of a stethoscope is a grade VI. 2. A quiet but easily heard murmur is a grade II. A moderately loud murmur without palpable thrill is a grade III. A very loud murmur with easily palpable thrill is a grade V. A murmur heard at the chest wall without the aid of a stethoscope is a grade VI. 3. A quiet but easily heard murmur is a grade II. A moderately loud murmur without palpable thrill is a grade III. A very loud murmur with easily palpable thrill is a grade V. A murmur heard at the chest wall without the aid of a stethoscope is a grade VI. 4. A quiet but easily heard murmur is a grade II. A moderately loud murmur without palpable thrill is a grade III. A very loud murmur with easily palpable thrill is a grade V. A murmur heard at the chest wall without the aid of a stethoscope is a grade VI.

The nurse is providing care for several pediatric clients. Which client would require an Individualized Health Plan (IHP) prior to returning to school? 1. A school-age client who has recently developed a penicillin allergy 2. An adolescent client newly diagnosed with insulin-dependent diabetes mellitus 3. A school-age client who has been treated for head lice 4. An adolescent client who has missed two weeks of school due to mononucleosis

Answer: 2 Explanation: 1. An IHP that ensures appropriate management of the child's healthcare needs must be developed for a child newly diagnosed with a chronic illness such as diabetes. A child who is allergic to penicillin will not receive this medication any longer and therefore should not encounter any problems related to it at school. A child who has been treated for head lice can return to school and does not need an IHP. While a child who has missed two weeks of school will need to make arrangements for makeup work, an IHP is not needed. 2. An IHP that ensures appropriate management of the child's healthcare needs must be developed for a child newly diagnosed with a chronic illness such as diabetes. A child who is allergic to penicillin will not receive this medication any longer and therefore should not encounter any problems related to it at school. A child who has been treated for head lice can return to school and does not need an IHP. While a child who has missed two weeks of school will need to make arrangements for makeup work, an IHP is not needed. 3. An IHP that ensures appropriate management of the child's healthcare needs must be developed for a child newly diagnosed with a chronic illness such as diabetes. A child who is allergic to penicillin will not receive this medication any longer and therefore should not encounter any problems related to it at school. A child who has been treated for head lice can return to school and does not need an IHP. While a child who has missed two weeks of school will need to make arrangements for makeup work, an IHP is not needed. 4. An IHP that ensures appropriate management of the child's healthcare needs must be developed for a child newly diagnosed with a chronic illness such as diabetes. A child who is allergic to penicillin will not receive this medication any longer and therefore should not encounter any problems related to it at school. A child who has been treated for head lice can return to school and does not need an IHP. While a child who has missed two weeks of school will need to make arrangements for makeup work, an IHP is not needed.

A 2-month-old infant with bronchopulmonary dysplasia (BPD) is being prepared for discharge from the neonatal intensive-care unit (NICU). The infant will continue to receive oxygen via nasal cannula at home. Prior to discharge, the home-health nurse assesses the home. Which finding poses the greatest risk to this infant? 1. Small toys strewn on the floor 2. A woodstove used for heating 3. A sibling who has an ear infection 4. Paint peeling on the walls

Answer: 2 Explanation: 1. Assessment of the home environment is essential prior to discharge of a medically fragile infant. The use of a woodstove poses great risk to the infant who already has fragile lungs. Oxygen and woodstove heat will produce a flammable reaction. Small toy pieces and paint peeling from the wall will pose a choking risk to the older infant who is crawling. Ear infections are not contagious. 2. Assessment of the home environment is essential prior to discharge of a medically fragile infant. The use of a woodstove poses great risk to the infant who already has fragile lungs. Oxygen and woodstove heat will produce a flammable reaction. Small toy pieces and paint peeling from the wall will pose a choking risk to the older infant who is crawling. Ear infections are not contagious. 3. Assessment of the home environment is essential prior to discharge of a medically fragile infant. The use of a woodstove poses great risk to the infant who already has fragile lungs. Oxygen and woodstove heat will produce a flammable reaction. Small toy pieces and paint peeling from the wall will pose a choking risk to the older infant who is crawling. Ear infections are not contagious. 4. Assessment of the home environment is essential prior to discharge of a medically fragile infant. The use of a woodstove poses great risk to the infant who already has fragile lungs. Oxygen and woodstove heat will produce a flammable reaction. Small toy pieces and paint peeling from the wall will pose a choking risk to the older infant who is crawling. Ear infections are not contagious.

Which assessment would not be included with a 17-year-old's screening during a routine health supervision visit? 1. STI evaluation 2. Autism screening 3. Hemoglobin test 4. Vision screening

Answer: 2 Explanation: 1. Autism screening would not be appropriate at this age. If autism were present, it would have presented before this age. STI evaluation, hemoglobin test, and vision screening are all appropriate for a 17-year-old. 2. Autism screening would not be appropriate at this age. If autism were present, it would have presented before this age. STI evaluation, hemoglobin test, and vision screening are all appropriate for a 17-year-old. 3. Autism screening would not be appropriate at this age. If autism were present, it would have presented before this age. STI evaluation, hemoglobin test, and vision screening are all appropriate for a 17-year-old. 4. Autism screening would not be appropriate at this age. If autism were present, it would have presented before this age. STI evaluation, hemoglobin test, and vision screening are all appropriate for a 17-year-old.

An infant weighs 9 pounds 3 ounces at birth. The nurse plans to make a home visit to the mother and infant when the infant is 7 days old. What is the lowest acceptable weight the infant should be at this age? 1. 7 pounds 12 ounces 2. 8 pounds 2 ounces 3. 8 pounds 12 ounces 4. 9 pounds

Answer: 2 Explanation: 1. In the first week of life, most infants lose about one-tenth of their birth weight; therefore, this infant's weight should be 8 pounds 2 ounces at 7 days of age. A weight loss to 7 pounds 12 ounces would be too much for this infant. A decline to 8 pounds 12 ounces is less than the expected one-tenth weight loss after birth, and an infant would not be expected to lose only 3 ounces during the first week of life. 2. In the first week of life, most infants lose about one-tenth of their birth weight; therefore, this infant's weight should be 8 pounds 2 ounces at 7 days of age. A weight loss to 7 pounds 12 ounces would be too much for this infant. A decline to 8 pounds 12 ounces is less than the expected one-tenth weight loss after birth, and an infant would not be expected to lose only 3 ounces during the first week of life. 3. In the first week of life, most infants lose about one-tenth of their birth weight; therefore, this infant's weight should be 8 pounds 2 ounces at 7 days of age. A weight loss to 7 pounds 12 ounces would be too much for this infant. A decline to 8 pounds 12 ounces is less than the expected one-tenth weight loss after birth, and an infant would not be expected to lose only 3 ounces during the first week of life. 4. In the first week of life, most infants lose about one-tenth of their birth weight; therefore, this infant's weight should be 8 pounds 2 ounces at 7 days of age. A weight loss to 7 pounds 12 ounces would be too much for this infant. A decline to 8 pounds 12 ounces is less than the expected one-tenth weight loss after birth, and an infant would not be expected to lose only 3 ounces during the first week of life.

A nurse caring for a school-age client notices some swelling in the child's ankles. The nurse presses against the ankle bone for five seconds, then releases the pressure and notices a markedly slow disappearance of the indentation. Which priority nursing assessment is appropriate? 1. Skin integrity, especially in the lower extremities 2. Urine output 3. Level of consciousness 4. Range of motion and ankle mobility

Answer: 2 Explanation: 1. Dependent, pitting edema, especially in the lower extremities, can be a symptom of both kidney and cardiac disorders. Decreases in urine output can also indicate compromise in both the renal and cardiac systems. Changes in level of consciousness, if present, would more than likely be a later effect in this situation. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important. 2. Dependent, pitting edema, especially in the lower extremities, can be a symptom of both kidney and cardiac disorders. Decreases in urine output can also indicate compromise in both the renal and cardiac systems. Changes in level of consciousness, if present, would more than likely be a later effect in this situation. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important. 3. Dependent, pitting edema, especially in the lower extremities, can be a symptom of both kidney and cardiac disorders. Decreases in urine output can also indicate compromise in both the renal and cardiac systems. Changes in level of consciousness, if present, would more than likely be a later effect in this situation. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important. 4. Dependent, pitting edema, especially in the lower extremities, can be a symptom of both kidney and cardiac disorders. Decreases in urine output can also indicate compromise in both the renal and cardiac systems. Changes in level of consciousness, if present, would more than likely be a later effect in this situation. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important.

During a clinic visit, the parents of a 15-month-old ask what disease and injury prevention topics would be appropriate to discuss at this age. Which response by the nurse is the most appropriate? 1. "It's never too early to teach a child to wear a helmet when riding a bicycle." 2. "Teaching simple handwashing is a good topic at this age." 3. "Tell the child over and over to stay away from water unless you are with him." 4. "Tell him firmly 'no' when he tries to cross the street."

Answer: 2 Explanation: 1. Disease and injury prevention are ongoing topics at all ages. Simple handwashing is appropriate for a 15-month-old child. A 15-month-old is too young for bicycle riding, so this can be delayed. A 15-month-old is too young to understand water safety and crossing the street, and should never be left unattended in these situations. 2. Disease and injury prevention are ongoing topics at all ages. Simple handwashing is appropriate for a 15-month-old child. A 15-month-old is too young for bicycle riding, so this can be delayed. A 15-month-old is too young to understand water safety and crossing the street, and should never be left unattended in these situations. 3. Disease and injury prevention are ongoing topics at all ages. Simple handwashing is appropriate for a 15-month-old child. A 15-month-old is too young for bicycle riding, so this can be delayed. A 15-month-old is too young to understand water safety and crossing the street, and should never be left unattended in these situations. 4. Disease and injury prevention are ongoing topics at all ages. Simple handwashing is appropriate for a 15-month-old child. A 15-month-old is too young for bicycle riding, so this can be delayed. A 15-month-old is too young to understand water safety and crossing the street, and should never be left unattended in these situations.

A mother of an 18-month old asks the nurse whether she can begin to introduce low-fat milk like the rest of the family drinks. The nurse answers the mother based on the knowledge that low-fat milk can safely be introduced at what age? 1. 18 months 2. 24 months 3. 3 years 4. 4 years

Answer: 2 Explanation: 1. Health promotion for the toddler includes whole milk until age 2. Age 1 is too early for low-fat milk; and it can safely be introduced before ages 3 and 4. 2. Health promotion for the toddler includes whole milk until age 2. Age 1 is too early for low-fat milk, and it can safely be introduced before ages 3 and 4. 3. Health promotion for the toddler includes whole milk until age 2. Age 1 is too early for low-fat milk, and it can safely be introduced before ages 3 and 4. 4. Health promotion for the toddler includes whole milk until age 2. Age 1 is too early for low-fat milk, and it can safely be introduced before ages 3 and 4.

A nurse is helping the parents of 2-year-old twins cope with the daily demands of life in an active household. Which strategy is most appropriate for the nurse to use? 1. Health maintenance 2. Health promotion 3. Health protection 4. Health supervision

Answer: 2 Explanation: 1. In health promotion, nurses partner with families to promote family strategies in the areas of lifestyle and coping. The definition of health maintenance and health supervision makes the other answers incorrect. Health protection is another term for health maintenance. 2. In health promotion, nurses partner with families to promote family strategies in the areas of lifestyle and coping. The definition of health maintenance and health supervision makes the other answers incorrect. Health protection is another term for health maintenance. 3. In health promotion, nurses partner with families to promote family strategies in the areas of lifestyle and coping. The definition of health maintenance and health supervision makes the other answers incorrect. Health protection is another term for health maintenance. 4. In health promotion, nurses partner with families to promote family strategies in the areas of lifestyle and coping. The definition of health maintenance and health supervision makes the other answers incorrect. Health protection is another term for health maintenance.

An adolescent reports participating in an exercise program at school each Wednesday throughout the school year. Further history reveals that the adolescent does not participate in any other physical activities. Which outcome is most appropriate for this adolescent? 1. The adolescent is reporting information consistent with what 60 percent of adolescents report as participation in physical activities. 2. The adolescent is not meeting the recommendations of the Healthy People 2020 initiative. 3. The adolescent should be encouraged to continue this program of exercise, since something is better than nothing. 4. The adolescent should be encouraged to vigorously exercise for at least 5 minutes each day.

Answer: 2 Explanation: 1. In this scenario, the adolescent is not receiving the recommended amount of exercise to support good health habits. Encouraging the adolescent to continue as is or to exercise vigorously for 5 minutes each day also is not consistent with current recommendations. Suggesting that "something is better than nothing" is not good practice. 2. In this scenario, the adolescent is not receiving the recommended amount of exercise to support good health habits. Encouraging the adolescent to continue as is or to exercise vigorously for 5 minutes each day also is not consistent with current recommendations. Suggesting that "something is better than nothing" is not good practice. 3. In this scenario, the adolescent is not receiving the recommended amount of exercise to support good health habits. Encouraging the adolescent to continue as is or to exercise vigorously for 5 minutes each day also is not consistent with current recommendations. Suggesting that "something is better than nothing" is not good practice. 4. In this scenario, the adolescent is not receiving the recommended amount of exercise to support good health habits. Encouraging the adolescent to continue as is or to exercise vigorously for 5 minutes each day also is not consistent with current recommendations. Suggesting that "something is better than nothing" is not good practice.

A nurse is preparing to perform a physical assessment on a toddler. Which action is most appropriate for the nurse to take? 1. Perform the assessment from head to toe. 2. Leave intrusive procedures such as ear and eye examinations until the end. 3. Explain each part of the examination to the child before performing it. 4. Ask the mother to tell the child not to be afraid.

Answer: 2 Explanation: 1. Intrusive procedures such as examination of the ears, throat, eye, and genital areas should be done last to decrease the anxiety of the child during the initial phases of the examination, which includes the heart and lungs. 2. Intrusive procedures such as examination of the ears, throat, eye, and genital areas should be done last to decrease the anxiety of the child during the initial phases of the examination, which includes the heart and lungs. 3. Intrusive procedures such as examination of the ears, throat, eye, and genital areas should be done last to decrease the anxiety of the child during the initial phases of the examination, which includes the heart and lungs. 4. Intrusive procedures such as examination of the ears, throat, eye, and genital areas should be done last to decrease the anxiety of the child during the initial phases of the examination, which includes the heart and lungs.

The nurse is performing a well-child exam on a child who turned 4 years old 3 months ago. What can the nurse ask the child to do to assess appropriate milestones for this age? 1. Jump up and down 2. Throw a ball 3. Stack three or more blocks 4. Draw lines on paper

Answer: 2 Explanation: 1. Jumping up and down, stacking three or more blocks, and drawing lines on paper are activities that represent milestones for young children. Throwing a ball and observing how it is thrown would assess a milestone for this age. By 4 to 5 years, a child begins to throw a ball overhand. 2. Jumping up and down, stacking three or more blocks, and drawing lines on paper are activities that represent milestones for young children. Throwing a ball and observing how it is thrown would assess a milestone for this age. By 4 to 5 years, a child begins to throw a ball overhand. 3. Jumping up and down, stacking three or more blocks, and drawing lines on paper are activities that represent milestones for young children. Throwing a ball and observing how it is thrown would assess a milestone for this age. By 4 to 5 years, a child begins to throw a ball overhand. 4. Jumping up and down, stacking three or more blocks, and drawing lines on paper are activities that represent milestones for young children. Throwing a ball and observing how it is thrown would assess a milestone for this age. By 4 to 5 years, a child begins to throw a ball overhand.

The nurse is preparing to perform a hearing screening on a 6-year-old child. The nurse knows this screening is what level of prevention? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Quaternary prevention

Answer: 2 Explanation: 1. Primary prevention includes immunizations, teaching regarding seatbelts, helmets, and so on. 2. Secondary prevention includes developmental, hearing and vision screenings. 3. Tertiary prevention includes rehab, PT, OT, and so on. 4. Quaternary prevention includes advanced levels of medicine, extensive tests.

When assessing the cognitive development, which technique would be appropriate to test the remote memory of a 5-year-old? 1. Say the name of an object and after 5 minutes ask the child to tell you what you said the object was. 2. Ask the child to repeat his address. 3. Ask the child to say a poem and listen to the child's speech articulation. 4. Have the child point to various parts of the body as you name them.

Answer: 2 Explanation: 1. Repeating the name of an object after 5 to 10 minutes is assessing recent memory. Asking the child to repeat his address is assessing remote memory. Listening to speech articulation and pointing to body parts both assess communication skills. 2. Repeating the name of an object after 5 to 10 minutes is assessing recent memory. Asking the child to repeat his address is assessing remote memory. Listening to speech articulation and pointing to body parts both assess communication skills. 3. Repeating the name of an object after 5 to 10 minutes is assessing recent memory. Asking the child to repeat his address is assessing remote memory. Listening to speech articulation and pointing to body parts both assess communication skills. 4. Repeating the name of an object after 5 to 10 minutes is assessing recent memory. Asking the child to repeat his address is assessing remote memory. Listening to speech articulation and pointing to body parts both assess communication skills.

Parents of a preschool-age child report that they find it necessary to spank the child at least once a day. Which response should the nurse make to the parents? 1. "Spanking is one form of discipline; however, you want to be certain that you do not leave any marks on the child." 2. "Let's talk about other forms of discipline that have a more positive effect on the child." 3. "Can you try only spanking the child every other day for one week and see how that affects the child's behavior?" 4. "I think you are not parenting your child properly, so let's talk about ways to improve your parenting skills."

Answer: 2 Explanation: 1. The behavior reported by the parent was excessive. The only response that is appropriate is to find a more positive way of influencing behavior in this age child. The nurse's response needs to reflect these feelings. To suggest spanking as an appropriate form of discipline is inappropriate, especially when the parent is describing daily spanking of the child. 2. The behavior reported by the parent was excessive. The only response that is appropriate is to find a more positive way of influencing behavior in this age child. The nurse's response needs to reflect these feelings. To suggest spanking as an appropriate form of discipline is inappropriate, especially when the parent is describing daily spanking of the child. 3. The behavior reported by the parent was excessive. The only response that is appropriate is to find a more positive way of influencing behavior in this age child. The nurse's response needs to reflect these feelings. To suggest spanking as an appropriate form of discipline is inappropriate, especially when the parent is describing daily spanking of the child. 4. The behavior reported by the parent was excessive. The only response that is appropriate is to find a more positive way of influencing behavior in this age child. The nurse's response needs to reflect these feelings. To suggest spanking as an appropriate form of discipline is inappropriate, especially when the parent is describing daily spanking of the child.

A mother reports that her adolescent is always late. The mother states, "She was born late and has been late every day of her life." Which response should the nurse make to this mother? 1. "You need to establish specific time frames for your adolescent and be certain she adheres to them." 2. "You should not expect your adolescent to be an 'on-time' individual unless you set specific alarms and then reinforce the value of being 'on-time.'" 3. "You should not expect your adolescent to be on time. Teenagers are always late." 4. "You have a major problem. There must be a lot of screaming in your home."

Answer: 2 Explanation: 1. The best response is to help the mother find a way to help the teen deal with the problem of lateness. The other responses will either create parent-child conflict or make assumptions about household communication. 2. The best response is to help the mother find a way to help the teen deal with the problem of lateness. The other responses will either create parent-child conflict or make assumptions about household communication. 3. The best response is to help the mother find a way to help the teen deal with the problem of lateness. The other responses will either create parent-child conflict or make assumptions about household communication. 4. The best response is to help the mother find a way to help the teen deal with the problem of lateness. The other responses will either create parent-child conflict or make assumptions about household communication.

A nurse who is the manager of an ambulatory pediatric healthcare center is planning protocols for the routine healthcare visits of the children. Children at this care center have a high incidence of obesity. At which age should the nurses at this clinic calculate the body mass index (BMI) for all pediatric clients? 1. 12 months 2. 24 months 3. 36 months 4. 4 years

Answer: 2 Explanation: 1. The body mass index is first calculated at 2 years of age and gives information about the relationship between the height and weight of the child. With this information, the nurse would be able to develop strategies that may reduce the incidence of obesity. 2. The body mass index is first calculated at 2 years of age and gives information about the relationship between the height and weight of the child. With this information, the nurse would be able to develop strategies that may reduce the incidence of obesity. 3. The body mass index is first calculated at 2 years of age and gives information about the relationship between the height and weight of the child. With this information, the nurse would be able to develop strategies that may reduce the incidence of obesity. 4. The body mass index is first calculated at 2 years of age and gives information about the relationship between the height and weight of the child. With this information, the nurse would be able to develop strategies that may reduce the incidence of obesity.

In the pediatric well-child clinic, the nurse explains the reason for an immunization series to the child's mother. This action represents which item? 1. Health assessment 2. Health promotion 3. Health maintenance 4. Health screening

Answer: 2 Explanation: 1. The explanation to the mother by the nurse provides an understanding of the immunization series to the mother and enables the mother to make an intelligent choice. While administering immunizations is considered health maintenance, the activity described in the question is clearly health promotion. A health assessment would be completed to determine what immunizations are needed. Health maintenance is the actual administration of the immunization and health screening involves looking at the immunization record to determine which immunizations are needed. 2. The explanation to the mother by the nurse provides an understanding of the immunization series to the mother and enables the mother to make an intelligent choice. While administering immunizations is considered health maintenance, the activity described in the question is clearly health promotion. A health assessment would be completed to determine what immunizations are needed. Health maintenance is the actual administration of the immunization and health screening involves looking at the immunization record to determine which immunizations are needed. 3. The explanation to the mother by the nurse provides an understanding of the immunization series to the mother and enables the mother to make an intelligent choice. While administering immunizations is considered health maintenance, the activity described in the question is clearly health promotion. A health assessment would be completed to determine what immunizations are needed. Health maintenance is the actual administration of the immunization and health screening involves looking at the immunization record to determine which immunizations are needed. 4. The explanation to the mother by the nurse provides an understanding of the immunization series to the mother and enables the mother to make an intelligent choice. While administering immunizations is considered health maintenance, the activity described in the question is clearly health promotion. A health assessment would be completed to determine what immunizations are needed. Health maintenance is the actual administration of the immunization and health screening involves looking at the immunization record to determine which immunizations are needed.

The nurse is planning care for clients seen in a newborn clinic. Which is the priority for a newborn client during the first clinic visit? 1. Providing pamphlets to reinforce information provided at the visit 2. Assessing the newborn-family interactions 3. Modeling infant-nurturing behaviors 4. Informing the parents of the infant's gains in height and weight

Answer: 2 Explanation: 1. The first step in the nursing process is assessment; therefore, the nurse should assess the interactions of the parents with the newborn. Providing pamphlets to help educate the parents should be done at each appropriate office visit; however, the pamphlets would be distributed after assessment of parent needs. While the nurse should be a role model for nurturing behaviors during the office visit, this would not be the first thing the nurse performs at the office visit. While parents are informed of the infant's gains in height and weight, this activity does not take priority. 2. The first step in the nursing process is assessment; therefore, the nurse should assess the interactions of the parents with the newborn. Providing pamphlets to help educate the parents should be done at each appropriate office visit; however, the pamphlets would be distributed after assessment of parent needs. While the nurse should be a role model for nurturing behaviors during the office visit, this would not be the first thing the nurse performs at the office visit. While parents are informed of the infant's gains in height and weight, this activity does not take priority. 3. The first step in the nursing process is assessment; therefore, the nurse should assess the interactions of the parents with the newborn. Providing pamphlets to help educate the parents should be done at each appropriate office visit; however, the pamphlets would be distributed after assessment of parent needs. While the nurse should be a role model for nurturing behaviors during the office visit, this would not be the first thing the nurse performs at the office visit. While parents are informed of the infant's gains in height and weight, this activity does not take priority. 4. The first step in the nursing process is assessment; therefore, the nurse should assess the interactions of the parents with the newborn. Providing pamphlets to help educate the parents should be done at each appropriate office visit; however, the pamphlets would be distributed after assessment of parent needs. While the nurse should be a role model for nurturing behaviors during the office visit, this would not be the first thing the nurse performs at the office visit. While parents are informed of the infant's gains in height and weight, this activity does not take priority.

The telephone triage nurse receives a call from a parent who states that her 18-month-old is making a crowing sound when he breathes and is hard to wake up. Which action by the nurse is the most appropriate? 1. Obtain the history of the illness from the parent. 2. Advise the parent to hang up and call 9-1-1. 3. Make an appointment for the child to see the healthcare provider. 4. Reassure the parent and provide instructions on home care for the child.

Answer: 2 Explanation: 1. The nurse should immediately recognize the symptoms of severe upper respiratory distress and advise the parent to call 9-1-1. Crowing is heard when there is severe narrowing of the airway. The other actions would be appropriate in nonemergency situations. 2. The nurse should immediately recognize the symptoms of severe upper respiratory distress and advise the parent to call 9-1-1. Crowing is heard when there is severe narrowing of the airway. The other actions would be appropriate in nonemergency situations. 3. The nurse should immediately recognize the symptoms of severe upper respiratory distress and advise the parent to call 9-1-1. Crowing is heard when there is severe narrowing of the airway. The other actions would be appropriate in nonemergency situations. 4. The nurse should immediately recognize the symptoms of severe upper respiratory distress and advise the parent to call 9-1-1. Crowing is heard when there is severe narrowing of the airway. The other actions would be appropriate in nonemergency situations.

The nurse is assessing an adolescent client whose weight is in the 5th percentile. Based on this information, which question is most appropriate for the nurse to ask the adolescent client? 1. "Do you eat the school lunches?" 2. "Do you have any concerns about your weight?" 3. "Do you eat fruits, vegetables, and drink milk?" 4. "How many meals do you eat each day?"

Answer: 2 Explanation: 1. The only question that addresses the adolescent's weight, which is below the expected norm, is "Do you have any concerns about your weight?" Asking about school lunches, eating fruits and vegetables, and how many meals eaten each day should be used to obtain a nutritional history; however, those questions do not address the underweight status of the adolescent. 2. The only question that addresses the adolescent's weight, which is below the expected norm, is "Do you have any concerns about your weight?" Asking about school lunches, eating fruits and vegetables, and how many meals eaten each day should be used to obtain a nutritional history; however, those questions do not address the underweight status of the adolescent. 3. The only question that addresses the adolescent's weight, which is below the expected norm, is "Do you have any concerns about your weight?" Asking about school lunches, eating fruits and vegetables, and how many meals eaten each day should be used to obtain a nutritional history; however, those questions do not address the underweight status of the adolescent. 4. The only question that addresses the adolescent's weight, which is below the expected norm, is "Do you have any concerns about your weight?" Asking about school lunches, eating fruits and vegetables, and how many meals eaten each day should be used to obtain a nutritional history; however, those questions do not address the underweight status of the adolescent.

A school-age client who recently moved to a new school in a different town presents to an ambulatory care center and describes the following: "I have no friends in my new school and I no longer want to play soccer. I know I will be lonely there, too." Which of these takes priority when speaking with the school-age client? 1. Helping the school-age client realize the value of soccer 2. Promoting healthy mental-health outcomes 3. Acknowledging the fact that it takes several months to make new friends at a new school 4. Stressing the importance of remaining in a close parent-child relationship during these stressful times

Answer: 2 Explanation: 1. The school-age client is obviously lonely with the move to the new school. The nurse should focus on appropriate coping skills, which will enhance good mental-health outcomes for the child. It would not be appropriate to discuss the importance of soccer at this time, since the school-age client must deal with the loss of friends and developing new friendships first. The parent-child relationship should not be used as a substitute for the development of new peer relationships. 2. The school-age client is obviously lonely with the move to the new school. The nurse should focus on appropriate coping skills, which will enhance good mental-health outcomes for the child. It would not be appropriate to discuss the importance of soccer at this time, since the school-age client must deal with the loss of friends and developing new friendships first. The parent-child relationship should not be used as a substitute for the development of new peer relationships. 3. The school-age client is obviously lonely with the move to the new school. The nurse should focus on appropriate coping skills, which will enhance good mental-health outcomes for the child. It would not be appropriate to discuss the importance of soccer at this time, since the school-age client must deal with the loss of friends and developing new friendships first. The parent-child relationship should not be used as a substitute for the development of new peer relationships. 4. The school-age client is obviously lonely with the move to the new school. The nurse should focus on appropriate coping skills, which will enhance good mental-health outcomes for the child. It would not be appropriate to discuss the importance of soccer at this time, since the school-age client must deal with the loss of friends and developing new friendships first. The parent-child relationship should not be used as a substitute for the development of new peer relationships.

A 9-year-old child who has been followed in the same pediatric home since birth is at the healthcare center for a well-child visit. A nurse who measures the height and weight of the child documents 35th percentile for height and 90th percentile for weight. How should the nurse interpret these data? 1. The child is beginning a growth spurt. 2. The child is obese and needs dietary counseling. 3. The parents are most likely below the 50th percentile for height and weight. 4. As soon as the child begins the adolescent growth spurt, the height and weight measurements will normalize.

Answer: 2 Explanation: 1. These data show that the child is disproportionate in height and weight. This child's weight is very high in comparison to height. The child would appear obese. Dietary history and counseling are the first steps. This child may also need an endocrine evaluation. This is not a growth spurt since height is what is referred to as a growth spurt. No assumptions about the parents can be made from the data presented. The statement about the adolescent growth spurt is incorrect for a child of this age. 2. These data show that the child is disproportionate in height and weight. This child's weight is very high in comparison to height. The child would appear obese. Dietary history and counseling are the first steps. This child may also need an endocrine evaluation. This is not a growth spurt since height is what is referred to as a growth spurt. No assumptions about the parents can be made from the data presented. The statement about the adolescent growth spurt is incorrect for a child of this age. 3. These data show that the child is disproportionate in height and weight. This child's weight is very high in comparison to height. The child would appear obese. Dietary history and counseling are the first steps. This child may also need an endocrine evaluation. This is not a growth spurt since height is what is referred to as a growth spurt. No assumptions about the parents can be made from the data presented. The statement about the adolescent growth spurt is incorrect for a child of this age. 4. These data show that the child is disproportionate in height and weight. This child's weight is very high in comparison to height. The child would appear obese. Dietary history and counseling are the first steps. This child may also need an endocrine evaluation. This is not a growth spurt since height is what is referred to as a growth spurt. No assumptions about the parents can be made from the data presented. The statement about the adolescent growth spurt is incorrect for a child of this age.

A 27-month-old toddler who is in the pediatric office for a well-child visit begins to cry the moment he is placed on the examination table. The parent attempts to comfort the toddler; however, nothing is effective. Which of these actions by the nurse takes priority? 1. Instruct the father to hold the toddler down tightly to complete the examination. 2. Allow the toddler to sit on the parent's lap and begin the assessment. 3. Allow the toddler to stand on the floor until he stops crying. 4. Ask another nurse in the office to hold the toddler, because the parent is not able to control the toddler's behavior.

Answer: 2 Explanation: 1. Toddlers are most comfortable when sitting with the parents. Much of the examination can be completed in this way. Allowing the toddler to stand on the floor is inappropriate. A nurse can assist if the parent is unable to hold the child during the examination of the throat and ears to prevent injury from movement. 2. Toddlers are most comfortable when sitting with the parents. Much of the examination can be completed in this way. Allowing the toddler to stand on the floor is inappropriate. A nurse can assist if the parent is unable to hold the child during the examination of the throat and ears to prevent injury from movement. 3. Toddlers are most comfortable when sitting with the parents. Much of the examination can be completed in this way. Allowing the toddler to stand on the floor is inappropriate. A nurse can assist if the parent is unable to hold the child during the examination of the throat and ears to prevent injury from movement. 4. Toddlers are most comfortable when sitting with the parents. Much of the examination can be completed in this way. Allowing the toddler to stand on the floor is inappropriate. A nurse can assist if the parent is unable to hold the child during the examination of the throat and ears to prevent injury from movement.

The community-health nurse is planning an education session for recently hired teachers at a child-care center. Which item is priority for the community-health nurse to include in the educational session? 1. The schedule for immunizations 2. Principles of infection control 3. How to interpret healthcare records 4. How to take a temperature

Answer: 2 Explanation: 1. While all of the information is nice to know, it is most essential that teachers know principles of infection control to decrease the spread of germs that can cause disease in young children. 2. While all of the information is nice to know, it is most essential that teachers know principles of infection control to decrease the spread of germs that can cause disease in young children. 3. While all of the information is nice to know, it is most essential that teachers know principles of infection control to decrease the spread of germs that can cause disease in young children. 4. While all of the information is nice to know, it is most essential that teachers know principles of infection control to decrease the spread of germs that can cause disease in young children.

The nurse is assessing the toddler for early childhood caries. The nurse will teach the family which factors contribute to this condition? Select all that apply. 1. Inadequate activity 2. Inadequate dental care 3. Inadequate diet 4. Inadequate brushing 5. Inadequate pacifiers

Answer: 2, 3, 4 Explanation: 1. Early childhood caries is promoted by inadequate preventive care, which can include diet, brushing, feeding habits, and lack of dental care. ECC is serious because young children with the condition are more likely to have continuing dental problems that can influence speech, cause pain, and delay development. 2. Early childhood caries is promoted by inadequate preventive care, which can include diet, brushing, feeding habits, and lack of dental care. ECC is serious because young children with the condition are more likely to have continuing dental problems that can influence speech, cause pain, and delay development. 3. Early childhood caries is promoted by inadequate preventive care, which can include diet, brushing, feeding habits, and lack of dental care. ECC is serious because young children with the condition are more likely to have continuing dental problems that can influence speech, cause pain, and delay development. 4. Early childhood caries is promoted by inadequate preventive care, which can include diet, brushing, feeding habits, and lack of dental care. ECC is serious because young children with the condition are more likely to have continuing dental problems that can influence speech, cause pain, and delay development. 5. Early childhood caries is promoted by inadequate preventive care, which can include diet, brushing, feeding habits, and lack of dental care. ECC is serious because young children with the condition are more likely to have continuing dental problems that can influence speech, cause pain, and delay development.

The nurse is assessing a school-age child's extraocular movements. The nurse recognizes which cranial nerves that involve testing extraocular movements? Select all that apply. 1. VII 2. III 3. IV 4. XII 5. VI

Answer: 2, 3, 5 Explanation: 1. VII is the facial nerve and is not involved in testing extraocular movements. Cranial nerves III, IV, and VI dominate eye movements and pupil constriction. Cranial nerve VII dominates the person's ability to smile and frown and cranial nerve XII dominates tongue movements. 2. III is the nerve and is involved in testing extraocular movements. 3. IV is the nerve and is involved in testing extraocular movements. 4. XII is the hypoglossal nerve and is not involved in testing extraocular movements. Cranial nerves III, IV, and VI dominate eye movements and pupil constriction. Cranial nerve VII dominates the person's ability to smile and frown and cranial nerve XII dominates tongue movements. 5. VI is the nerve and is involved in testing extraocular movements.

Which of these developmental milestones should the nurse expect to find in children who are between 2 and 3 years old? Select all that apply. 1. Always feeds self 2. Scribbles and draws on paper 3. Kicks a ball 4. Throws ball overhand 5. Goes up and down stairs

Answer: 2, 3, 5 Explanation: 1. Children between the ages of 2 and 3 years can scribble and draw on paper, kick a ball, and go up and down the stairs. Children who are between the ages of 3 and 4 years can feed themselves. Children between the ages of 4 and 5 years can throw a ball overhand. 2. Children between the ages of 2 and 3 years can scribble and draw on paper, kick a ball, and go up and down the stairs. Children who are between the ages of 3 and 4 years can feed themselves. Children between the ages of 4 and 5 years can throw a ball overhand. 3. Children between the ages of 2 and 3 years can scribble and draw on paper, kick a ball, and go up and down the stairs. Children who are between the ages of 3 and 4 years can feed themselves. Children between the ages of 4 and 5 years can throw a ball overhand. 4. Children between the ages of 2 and 3 years can scribble and draw on paper, kick a ball, and go up and down the stairs. Children who are between the ages of 3 and 4 years can feed themselves. Children between the ages of 4 and 5 years can throw a ball overhand. 5. Children between the ages of 2 and 3 years can scribble and draw on paper, kick a ball, and go up and down the stairs. Children who are between the ages of 3 and 4 years can feed themselves. Children between the ages of 4 and 5 years can throw a ball overhand.

The nurse is preparing to assess a toddler client. Which activities would gain cooperation from the toddler? Select all that apply. 1. Asking the parents to wait outside 2. Allowing the client to sit in the parent's lap 3. Administering vaccinations prior to the assessment 4. Handing the client a stethoscope while taking the health history 5. Making a game out of the assessment process

Answer: 2, 4 Explanation: 1. Allowing the client to stay on the parents lap and allowing the client to play with instruments that will be used in the assessment process are activities the nurse can implement to gain the toddler's cooperation during the assessment process. Asking the parents to wait outside may cause the toddler to become fearful. Vaccinations should be administered at the end of the visit. While making a game out of the assessment process may be appropriate for older children, this is not an appropriate strategy for a toddler client. 2. Allowing the client to stay on the parents lap and allowing the client to play with instruments that will be used in the assessment process are activities the nurse can implement to gain the toddler's cooperation during the assessment process. Asking the parents to wait outside may cause the toddler to become fearful. Vaccinations should be administered at the end of the visit. While making a game out of the assessment process may be appropriate for older children, this is not an appropriate strategy for a toddler client. 3. Allowing the client to stay on the parents lap and allowing the client to play with instruments that will be used in the assessment process are activities the nurse can implement to gain the toddler's cooperation during the assessment process. Asking the parents to wait outside may cause the toddler to become fearful. Vaccinations should be administered at the end of the visit. While making a game out of the assessment process may be appropriate for older children, this is not an appropriate strategy for a toddler client. 4. Allowing the client to stay on the parents lap and allowing the client to play with instruments that will be used in the assessment process are activities the nurse can implement to gain the toddler's cooperation during the assessment process. Asking the parents to wait outside may cause the toddler to become fearful. Vaccinations should be administered at the end of the visit. While making a game out of the assessment process may be appropriate for older children, this is not an appropriate strategy for a toddler client. 5. Allowing the client to stay on the parents lap and allowing the client to play with instruments that will be used in the assessment process are activities the nurse can implement to gain the toddler's cooperation during the assessment process. Asking the parents to wait outside may cause the toddler to become fearful. Vaccinations should be administered at the end of the visit. While making a game out of the assessment process may be appropriate for older children, this is not an appropriate strategy for a toddler client.

The nurse is teaching the mothers of three-month-olds about oral health. Which of the following should the nurse include? Select all that apply. 1. Include iron vitamins once a day. 2. Avoid breastfeeding or drinking from a bottle when sleeping. 3. Allow to drink from a bottle at will during the day. 4. Cleanse gums 1 to 2 times a day. 5. Put baby to bed with a bottle of 2 percent milk only.

Answer: 2, 4 Explanation: 1. The parents should wipe the infant's gums with soft moist gauze once or twice daily. Families are also cautioned to avoid having the infant breastfeed when sleeping, to avoid use of bottles in bed, and not to allow the infant to drink at will from a bottle during the day. These practices are linked to early childhood caries and can lead to tooth decay. 2. The parents should wipe the infant's gums with soft moist gauze once or twice daily. Families are also cautioned to avoid having the infant breastfeed when sleeping, to avoid use of bottles in bed, and not to allow the infant to drink at will from a bottle during the day. These practices are linked to early childhood caries and can lead to tooth decay. 3. The parents should wipe the infant's gums with soft moist gauze once or twice daily. Families are also cautioned to avoid having the infant breastfeed when sleeping, to avoid use of bottles in bed, and not to allow the infant to drink at will from a bottle during the day. These practices are linked to early childhood caries and can lead to tooth decay. 4. The parents should wipe the infant's gums with soft moist gauze once or twice daily. Families are also cautioned to avoid having the infant breastfeed when sleeping, to avoid use of bottles in bed, and not to allow the infant to drink at will from a bottle during the day. These practices are linked to early childhood caries and can lead to tooth decay. 5. The parents should wipe the infant's gums with soft moist gauze once or twice daily. Families are also cautioned to avoid having the infant breastfeed when sleeping, to avoid use of bottles in bed, and not to allow the infant to drink at will from a bottle during the day. These practices are linked to early childhood caries and can lead to tooth decay.

Which health promotion activities can the nurse recommend to the parents of a preschool-age child in order to enhance the child's self-concept? Select all that apply. 1. Encourage a play date with a school-age child. 2. Praise the child for staying dry at night. 3. Tell the child there will be a punishment for bathroom accidents. 4. Set aside time for the child each day. 5. Discuss appropriate activities to engage in with the daycare provider.

Answer: 2, 4, 5 Explanation: 1. Health promotion activities focus on development of a healthy self-concept in the toddler and young child by helping parents to set up successful play experiences, to praise the child for successes, to use effective limit-setting techniques, and to realize and appreciate the child's unique characteristics. Health maintenance seeks to avoid the poor self-image that can occur with constant criticism or expectations not in alignment with the toddler's or preschooler's developmental capabilities. 2. Health promotion activities focus on development of a healthy self-concept in the toddler and young child by helping parents to set up successful play experiences, to praise the child for successes, to use effective limit-setting techniques, and to realize and appreciate the child's unique characteristics. Health maintenance seeks to avoid the poor self-image that can occur with constant criticism or expectations not in alignment with the toddler's or preschooler's developmental capabilities. 3. Health promotion activities focus on development of a healthy self-concept in the toddler and young child by helping parents to set up successful play experiences, to praise the child for successes, to use effective limit-setting techniques, and to realize and appreciate the child's unique characteristics. Health maintenance seeks to avoid the poor self-image that can occur with constant criticism or expectations not in alignment with the toddler's or preschooler's developmental capabilities. 4. Health promotion activities focus on development of a healthy self-concept in the toddler and young child by helping parents to set up successful play experiences, to praise the child for successes, to use effective limit-setting techniques, and to realize and appreciate the child's unique characteristics. Health maintenance seeks to avoid the poor self-image that can occur with constant criticism or expectations not in alignment with the toddler's or preschooler's developmental capabilities. 5. Health promotion activities focus on development of a healthy self-concept in the toddler and young child by helping parents to set up successful play experiences, to praise the child for successes, to use effective limit-setting techniques, and to realize and appreciate the child's unique characteristics. Health maintenance seeks to avoid the poor self-image that can occur with constant criticism or expectations not in alignment with the toddler's or preschooler's developmental capabilities.

The nurse is taking a health history from a family of a 3-year-old child. Which statement by the nurse would most likely establish rapport and elicit an accurate response from the family? 1. "Does any member of your family have a history of asthma, heart disease, or diabetes?" 2. "Hello, I would like to talk with you and get some information on you and your child." 3. "Tell me about the concerns that brought you to the clinic today." 4. "You will need to fill out these forms; make sure that the information is as complete as possible."

Answer: 3 Explanation: 1. Asking the parents to talk about their concerns is an open-ended question and one which is more likely to establish rapport and an understanding of the parent's perceptions. Giving the family a list of items to answer at once may be confusing to the parents. Giving an introduction before asking the parents for information is likely to establish rapport, but giving an explanation of why the information would be needed would be even more effective at establishing rapport and also for getting more accurate, pertinent information. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified if the nurse is directing the interview. Asking the parents to talk about their concerns is an open-ended question and one which is more likely to establish rapport and an understanding of the parent's perceptions. Giving the family a list of items to answer at once may be confusing to the parents. Giving an introduction before asking the parents for information is likely to establish rapport, but giving an explanation of why the information would be needed would be even more effective at establishing rapport and also for getting more accurate, pertinent information. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified if the nurse is directing the interview. 3. Asking the parents to talk about their concerns is an open-ended question and one which is more likely to establish rapport and an understanding of the parent's perceptions. Giving the family a list of items to answer at once may be confusing to the parents. Giving an introduction before asking the parents for information is likely to establish rapport, but giving an explanation of why the information would be needed would be even more effective at establishing rapport and also for getting more accurate, pertinent information. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified if the nurse is directing the interview. 4. Asking the parents to talk about their concerns is an open-ended question and one which is more likely to establish rapport and an understanding of the parent's perceptions. Giving the family a list of items to answer at once may be confusing to the parents. Giving an introduction before asking the parents for information is likely to establish rapport, but giving an explanation of why the information would be needed would be even more effective at establishing rapport and also for getting more accurate, pertinent information. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified if the nurse is directing the interview.

The school nurse is preparing a plan of care specific to several children in the school who have asthma. What is the initial action on the plan of care? 1. Call 911 to request emergency medical assistance. 2. Call the child's parents to come and pick up the child. 3. Have the child use his or her metered-dose inhaler. 4. Have the child lie down to see if the symptoms subside.

Answer: 3 Explanation: 1. A child with a history of asthma may have episodes of wheezing that can be controlled by prompt use of the child's rescue inhaler. An inhaler should be readily available in the school setting for a child previously diagnosed with asthma. This should be tried first. Emergency personnel should be notified if the inhaler does not provide relief and the child is in respiratory distress. Parents may be notified if the child does not feel well, but this is not the initial action. Having the child lie down will likely worsen his condition. 2. A child with a history of asthma may have episodes of wheezing that can be controlled by prompt use of the child's rescue inhaler. An inhaler should be readily available in the school setting for a child previously diagnosed with asthma. This should be tried first. Emergency personnel should be notified if the inhaler does not provide relief and the child is in respiratory distress. Parents may be notified if the child does not feel well, but this is not the initial action. Having the child lie down will likely worsen his condition. 3. A child with a history of asthma may have episodes of wheezing that can be controlled by prompt use of the child's rescue inhaler. An inhaler should be readily available in the school setting for a child previously diagnosed with asthma. This should be tried first. Emergency personnel should be notified if the inhaler does not provide relief and the child is in respiratory distress. Parents may be notified if the child does not feel well, but this is not the initial action. Having the child lie down will likely worsen his condition. 4. A child with a history of asthma may have episodes of wheezing that can be controlled by prompt use of the child's rescue inhaler. An inhaler should be readily available in the school setting for a child previously diagnosed with asthma. This should be tried first. Emergency personnel should be notified if the inhaler does not provide relief and the child is in respiratory distress. Parents may be notified if the child does not feel well, but this is not the initial action. Having the child lie down will likely worsen his condition.

An adolescent female presents at a nurse practitioner's office and requests a signature for working papers. The nurse reviews her chart and notes that the last physical examination was two years ago. In addition to providing the signature for the working papers, what else should the nurse use this visit? 1. An opportunity to discuss birth-control measures 2. A time to discuss exercise and sports participation 3. A health-supervision opportunity 4. A chance to discuss the importance of pursuing post-secondary education

Answer: 3 Explanation: 1. All visits should be used as health-promotion and health-supervision visits. While discussing birth control, exercise, and future plans is important, these can be included in the overall health-supervision protocols. 2. All visits should be used as health-promotion and health-supervision visits. While discussing birth control, exercise, and future plans is important, these can be included in the overall health-supervision protocols. 3. All visits should be used as health-promotion and health-supervision visits. While discussing birth control, exercise, and future plans is important, these can be included in the overall health-supervision protocols. 4. All visits should be used as health-promotion and health-supervision visits. While discussing birth control, exercise, and future plans is important, these can be included in the overall health-supervision protocols.

During an examination, a nurse asks a 5-year-old child to repeat his address. What is the nurse evaluating with this action? 1. Recent memory 2. Language development 3. Remote memory 4. Social-skill development

Answer: 3 Explanation: 1. Asking children to remember addresses, phone numbers, and dates assesses remote-memory development. To evaluate recent memory, the nurse would have the child name something and then ask him to name it again in 10 to 15 minutes. Listening to how the child talks and his sentence structure evaluates the child's language development, and assessing how he interacts with others evaluates social-skill development. 2. Asking children to remember addresses, phone numbers, and dates assesses remote-memory development. To evaluate recent memory, the nurse would have the child name something and then ask him to name it again in 10 to 15 minutes. Listening to how the child talks and his sentence structure evaluates the child's language development, and assessing how he interacts with others evaluates social-skill development. 3. Asking children to remember addresses, phone numbers, and dates assesses remote-memory development. To evaluate recent memory, the nurse would have the child name something and then ask him to name it again in 10 to 15 minutes. Listening to how the child talks and his sentence structure evaluates the child's language development, and assessing how he interacts with others evaluates social-skill development. 4. Asking children to remember addresses, phone numbers, and dates assesses remote-memory development. To evaluate recent memory, the nurse would have the child name something and then ask him to name it again in 10 to 15 minutes. Listening to how the child talks and his sentence structure evaluates the child's language development, and assessing how he interacts with others evaluates social-skill development.

A nurse obtains a nutritional health history from a 10-year-old child. Which of these food selections, if consumed on a regular basis, should lead the nurse to become concerned about the need for improving oral hygiene? 1. Peanuts and crackers 2. Sorbet and yogurt 3. Gummy bears and licorice 4. Fluoridated water

Answer: 3 Explanation: 1. Food items that stick to the teeth lead to dental caries. Items such as gummy bears and licorice all stick to the teeth and lead to dental caries. Foods such as peanut butter, crackers, sorbet, and yogurt do not stick to the teeth and are not considered foods that increase dental caries. Fluoridated water has been shown to decrease the incidence of dental caries. 2. Food items that stick to the teeth lead to dental caries. Items such as gummy bears and licorice all stick to the teeth and lead to dental caries. Foods such as peanut butter, crackers, sorbet, and yogurt do not stick to the teeth and are not considered foods that increase dental caries. Fluoridated water has been shown to decrease the incidence of dental caries. 3. Food items that stick to the teeth lead to dental caries. Items such as gummy bears and licorice all stick to the teeth and lead to dental caries. Foods such as peanut butter, crackers, sorbet, and yogurt do not stick to the teeth and are not considered foods that increase dental caries. Fluoridated water has been shown to decrease the incidence of dental caries. 4. Food items that stick to the teeth lead to dental caries. Items such as gummy bears and licorice all stick to the teeth and lead to dental caries. Foods such as peanut butter, crackers, sorbet, and yogurt do not stick to the teeth and are not considered foods that increase dental caries. Fluoridated water has been shown to decrease the incidence of dental caries.

A nurse asks the mother of a 4-month-old infant to undress the infant. The nurse observes the mother taking off several layers of clothing and knows that the outdoor temperature is 70 degrees Fahrenheit. Which statement by the nurse is most appropriate in this situation? 1. "My, you are dressing your infant warmly today." 2. "Did you think it was cold when you left your home this morning?" 3. "I see that you have many layers of clothing on your baby. This may cause your baby's temperature to rise." 4. "When you leave the office, only put one layer of clothing on your baby."

Answer: 3 Explanation: 1. In this scenario, the mother has overdressed the infant. The nurse needs to gently inform the mother of this problem and to provide information to the mother on why it is a problem. Just making a statement on how warmly the child is dressed will not accomplish this goal or just telling the mother to only put one layer of clothing on the child does not provide a rationale for the mother to make a better decision the next time, so this statement also is not helpful to the mother. 2. In this scenario, the mother has overdressed the infant. The nurse needs to gently inform the mother of this problem and to provide information to the mother on why it is a problem. Just making a statement on how warmly the child is dressed will not accomplish this goal or just telling the mother to only put one layer of clothing on the child does not provide a rationale for the mother to make a better decision the next time, so this statement also is not helpful to the mother. 3. In this scenario, the mother has overdressed the infant. The nurse needs to gently inform the mother of this problem and to provide information to the mother on why it is a problem. Just making a statement on how warmly the child is dressed will not accomplish this goal or just telling the mother to only put one layer of clothing on the child does not provide a rationale for the mother to make a better decision the next time, so this statement also is not helpful to the mother. 4. In this scenario, the mother has overdressed the infant. The nurse needs to gently inform the mother of this problem and to provide information to the mother on why it is a problem. Just making a statement on how warmly the child is dressed will not accomplish this goal or just telling the mother to only put one layer of clothing on the child does not provide a rationale for the mother to make a better decision the next time, so this statement also is not helpful to the mother.

The nurse is caring for a newly-admitted infant diagnosed with "failure to thrive." The nurse begins to implement the healthcare provider prescribed orders by taking blood pressures in all four extremities. Which congenital cardiac defect does the nurse anticipate based on the prescribed order? 1. Tetralogy of Fallot 2. Pulmonary atresia 3. Coarctation of the aorta 4. Ventricular septal defect

Answer: 3 Explanation: 1. Normally, blood pressures in the lower extremities are the same as or higher than upper-extremity blood pressures. But in coarctation of the aorta, the narrowing of the aorta causes decreased blood flow to the lower extremities and thus lower-extremity blood-pressure readings are significantly lower than upper-extremity readings. There are minimal differences between upper and lower blood-pressure readings in tetralogy of Fallot, pulmonary atresia, and ventricular septal defect. 2. Normally, blood pressures in the lower extremities are the same as or higher than upper-extremity blood pressures. But in coarctation of the aorta, the narrowing of the aorta causes decreased blood flow to the lower extremities and thus lower-extremity blood-pressure readings are significantly lower than upper-extremity readings. There are minimal differences between upper and lower blood-pressure readings in tetralogy of Fallot, pulmonary atresia, and ventricular septal defect. 3. Normally, blood pressures in the lower extremities are the same as or higher than upper-extremity blood pressures. But in coarctation of the aorta, the narrowing of the aorta causes decreased blood flow to the lower extremities and thus lower-extremity blood-pressure readings are significantly lower than upper-extremity readings. There are minimal differences between upper and lower blood-pressure readings in tetralogy of Fallot, pulmonary atresia, and ventricular septal defect. 4. Normally, blood pressures in the lower extremities are the same as or higher than upper-extremity blood pressures. But in coarctation of the aorta, the narrowing of the aorta causes decreased blood flow to the lower extremities and thus lower-extremity blood-pressure readings are significantly lower than upper-extremity readings. There are minimal differences between upper and lower blood-pressure readings in tetralogy of Fallot, pulmonary atresia, and ventricular septal defect.

A mother asks which developmental milestones she can expect when her baby is 6 months old. Which response by the nurse is the most appropriate? 1. Lifts head momentarily when prone 2. Has well-developed pincer grasp 3. Transfers objects from one hand to the other 4. Rolls from front to back

Answer: 3 Explanation: 1. Lifting head when prone is a milestone at 1 month. A well-developed pincer grasp is a milestone at 12 months. Transferring objects from one hand to the other is a milestone at 6 months. Rolling from front to back is a milestone at 4 months. 2. Lifting head when prone is a milestone at 1 month. A well-developed pincer grasp is a milestone at 12 months. Transferring objects from one hand to the other is a milestone at 6 months. Rolling from front to back is a milestone at 4 months. 3. Lifting head when prone is a milestone at 1 month. A well-developed pincer grasp is a milestone at 12 months. Transferring objects from one hand to the other is a milestone at 6 months. Rolling from front to back is a milestone at 4 months. 4. Lifting head when prone is a milestone at 1 month. A well-developed pincer grasp is a milestone at 12 months. Transferring objects from one hand to the other is a milestone at 6 months. Rolling from front to back is a milestone at 4 months.

Injury prevention is an important aspect of parent teaching. Which injury prevention strategy would reduce the risk of suffocation? 1. Measure crib slat spacing at 2-3/8 inches or less. 2. Never leave an infant alone in a bath. 3. Position the infant on her back to sleep. 4. Use only approved restraint systems.

Answer: 3 Explanation: 1. Measuring crib slats will reduce strangulation. Not leaving an infant alone in a bath will reduce drowning. Positioning an infant on her back will reduce suffocation. Using approved restraint systems will reduce motor vehicle injury. 2. Measuring crib slats will reduce strangulation. Not leaving an infant alone in a bath will reduce drowning. Positioning an infant on her back will reduce suffocation. Using approved restraint systems will reduce motor vehicle injury. 3. Measuring crib slats will reduce strangulation. Not leaving an infant alone in a bath will reduce drowning. Positioning an infant on her back will reduce suffocation. Using approved restraint systems will reduce motor vehicle injury. 4. Measuring crib slats will reduce strangulation. Not leaving an infant alone in a bath will reduce drowning. Positioning an infant on her back will reduce suffocation. Using approved restraint systems will reduce motor vehicle injury.

The school health nurse is evaluating the home environment of several children as it relates to child safety. The nurse visits the home of each child and gathers the following data. Which activity places a child at greatest risk for bodily harm? 1. The parents are in a methadone program. 2. The parents consume alcohol on a daily basis. 3. The child is permitted to target practice with a revolver, unsupervised. 4. The child is a latchkey child.

Answer: 3 Explanation: 1. Of all the activities mentioned, the child who is playing with guns is most at risk for injury. The inappropriate behaviors, such as drug and alcohol use or past use, also place the child at risk, but the use of firearms is more risky. A latchkey child needs special attention but in regard to the situations given is not at the greatest risk of injury. 2. Of all the activities mentioned, the child who is playing with guns is most at risk for injury. The inappropriate behaviors, such as drug and alcohol use or past use, also place the child at risk, but the use of firearms is more risky. A latchkey child needs special attention but in regard to the situations given is not at the greatest risk of injury. 3. Of all the activities mentioned, the child who is playing with guns is most at risk for injury. The inappropriate behaviors, such as drug and alcohol use or past use, also place the child at risk, but the use of firearms is more risky. A latchkey child needs special attention but in regard to the situations given is not at the greatest risk of injury. 4. Of all the activities mentioned, the child who is playing with guns is most at risk for injury. The inappropriate behaviors, such as drug and alcohol use or past use, also place the child at risk, but the use of firearms is more risky. A latchkey child needs special attention but in regard to the situations given is not at the greatest risk of injury.

Some nursing students are discussing job options. One of the student states that a position as a school nurse sounds interesting. What is an important role of the school nurse? 1. Screening for congenital heart disease 2. Prescribing antibiotics for streptococcal pharyngitis 3. Developing a plan for emergency care of injured children 4. Diagnosing an ear infection

Answer: 3 Explanation: 1. Screening of students for certain conditions; educating students, teachers, and staff; and developing emergency plans are all roles of the school nurse. Diagnosing acute illness and prescribing medication for a new illness are beyond the scope of practice for the school nurse unless the nurse is licensed as an advance-practice nurse. 2. Screening of students for certain conditions; educating students, teachers, and staff; and developing emergency plans are all roles of the school nurse. Diagnosing acute illness and prescribing medication for a new illness are beyond the scope of practice for the school nurse unless the nurse is licensed as an advance-practice nurse. 3. Screening of students for certain conditions; educating students, teachers, and staff; and developing emergency plans are all roles of the school nurse. Diagnosing acute illness and prescribing medication for a new illness are beyond the scope of practice for the school nurse unless the nurse is licensed as an advance-practice nurse. 4. Screening of students for certain conditions; educating students, teachers, and staff; and developing emergency plans are all roles of the school nurse. Diagnosing acute illness and prescribing medication for a new illness are beyond the scope of practice for the school nurse unless the nurse is licensed as an advance-practice nurse.

The nurse is evaluating the car seat of a 3-year-old who weighs 42 pounds. Which recommendation should the nurse make about the car seat to the parents? 1. Convertible, rear-facing seat 2. Belt-positioning booster seat 3. A car seat with a harness approved for higher weights and heights 4. A regular seat with lap and shoulder strap

Answer: 3 Explanation: 1. The American Academy of Pediatrics and the National Highway Safety Administration recommend booster seats for children over 40 pounds and 4 years of age. A 3-year-old should be in a regular car seat with approved harness for higher-weight/height children so that the child is protected from injury. Rear-facing seats and regular seat with lap and shoulder strap are not appropriate for a 3-year-old. 2. The American Academy of Pediatrics and the National Highway Safety Administration recommend booster seats for children over 40 pounds and 4 years of age. A 3-year-old should be in a regular car seat with approved harness for higher-weight/height children so that the child is protected from injury. Rear-facing seats and regular seat with lap and shoulder strap are not appropriate for a 3-year-old. 3. The American Academy of Pediatrics and the National Highway Safety Administration recommend booster seats for children over 40 pounds and 4 years of age. A 3-year-old should be in a regular car seat with approved harness for higher-weight/height children so that the child is protected from injury. Rear-facing seats and regular seat with lap and shoulder strap are not appropriate for a 3-year-old. 4. The American Academy of Pediatrics and the National Highway Safety Administration recommend booster seats for children over 40 pounds and 4 years of age. A 3-year-old should be in a regular car seat with approved harness for higher-weight/height children so that the child is protected from injury. Rear-facing seats and regular seat with lap and shoulder strap are not appropriate for a 3-year-old.

A new mother is worried about a "soft spot" on the top of her newborn infant's head. The nurse informs her that this is a normal physical finding called the anterior fontanel. At what age will the nurse educate the mother that the soft spot will close? 1. 2 to 3 months of age 2. 6 to 9 months of age 3. 12 to 18 months of age 4. Approximately 2 years of age

Answer: 3 Explanation: 1. The anterior fontanel is located at the top of the head and is the opening at the intersection of the suture lines. As the infant grows, the suture lines begin to fuse, and the anterior fontanel closes at 12 to 18 months of age. 2. The anterior fontanel is located at the top of the head and is the opening at the intersection of the suture lines. As the infant grows, the suture lines begin to fuse, and the anterior fontanel closes at 12 to 18 months of age. 3. The anterior fontanel is located at the top of the head and is the opening at the intersection of the suture lines. As the infant grows, the suture lines begin to fuse, and the anterior fontanel closes at 12 to 18 months of age. 4. The anterior fontanel is located at the top of the head and is the opening at the intersection of the suture lines. As the infant grows, the suture lines begin to fuse, and the anterior fontanel closes at 12 to 18 months of age.

A nurse observes the parent/child interaction during the 4-year-old well-child checkup and notes that the parent speaks harshly to the child and uses negative remarks when speaking with the nurse. Which statement by the nurse would be most beneficial? 1. "Perhaps you should leave the room so that I can speak with your child privately." 2. "I am going to refer you for counseling since your interactions with your child seem so negative." 3. "Let's talk privately. Let's discuss the way you speak with your child and possible ways to be more positive." 4. Addressing the child, the nurse says, "Are you unhappy when Mommy talks to you like this?"

Answer: 3 Explanation: 1. The best approach to this encounter would be for the nurse to discuss concerns with the parent privately, since the nurse wants to help the parent develop a good relationship with the child. The child should not be a part of this conversation. Because the child is only 4 years old, it would be difficult to ask the parent to leave the room. If the nurse also wants to speak alone with the child, the nurse perhaps would escort the child to another area and speak briefly with the child. Referring to counseling without a discussion with the parent is not appropriate. The nurse should not ask the child if she is "unhappy" with the parent. 2. The best approach to this encounter would be for the nurse to discuss concerns with the parent privately, since the nurse wants to help the parent develop a good relationship with the child. The child should not be a part of this conversation. Because the child is only 4 years old, it would be difficult to ask the parent to leave the room. If the nurse also wants to speak alone with the child, the nurse perhaps would escort the child to another area and speak briefly with the child. Referring to counseling without a discussion with the parent is not appropriate. The nurse should not ask the child if she is "unhappy" with the parent. 3. The best approach to this encounter would be for the nurse to discuss concerns with the parent privately, since the nurse wants to help the parent develop a good relationship with the child. The child should not be a part of this conversation. Because the child is only 4 years old, it would be difficult to ask the parent to leave the room. If the nurse also wants to speak alone with the child, the nurse perhaps would escort the child to another area and speak briefly with the child. Referring to counseling without a discussion with the parent is not appropriate. The nurse should not ask the child if she is "unhappy" with the parent. 4. The best approach to this encounter would be for the nurse to discuss concerns with the parent privately, since the nurse wants to help the parent develop a good relationship with the child. The child should not be a part of this conversation. Because the child is only 4 years old, it would be difficult to ask the parent to leave the room. If the nurse also wants to speak alone with the child, the nurse perhaps would escort the child to another area and speak briefly with the child. Referring to counseling without a discussion with the parent is not appropriate. The nurse should not ask the child if she is "unhappy" with the parent.

) A nurse in the outpatient pediatric clinic is reviewing the records of a preschool-age child and notes that because the parents often miss routine healthcare visits the child has not received the second measles, mumps, and rubella (MMR) vaccine. Which action by the nurse is most appropriate in this situation? 1. Speak firmly with the parents about the importance of being compliant. 2. Notify the physician that the child's immunizations are no longer up to date. 3. Call the parents and encourage them to bring the child for recommended care. 4. Plan to discuss the principles of health supervision at the next scheduled visit.

Answer: 3 Explanation: 1. The nurse in the pediatric healthcare setting is responsible for reviewing the health supervision of the child. Partnering with the parents and encouraging the parents to follow health-supervision guidelines are the best strategies to use. Speaking firmly with the parents about compliance will alienate the parents at this time. A discussion of the principles of health supervision without an intervention at this visit would mean a delay in needed healthcare for the child in this example. Discussing with the physician that the immunizations are not up to date is not necessary in an outpatient clinic. Immunizations are given per schedule. 2. The nurse in the pediatric healthcare setting is responsible for reviewing the health supervision of the child. Partnering with the parents and encouraging the parents to follow health-supervision guidelines are the best strategies to use. Speaking firmly with the parents about compliance will alienate the parents at this time. A discussion of the principles of health supervision without an intervention at this visit would mean a delay in needed healthcare for the child in this example. Discussing with the physician that the immunizations are not up to date is not necessary in an outpatient clinic. Immunizations are given per schedule. 3. The nurse in the pediatric healthcare setting is responsible for reviewing the health supervision of the child. Partnering with the parents and encouraging the parents to follow health-supervision guidelines are the best strategies to use. Speaking firmly with the parents about compliance will alienate the parents at this time. A discussion of the principles of health supervision without an intervention at this visit would mean a delay in needed healthcare for the child in this example. Discussing with the physician that the immunizations are not up to date is not necessary in an outpatient clinic. Immunizations are given per schedule. 4. The nurse in the pediatric healthcare setting is responsible for reviewing the health supervision of the child. Partnering with the parents and encouraging the parents to follow health-supervision guidelines are the best strategies to use. Speaking firmly with the parents about compliance will alienate the parents at this time. A discussion of the principles of health supervision without an intervention at this visit would mean a delay in needed healthcare for the child in this example. Discussing with the physician that the immunizations are not up to date is not necessary in an outpatient clinic. Immunizations are given per schedule.

An obese adolescent who adamantly denies sexual activity has a positive pregnancy test, which was performed in the adolescent clinic. Which statement by the nurse is the most appropriate in this situation? 1. "Tell me how you feel about your body image." 2. "When was your last menstrual period (LMP)?" 3. "Let's discuss some activities that you have done within the past few months that could possibly lead to pregnancy." 4. "Were you involved in a date rape and are you hesitant to speak about it?"

Answer: 3 Explanation: 1. The nurse must help the adolescent realize that previous behaviors have led to a positive pregnancy test. The only response by the nurse that will accomplish this goal is for the nurse to ask a direct question in which the nurse and client search for an answer. 2. The nurse must help the adolescent realize that previous behaviors have led to a positive pregnancy test. The only response by the nurse that will accomplish this goal is for the nurse to ask a direct question in which the nurse and client search for an answer. 3. The nurse must help the adolescent realize that previous behaviors have led to a positive pregnancy test. The only response by the nurse that will accomplish this goal is for the nurse to ask a direct question in which the nurse and client search for an answer. 4. The nurse must help the adolescent realize that previous behaviors have led to a positive pregnancy test. The only response by the nurse that will accomplish this goal is for the nurse to ask a direct question in which the nurse and client search for an answer.

While assessing a 10-month-old African American infant, the nurse notices that the sclerae have a yellowish tint. Which organ system should the nurse further evaluate to determine an ongoing disease process? 1. Cardiac 2. Respiratory 3. Gastrointestinal 4. Genitourinary

Answer: 3 Explanation: 1. This infant's sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver in the gastrointestinal system. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system. Tenting of the skin and dry mucous membranes could be a sign of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system. 2. This infant's sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver in the gastrointestinal system. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system. Tenting of the skin and dry mucous membranes could be a sign of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system. 3. This infant's sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver in the gastrointestinal system. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system. Tenting of the skin and dry mucous membranes could be a sign of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system. 4. This infant's sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver in the gastrointestinal system. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system. Tenting of the skin and dry mucous membranes could be a sign of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system.

) At a routine healthcare visit, a nurse measures a toddler and plots the height and weight on the growth charts. The nurse documents that the toddler is above the 95th percentile for weight and is at the 5th percentile for height. How should the nurse interpret these data? 1. The toddler is proportionate for the age. 2. The toddler needs to eat more at each feeding. 3. The height and weight are disproportionate, and the toddler needs further evaluation. 4. The family is most likely short.

Answer: 3 Explanation: 1. Usually height and weight are at approximately the same percentile. When the weight of a child is found to be at the 95th percentile, the child's height is also greater than the 50th percentile. The height and weight for the child described in this question are a concern, and the child may need further endocrine testing. 2. Usually height and weight are at approximately the same percentile. When the weight of a child is found to be at the 95th percentile, the child's height is also greater than the 50th percentile. The height and weight for the child described in this question are a concern, and the child may need further endocrine testing. 3. Usually height and weight are at approximately the same percentile. When the weight of a child is found to be at the 95th percentile, the child's height is also greater than the 50th percentile. The height and weight for the child described in this question are a concern, and the child may need further endocrine testing. 4. Usually height and weight are at approximately the same percentile. When the weight of a child is found to be at the 95th percentile, the child's height is also greater than the 50th percentile. The height and weight for the child described in this question are a concern, and the child may need further endocrine testing.

Which aspect of an Emergency Medical Services (EMS) system is most indicative that EMS providers are prepared to provide emergency care to children? 1. Placement of small stretchers in emergency vehicles 2. Lists of hospitals in the area that treat children 3. Staff education related to assessment and treatment of children of all ages 4. Pediatric-sized equipment and supplies

Answer: 3 Explanation: 1. While size-appropriate equipment and lists of hospitals that treat children are essential parts of an EMS system, the aspect that is most indicative that EMS providers are actually prepared to take care of children is evidence of education related to assessment and emergency treatment. 2. While size-appropriate equipment and lists of hospitals that treat children are essential parts of an EMS system, the aspect that is most indicative that EMS providers are actually prepared to take care of children is evidence of education related to assessment and emergency treatment. 3. While size-appropriate equipment and lists of hospitals that treat children are essential parts of an EMS system, the aspect that is most indicative that EMS providers are actually prepared to take care of children is evidence of education related to assessment and emergency treatment. 4. While size-appropriate equipment and lists of hospitals that treat children are essential parts of an EMS system, the aspect that is most indicative that EMS providers are actually prepared to take care of children is evidence of education related to assessment and emergency treatment.

The nurse is providing care to a school-age client and family. The family, which consists of two parents and 4 children, live in a one-bedroom apartment. The father recently lost his job and the mother stays at home with the children. Which community resources would most benefit this family? Select all that apply. 1. Play groups 2. Parenting programs 3. Social services programs 4. Job skills training 5. Respite care

Answer: 3, 4 Explanation: 1. This family is currently living in a one-bedroom apartment and the sole income earner recently lost his job. This family would most benefit from social services programs for monetary assistance and job skills training which would allow the parents to learn a trade and become employed. Play groups, parenting programs, and respite care are not applicable to this family's situation. 2. This family is currently living in a one-bedroom apartment and the sole income earner recently lost his job. This family would most benefit from social services programs for monetary assistance and job skills training which would allow the parents to learn a trade and become employed. Play groups, parenting programs, and respite care are not applicable to this family's situation. 3. This family is currently living in a one-bedroom apartment and the sole income earner recently lost his job. This family would most benefit from social services programs for monetary assistance and job skills training which would allow the parents to learn a trade and become employed. Play groups, parenting programs, and respite care are not applicable to this family's situation. 4. This family is currently living in a one-bedroom apartment and the sole income earner recently lost his job. This family would most benefit from social services programs for monetary assistance and job skills training which would allow the parents to learn a trade and become employed. Play groups, parenting programs, and respite care are not applicable to this family's situation. 5. This family is currently living in a one-bedroom apartment and the sole income earner recently lost his job. This family would most benefit from social services programs for monetary assistance and job skills training which would allow the parents to learn a trade and become employed. Play groups, parenting programs, and respite care are not applicable to this family's situation.

The nurse is assessing an infant client and parents during a routine health supervision visit at 2 months of age. Which items will the nurse assess to determine if the infant's mental health needs are being addressed? Select all that apply. 1. Immunization record 2. Newborn screen results 3. Temperament during the visit 4. Feeding schedule 5. Sleep-wake patterns

Answer: 3, 4, 5 Explanation: 1. When addressing mental health issues, the nurse would assess the infant's temperament during the visit, feeding schedule, and sleep-wake patterns. The infant's mental health is related to early experiences, inborn characteristics such as temperament and resilience, and relationships with caregivers. The first year of life provides many opportunities for the infant to develop positive mental health; interventions during this important period can enhance the child's future mental status. The immunization record and the newborn screen results will not provide the needed information for the nurse in terms of whether the infant's mental health needs are being addressed. 2. When addressing mental health issues, the nurse would assess the infant's temperament during the visit, feeding schedule, and sleep-wake patterns. The infant's mental health is related to early experiences, inborn characteristics such as temperament and resilience, and relationships with caregivers. The first year of life provides many opportunities for the infant to develop positive mental health; interventions during this important period can enhance the child's future mental status. The immunization record and the newborn screen results will not provide the needed information for the nurse in terms of whether the infant's mental health needs are being addressed. 3. When addressing mental health issues, the nurse would assess the infant's temperament during the visit, feeding schedule, and sleep-wake patterns. The infant's mental health is related to early experiences, inborn characteristics such as temperament and resilience, and relationships with caregivers. The first year of life provides many opportunities for the infant to develop positive mental health; interventions during this important period can enhance the child's future mental status. The immunization record and the newborn screen results will not provide the needed information for the nurse in terms of whether the infant's mental health needs are being addressed. 4. When addressing mental health issues, the nurse would assess the infant's temperament during the visit, feeding schedule, and sleep-wake patterns. The infant's mental health is related to early experiences, inborn characteristics such as temperament and resilience, and relationships with caregivers. The first year of life provides many opportunities for the infant to develop positive mental health; interventions during this important period can enhance the child's future mental status. The immunization record and the newborn screen results will not provide the needed information for the nurse in terms of whether the infant's mental health needs are being addressed.

During the newborn examination, the nurse assesses the infant for signs of developmental dysplasia of the hip. A finding that would strongly indicate this disorder would be: 1. soles are flat with prominent fat pads. 2. positive Babinski reflex. 3. metatarsus varus. 4. asymmetric thigh and gluteal folds.

Answer: 4 Explanation: 1. A positive Babinski reflex and flat soles are normal newborn findings. Metatarsus varus is an in-toeing of the feet that usually occurs secondary to intra-uterine positioning and frequently resolves on its own, but approximately 10 percent of infants with metatarsus varus also have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip requiring follow-up with ultrasound. 2. A positive Babinski reflex and flat soles are normal newborn findings. Metatarsus varus is an in-toeing of the feet that usually occurs secondary to intra-uterine positioning and frequently resolves on its own, but approximately 10 percent of infants with metatarsus varus also have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip requiring follow-up with ultrasound. 3. A positive Babinski reflex and flat soles are normal newborn findings. Metatarsus varus is an in-toeing of the feet that usually occurs secondary to intra-uterine positioning and frequently resolves on its own, but approximately 10 percent of infants with metatarsus varus also have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip requiring follow-up with ultrasound. 4. A positive Babinski reflex and flat soles are normal newborn findings. Metatarsus varus is an in-toeing of the feet that usually occurs secondary to intra-uterine positioning and frequently resolves on its own, but approximately 10 percent of infants with metatarsus varus also have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip requiring follow-up with ultrasound.

The number of serious injuries in children has doubled in the past year. Based on this information, which is the most appropriate community nursing diagnosis? 1. Noncompliance Related to Inappropriate Use of Child Safety Seats 2. Risk for Injury Related to Inadequate Use of Bicycle Helmets 3. Altered Family Processes Related to Hospitalization of an Injured Child 4. Knowledge Deficit Related to Injury Prevention in Children

Answer: 4 Explanation: 1. All of these diagnoses might be appropriate in specific situations, but Knowledge Deficit Related to Injury Prevention in Children is the only one that is general to the problem as a whole and is therefore the most appropriate community nursing diagnosis. 2. All of these diagnoses might be appropriate in specific situations, but Knowledge Deficit Related to Injury Prevention in Children is the only one that is general to the problem as a whole and is therefore the most appropriate community nursing diagnosis. 3. All of these diagnoses might be appropriate in specific situations, but Knowledge Deficit Related to Injury Prevention in Children is the only one that is general to the problem as a whole and is therefore the most appropriate community nursing diagnosis. 4. All of these diagnoses might be appropriate in specific situations, but Knowledge Deficit Related to Injury Prevention in Children is the only one that is general to the problem as a whole and is therefore the most appropriate community nursing diagnosis.

While teaching parents of a newborn about normal growth and development, which statement is most appropriate for the nurse to include in the session? 1. Weight should triple by 6 months of age. 2. Weight should double by 1 year of age. 3. Weight should double by 4 months of age. 4. Weight should triple by 1 year of age.

Answer: 4 Explanation: 1. An infant should triple its birth weight by 1 year of age. The other answers are not appropriate weight gains. 2. An infant should triple its birth weight by 1 year of age. The other answers are not appropriate weight gains. 3. An infant should triple its birth weight by 1 year of age. The other answers are not appropriate weight gains. 4. An infant should triple its birth weight by 1 year of age. The other answers are not appropriate weight gains.

Which assessment question would get the most accurate response when a nurse is assessing learning and reading skills in the early childhood years? 1. "What rewards do you use when your child does something good?" 2. "What is your child's language like now?" 3. "Does your child get along well with others?" 4. "Do you keep books for your child readily available?"

Answer: 4 Explanation: 1. Keeping books readily available will stimulate reading skills. This is the question that will provide the most information about learning and reading skills. Language and getting along with others are more communication skills. Rewards are more closely related to discipline. 2. Keeping books readily available will stimulate reading skills. This is the question that will provide the most information about learning and reading skills. Language and getting along with others are more communication skills. Rewards are more closely related to discipline. 3. Keeping books readily available will stimulate reading skills. This is the question that will provide the most information about learning and reading skills. Language and getting along with others are more communication skills. Rewards are more closely related to discipline. 4. Keeping books readily available will stimulate reading skills. This is the question that will provide the most information about learning and reading skills. Language and getting along with others are more communication skills. Rewards are more closely related to discipline.

A young school-age client who has had a tracheostomy for several years is scheduled to begin school in the fall. The teacher is concerned about this child's being in her class and consults the school nurse. Which action by the nurse is the most appropriate? 1. Make arrangements for the child to go to a special school. 2. Ask the parents of the child to provide a caregiver during school hours. 3. Recommend that the child be home schooled. 4. Teach the teacher how to care for the child in the classroom.

Answer: 4 Explanation: 1. Section 504 of the Rehabilitation Act of 1973 guarantees access for children with disabilities to federally funded programs, including public schools. The child may need little extra attention while in the school setting, since he has had the tracheostomy for several years. The teacher should be taught how to care for the child if needed and the signs of distress. If needed, a health aide may be assigned to the child, but this is not the responsibility of the parents. 2. Section 504 of the Rehabilitation Act of 1973 guarantees access for children with disabilities to federally funded programs, including public schools. The child may need little extra attention while in the school setting, since he has had the tracheostomy for several years. The teacher should be taught how to care for the child if needed and the signs of distress. If needed, a health aide may be assigned to the child, but this is not the responsibility of the parents. 3. Section 504 of the Rehabilitation Act of 1973 guarantees access for children with disabilities to federally funded programs, including public schools. The child may need little extra attention while in the school setting, since he has had the tracheostomy for several years. The teacher should be taught how to care for the child if needed and the signs of distress. If needed, a health aide may be assigned to the child, but this is not the responsibility of the parents. 4. Section 504 of the Rehabilitation Act of 1973 guarantees access for children with disabilities to federally funded programs, including public schools. The child may need little extra attention while in the school setting, since he has had the tracheostomy for several years. The teacher should be taught how to care for the child if needed and the signs of distress. If needed, a health aide may be assigned to the child, but this is not the responsibility of the parents.

The nurse is providing anticipatory guidance instructions to the parents of a newborn. Which instruction should the nurse give as a strategy for illness/disease prevention? 1. Don't allow visitors for the first month 2. Smoke outside only 3. Take the newborn to weekly child-stimulation classes 4. SIDS risk-reduction measures

Answer: 4 Explanation: 1. Several disease-prevention strategies are used during anticipatory guidance for the parents of newborns. Not allowing visitors is unreasonable but screening for illness is appropriate. Smoking outside will not prevent disease. Attending weekly stimulation classes is not a disease prevention strategy. SIDS risk-reduction measures can reduce the risk of sudden infant death syndrome. 2. Several disease-prevention strategies are used during anticipatory guidance for the parents of newborns. Not allowing visitors is unreasonable but screening for illness is appropriate. Smoking outside will not prevent disease. Attending weekly stimulation classes is not a disease prevention strategy. SIDS risk-reduction measures can reduce the risk of sudden infant death syndrome. 3. Several disease-prevention strategies are used during anticipatory guidance for the parents of newborns. Not allowing visitors is unreasonable but screening for illness is appropriate. Smoking outside will not prevent disease. Attending weekly stimulation classes is not a disease prevention strategy. SIDS risk-reduction measures can reduce the risk of sudden infant death syndrome. 4. Several disease-prevention strategies are used during anticipatory guidance for the parents of newborns. Not allowing visitors is unreasonable but screening for illness is appropriate. Smoking outside will not prevent disease. Attending weekly stimulation classes is not a disease prevention strategy. SIDS risk-reduction measures can reduce the risk of sudden infant death syndrome.

A nurse is discussing health promotion activities with parents of a 4-year-old client. What health-promotion activity is most appropriate for this family? 1. Make arrangements to tour the kindergarten in which the child will enroll next year. 2. Plan a "movie afternoon" with the child's big brother. 3. Maintain appropriate immunizations. 4. Teach the child the proper method for brushing the teeth.

Answer: 4 Explanation: 1. Teaching proper oral hygiene through proper teeth brushing is a health-promotion activity. Touring the kindergarten might alleviate anxiety, but is not health promotion. A movie afternoon with the big brother is sedentary, and also not a health-promotion activity. Maintaining immunizations is a health-maintenance, not health-promotion, activity. 2. Teaching proper oral hygiene through proper teeth brushing is a health-promotion activity. Touring the kindergarten might alleviate anxiety, but is not health promotion. A movie afternoon with the big brother is sedentary, and also not a health-promotion activity. Maintaining immunizations is a health-maintenance, not health-promotion, activity. 3. Teaching proper oral hygiene through proper teeth brushing is a health-promotion activity. Touring the kindergarten might alleviate anxiety, but is not health promotion. A movie afternoon with the big brother is sedentary, and also not a health-promotion activity. Maintaining immunizations is a health-maintenance, not health-promotion, activity. 4. Teaching proper oral hygiene through proper teeth brushing is a health-promotion activity. Touring the kindergarten might alleviate anxiety, but is not health promotion. A movie afternoon with the big brother is sedentary, and also not a health-promotion activity. Maintaining immunizations is a health-maintenance, not health-promotion, activity.

The nurse is reviewing the immunization record of an adolescent who will be seen later in the day. Which item in the client's history makes hepatitis B status a priority? 1. Chronic acne 2. Overuse injuries from playing varsity sports 3. Chronic asthma 4. Plans to get a tattoo

Answer: 4 Explanation: 1. The adolescent who is most at risk in the scenario presented is the teen who is planning on getting a tattoo. Adolescents with chronic acne or asthma do not have an increased risk for hepatitis B, since transmission has nothing to do with a diagnosis of acne. Overuse of muscles while playing sports is not related to development of hepatitis B. 2. The adolescent who is most at risk in the scenario presented is the teen who is planning on getting a tattoo. Adolescents with chronic acne or asthma do not have an increased risk for hepatitis B, since transmission has nothing to do with a diagnosis of acne. Overuse of muscles while playing sports is not related to development of hepatitis B. 3. The adolescent who is most at risk in the scenario presented is the teen who is planning on getting a tattoo. Adolescents with chronic acne or asthma do not have an increased risk for hepatitis B, since transmission has nothing to do with a diagnosis of acne. Overuse of muscles while playing sports is not related to development of hepatitis B. 4. The adolescent who is most at risk in the scenario presented is the teen who is planning on getting a tattoo. Adolescents with chronic acne or asthma do not have an increased risk for hepatitis B, since transmission has nothing to do with a diagnosis of acne. Overuse of muscles while playing sports is not related to development of hepatitis B.

What must a home-health nurse realize prior to accepting an assignment? 1. All decisions will be made by the healthcare provider. 2. The family will adapt their lifestyle to the needs of the nurse. 3. Independent decisions regarding emergency care of the child will be made by the nurse. 4. The family is in charge.

Answer: 4 Explanation: 1. The home-health nurse must realize that the family is in charge. The nurse must be flexible and adaptable to the lifestyle of the family. The family must provide informed consent for emergency care. 2. The home-health nurse must realize that the family is in charge. The nurse must be flexible and adaptable to the lifestyle of the family. The family must provide informed consent for emergency care. 3. The home-health nurse must realize that the family is in charge. The nurse must be flexible and adaptable to the lifestyle of the family. The family must provide informed consent for emergency care. 4. The home-health nurse must realize that the family is in charge. The nurse must be flexible and adaptable to the lifestyle of the family. The family must provide informed consent for emergency care.

A nurse says to the mother of a 6-month-old infant, "Does the baby sit without assistance, and is the baby crawling?" Which process is the nurse using in this interaction? 1. Health promotion 2. Health maintenance 3. Disease surveillance 4. Developmental surveillance

Answer: 4 Explanation: 1. The question asked by the nurse is seeking information about developmental milestones; therefore, the nurse is involved in developmental surveillance. While health-promotion and health-maintenance activities are related to developmental surveillance, this question is looking specifically at the milestones; therefore, the answers "health promotion" and "health maintenance" are incorrect. The questions asked in the stem are not classified as disease-surveillance questions. 2. The question asked by the nurse is seeking information about developmental milestones; therefore, the nurse is involved in developmental surveillance. While health-promotion and health-maintenance activities are related to developmental surveillance, this question is looking specifically at the milestones; therefore, the answers "health promotion" and "health maintenance" are incorrect. The questions asked in the stem are not classified as disease-surveillance questions. 3. The question asked by the nurse is seeking information about developmental milestones; therefore, the nurse is involved in developmental surveillance. While health-promotion and health-maintenance activities are related to developmental surveillance, this question is looking specifically at the milestones; therefore, the answers "health promotion" and "health maintenance" are incorrect. The questions asked in the stem are not classified as disease-surveillance questions. 4. The question asked by the nurse is seeking information about developmental milestones; therefore, the nurse is involved in developmental surveillance. While health-promotion and health-maintenance activities are related to developmental surveillance, this question is looking specifically at the milestones; therefore, the answers "health promotion" and "health maintenance" are incorrect. The questions asked in the stem are not classified as disease-surveillance questions.

A school nurse is performing annual height and weight screening. The nurse notes that three females who are close friends each lost 15 pounds over the past year. What is the priority nursing action in this situation? 1. Call the respective parents to discuss the eating patterns of each adolescent. 2. Speak with the girls in a group to discuss the problems associated with anorexia nervosa. 3. Refer these adolescents to the school psychologist. 4. Obtain a nutritional history for each of these adolescents.

Answer: 4 Explanation: 1. The school nurse must evaluate why these three friends have all lost 15 pounds in one year. The best way to begin this assessment is to obtain a nutritional history for each client. Speaking with the parents would not be appropriate at this time. Discussing anorexia nervosa is too extreme, as is referring the adolescents to a school psychologist without performing a complete nursing assessment. 2. The school nurse must evaluate why these three friends have all lost 15 pounds in one year. The best way to begin this assessment is to obtain a nutritional history for each client. Speaking with the parents would not be appropriate at this time. Discussing anorexia nervosa is too extreme, as is referring the adolescents to a school psychologist without performing a complete nursing assessment. 3. The school nurse must evaluate why these three friends have all lost 15 pounds in one year. The best way to begin this assessment is to obtain a nutritional history for each client. Speaking with the parents would not be appropriate at this time. Discussing anorexia nervosa is too extreme, as is referring the adolescents to a school psychologist without performing a complete nursing assessment. 4. The school nurse must evaluate why these three friends have all lost 15 pounds in one year. The best way to begin this assessment is to obtain a nutritional history for each client. Speaking with the parents would not be appropriate at this time. Discussing anorexia nervosa is too extreme, as is referring the adolescents to a school psychologist without performing a complete nursing assessment.

The community-health nurse visits the child-care center. Which finding indicates the need for staff education? 1. A group of 2-year-olds are eating a snack of Cheerios. 2. Several 4-year-olds are outside playing on a slide. 3. An 18-month-old is pushing a toy truck. 4. A 2-month-old is sleeping in a crib on his stomach.

Answer: 4 Explanation: 1. To decrease the incidence of sudden infant death syndrome (SIDS), infants should be placed on their backs to sleep. All of the other examples are developmentally appropriate activities for the specified age group. 2. To decrease the incidence of sudden infant death syndrome (SIDS), infants should be placed on their backs to sleep. All of the other examples are developmentally appropriate activities for the specified age group. 3. To decrease the incidence of sudden infant death syndrome (SIDS), infants should be placed on their backs to sleep. All of the other examples are developmentally appropriate activities for the specified age group. 4. To decrease the incidence of sudden infant death syndrome (SIDS), infants should be placed on their backs to sleep. All of the other examples are developmentally appropriate activities for the specified age group.

The nurse of an outpatient clinic is sitting with the parents while their adolescent goes for a test. The parents are complaining about their child's behavior. Which statement by the nurse fosters family-centered communication? 1. "I agree with you; discipline is an important part of parenting." 2. "I know just how you feel. I had the same experience with my children." 3. "You are so right. Adolescents function in the "me-first" mode all the time." 4. "Tell me what concerns you about your child's behavior."

Answer: 4 Explanation: 1. Using an open-ended question allows the parents to discuss a family concern. All the other questions or statements are blocking statements and would not foster family-centered communication. 2. Using an open-ended question allows the parents to discuss a family concern. All the other questions or statements are blocking statements and would not foster family-centered communication. 3. Using an open-ended question allows the parents to discuss a family concern. All the other questions or statements are blocking statements and would not foster family-centered communication. 4. Using an open-ended question allows the parents to discuss a family concern. All the other questions or statements are blocking statements and would not foster family-centered communication

A pediatric nurse who is employed in a busy ambulatory clinic setting is informed by the nurse manager that average nursing time allocated for each child and family is being reduced to 10 minutes to more efficiently manage the clinic. The nursing activities must include a nursing assessment and discussion on anticipatory guidance. Which of these strategies should the nurse utilize in the plan of care delivery? 1. Attempt to complete the assessment and education in 10 minutes, but extend the time whenever the nurse deems necessary. 2. Plan to do the anticipatory guidance first since either the nurse practitioner or the physician can perform the assessment of the child. 3. Encourage the parent to ask for specific time to talk with the nurse privately at each office visit. 4. Focus anticipatory guidance strategies on topics that the parent or child have expressed as an area of interest.

Answer: 4 Explanation: 1. With limited time for each visit, the nurse should focus on anticipatory guidance strategies that will most benefit the parent and child during that office visit. 2. With limited time for each visit, the nurse should focus on anticipatory guidance strategies that will most benefit the parent and child during that office visit. 3. With limited time for each visit, the nurse should focus on anticipatory guidance strategies that will most benefit the parent and child during that office visit. 4. With limited time for each visit, the nurse should focus on anticipatory guidance strategies that will most benefit the parent and child during that office visit.

Place the nursing assessments of a toddler in the best order. 1. Examination of eyes, ears, and throat 2. Auscultation of chest 3. Palpation of abdomen 4. Developmental assessment

Answer: 4, 2, 3, 1 Developmental assessment Auscultation of chest Palpation of abdomen Examination of eyes, ears, and throat Explanation: In examining a toddler, it is usually best to go from least invasive to most invasive examination in order to build trust and cooperation. Developmental assessment involves visual inspection and activities that the toddler may view as games and will likely cooperate with. Auscultation is usually less threatening to the toddler than palpation, especially if the nurse were to use the stethoscope on a parent or a toy. The most uncomfortable, invasive exam for the toddler is most likely to be the examination of the eyes, ears, and throat, so that should be performed last.