Quiz 1-3

The nurse is performing a routine health assessment on a 7-year-old child. Which specific approaches does the nurse use for this child? Select all that apply. a. Expect the child to be undressed and in a gown. b. Start the assessment by obtaining vital signs. c. Share which immunizations will be given today. d. Visually inspect the child's general appearance. e. Listen to information shared by the child.

d. Visually inspect the child's general appearance. e. Listen to information shared by the child.

The nurse is preparing to perform a physical examination of an adolescent who is 13 years of age. Which action by the nurse will decrease the adolescent's anxiety during the examination? a. Referring patient concerns to the physician b. Teaching the anatomical names of body parts c. Verbalizing findings of physical abnormalities d. Telling the patient what to expect and why

d. Telling the patient what to expect and why

The nurse in a pediatric clinic is performing well-baby checks. The nurse is checking an infant who is 7 months old for developmental milestones. Which finding is of greatest concern to the nurse? a. The infant exhibits a lack of startle reflex to sound. b. The infant exhibits a Babinski reflex. c. The infant opens and closes her hands to grasp objects. d. The infant remains flat when in a prone position.

d. The infant remains flat when in a prone position.

The nurse is providing information to the parents of a toddler who is scheduled for surgery for the replacement of the pulmonic valve. The parents have questions about the function of the valve. Which information from the nurse is accurate? a. A defect in the valve causes less blood to get to the lungs for oxygenation. b. The valve must work correctly to get oxygen from the lungs to the body. c. When the valve is defective, the blood leaving the heart is decreased. d. If the valve does not work correctly, blood is kept from entering the heart.

a. A defect in the valve causes less blood to get to the lungs for oxygenation.

The nurse in the newborn unit of a pediatric hospital is providing care for a neonate born at 32 weeks' gestation. The nurse is aware that the immediate risk to the neonate is which condition? a. A lack of surfactant in the alveoli b. Delay in closure of the foramen ovale c. A decreased ability to concentrate urine d. Inability to maintain body temperature

a. A lack of surfactant in the alveoli

A neonate became dusky and developed respiratory distress at the age of 4 days and is diagnosed with a hypoplastic left heart. The surgeon obtains an informed consent from the parents to perform emergency surgery. Which information will the nurse provide to promote parental understanding? Select all that apply. a. A normally existing connection between vessels prior to birth will be kept open. b. The function of left side of the heart is to pump blood to the body. c. Explain that medical management of the condition is needed for at least one year. d. Reassurance to the parents that the surgery will correct the problem. e. The left side of the neonate's heart did not develop correctly.

a. A normally existing connection between vessels prior to birth will be kept open. b. The function of left side of the heart is to pump blood to the body. e. The left side of the neonate's heart did not develop correctly.

The nurse works in a pediatric hospice unit in an acute care facility. The nurse is currently providing care to an infant. Which assessment tool does the nurse use to identify the infant's level of pain? a. FLACC b. NIPS c. Visual analogy scale d. faces scale

a. FLACC

The nurse is providing care to a toddler recently diagnosed with asthma. The parents have become verbally aggressive with staff and have challenged many of the unit rules. Which of the following may have contributed to the family's challenging behavior? Select all that apply. a. The family has researched asthma on the Internet and does not agree with the treatment protocol. b. The parents are both working professionals in leadership roles and fear loss of control. c. The staff members have maintained therapeutic communication with the patient and family. d. The nurse has developed a mutual set of goals and interventions with the family. e. The staff members have provided a medically trained translator to promote understanding in care.

a. The family has researched asthma on the Internet and does not agree with the treatment protocol. b. The parents are both working professionals in leadership roles and fear loss of control.

The nurse is counseling parents about management of their children who are 2, 4, and 6 years of age. One of the parents states, "We believe in Kohlberg's theory of social-moral development." The nurse is aware that the preconventional stage of this theory involves which characteristic? a. A personal and functional value system is constructed by the child. b. Behavior is adjusted according to good/bad and right/wrong thinking. c. The focus of the child is on following rules and maintaining social order. d. Value systems are independent of authority figures and peers.

b. Behavior is adjusted according to good/bad and right/wrong thinking.

The nurse encourages the mother of a toddler with acute laryngotracheobronchitis to stay at the bedside as much as possible. The nurse's rationale for this action is primarily that: a. Mothers of hospitalized toddlers often experience guilt. b. The mother can provide constant observations of the child's respiratory efforts. c. The mother's presence will reduce anxiety and ease the child's respiratory efforts. d. Separation from the mother is a major developmental threat at this age.

c. The mother's presence will reduce anxiety and ease the child's respiratory efforts.

An infant's parents ask the nurse about preventing otitis media (OM). What should the nurse recommend? a. Avoid children with OM. b. Use nasal decongestant. c. Bottle-feed or breastfeed in supine position. d. Avoid tobacco smoke.

d. Avoid tobacco smoke.

The nurse in a pediatric clinic is performing assessments on multiple infants. Which infant does the nurse recognize as being at greatest risk for a respiratory disorder? a. The infant with recurrent sore throats and both pets and smokers in the house b. The infant who sleeps all night, exhibits eczema, and has a family history of asthma c. The infant who was born at term and recently adopted from another country d. The infant born at 33 weeks who exhibited respiratory problems at birth

a. The infant with recurrent sore throats and both pets and smokers in the house

The nurse is providing care for a pediatric patient and family during the time when death of the patient seems imminent. The family is of American Indian culture and has summoned tribal members to come and chant and pray at the bedside. Which behavior by the nurse is culturally correct? a. Ask if the family has any additional needs, close the door, and provide privacy. b. Ask the family to respect other patients by keeping the volume of chanting low. c. Move the patient, family, and tribal members to an isolated location. d. Call the nursing supervisor and ask for assistance in managing the situation.

a. Ask if the family has any additional needs, close the door, and provide privacy.

The nurse is performing a physical examination on a male who is 15 years of age. The nurse notices the presence of gynecomastia. The patient states, "I hate these breasts and won't even take my shirt off in front of my friends." Which information does the nurse provide for this patient? a. The condition is self-limiting. b. It indicates the patient is overweight. c. The male hormone testosterone is deficient. d. Surgical removal is recommended.

a. The condition is self-limiting.

he nurse is providing care for a 5-year-old patient whose tonsils were removed this morning. The nurse identifies the patient is in pain but not willing to speak. The nurse uses the Wong-Baker FACES scale for pain evaluation. Which indicator does the nurse expect the patient to use to describe the level of pain? a. The frowning face out of a series of faces b. An intense red color on a range from pink to deep red c. A number between 7 and 10 from a scale of 0 to 10 d. The word that identifies the degree of pain (i.e., ouch, hurts bad)

a. The frowning face out of a series of faces

The nurse in a pediatric office is aware that certain factors may be indicators of congenital heart disease in children. Which children does the nurse recognize with manifestations associated with heart disease? Select all that apply. a. A toddler with clubbing and erythema of the fingers and toes b. An infant who is unable to gain weight and meet developmental milestones c. The adolescent with crackles and wheezing on auscultation d. The newborn with features of Trisomy 21 e. The preschooler with bluish tint around the mouth and nose

a. A toddler with clubbing and erythema of the fingers and toes b. An infant who is unable to gain weight and meet developmental milestones d. The newborn with features of Trisomy 21 e. The preschooler with bluish tint around the mouth and nose

The nurse is interviewing an adolescent patient 17 years of age who was diagnosed with cystic fibrosis (CF) as an infant. The patient shares feelings of frustration about needing to always live with parents. Which information provided by the nurse is likely to be most important to the patient? a. How chest physiotherapy (CPT) can be performed independently b. The availability of home meal delivery to those needing a therapeutic diet c. A list of social organizations available for young persons who have special needs d. Organizations that will provide transportation for persons with chronic illness

a. How chest physiotherapy (CPT) can be performed independently

The nurse is assessing an adolescent patient in the emergency department with a suspected intentional overdose. After given treatment, the patient refuses to give her parent's contact information and states, "It is none of their business." What is the nurse's best response? a. I'm sorry, but I'm obligated to tell them. Let me help you develop a plan for their possible responses." b. "Although most of your health care is confidential, we are obligated to notify them." c. "Now that you are safe, let me help you develop a plan to prevent a recurrence." d. "I think you should tell them, but we will honor your confidentiality and not disclose the reason for your visit."

a. I'm sorry, but I'm obligated to tell them. Let me help you develop a plan for their possible responses."

A parent brings a 15-month-old child with a prolonged fever and a rash to the hospital and is diagnosed with Kawasaki disease. Which treatments does the nurse expect to be prescribed? Select all that apply. a. IV gamma globulin therapy b. Aspirin therapy c. Missed varicella vaccine d. Droplet precautions e. Antibiotic therapy

a. IV gamma globulin therapy b. Aspirin therapy

The nurse in a pediatric clinic is assessing the motor development of a 3-year-old patient. The nurse reviews the toddler's last assessment results prior to determining changes. Which new development does the nurse expect to find during assessment? a. Independently builds a tower of seven blocks b. Climbs stairs while holding the railing c. Rides a bicycle with training wheels d. Climbs on furniture unassisted

a. Independently builds a tower of seven blocks

The nurse is caring for an 8-year-old patient who has had a cardiac catheterization. Which intervention will the nurse initiate immediately post-procedure? a. Keep the involved extremity straight for 4 to 6 hours. b. Hold food and fluids until gag reflex returns. c. Observe for signs and symptoms of infection. d. Notify physician if green or yellow drainage is noted.

a. Keep the involved extremity straight for 4 to 6 hours.

The school nurse attends a workshop focusing on the identification and prevention of bullying among school-age children. Which factor(s) are associated with both bullies and victims? Select all that apply. a. Lower education level of parents b. Poor academic achievement c. Leader or follower personality types d. Jealousy over sexual attention e. Poor health status or increased health needs

a. Lower education level of parents b. Poor academic achievement e. Poor health status or increased health needs

The nurse is examining a 10-year-old child brought to the clinic because of episodes of shortness of breath, headaches, and stomach upset. The nurse notices bruises in various stages of resolution on the upper arms and upper legs. Which additional information is most important for the nurse to obtain? a. Seek information about the cause of the bruises. b. Ascertain if there is a change in school performance. c. Ask the caregiver if the child is being abused. d. Ask about the duration of the presenting symptoms.

a. Seek information about the cause of the bruises.

The nurse is gathering information during a routine checkup for a preschool-age child who lives with grandparents. The grandmother expresses distress about "how loud and busy" the child is, and "how expensive it is to feed and clothe" the child. Which referrals does the nurse make to the grandmother? Select all that apply. a. Social service for determination of benefits available for the care of the child b. Child protection services to survey the home and psychosocial environment c. Community programs for the child aimed at playing and learning d. Legal services to assist in obtaining financial support from the parents e. Caretaker programs and support groups for grandparents performing as parents

a. Social service for determination of benefits available for the care of the child c. Community programs for the child aimed at playing and learning e. Caretaker programs and support groups for grandparents performing as parents

The health department informs the school nurse that a high school student has been identified with active TB, and students are to be given a TB skin test. Which consideration does the nurse make in regards to student testing? Select all that apply. a. Students are informed the test administration will cause minor pain. b. Students and parents/guardians are assured of confidentiality. c. Permission for testing is obtained from parents or guardians. d. The rationale for the testing is explained to students and parents/guardians. e. Only students who were in physical contact with the infected student are tested.

a. Students are informed the test administration will cause minor pain. b. Students and parents/guardians are assured of confidentiality. c. Permission for testing is obtained from parents or guardians. d. The rationale for the testing is explained to students and parents/guardians.

The parents of a toddler, diagnosed to be in the end stage of a terminal illness, are concerned about how to manage pain without the sedation effects of pain medications. Which suggestion by the nurse is likely to meet the needs of both the parents and the patient? a. Suggest a parent hold the patient and perform gentle massage. b. Provide age-appropriate videos for patient distraction. c. Initiate playtime in the playroom with other patients. d. Encourage the parents to bring favorite toys and books.

a. Suggest a parent hold the patient and perform gentle massage.

The nurse in a pediatric office is performing physical assessments on multiple patients. Which patient will the nurse specifically report to the physician because of physical assessment findings? a. The 3-year-old patient with a history of prematurely closed fontanels who has a headache. b. The 2-year-old patient with asthma who exhibits abdominal breathing at 26 breaths per minute. c. The 3-year-old patient with a soiled diaper, at the 70th percentile of weight and height. d. The 4-year-old patient with a blood pressure of 100/75 mm Hg, pulse of 98 beats/minute.

a. The 3-year-old patient with a history of prematurely closed fontanels who has a headache.

The nurse is performing a development assessment on a 3-month-old infant who was 6 weeks premature. The nurse states the infant's development is normal. The parent expresses that the baby seems behind what her other children were doing at the same age. Which information is BEST for the nurse to share to provide reassurance to the parent? a. The infant's age is adjusted because of prematurity. b. The infant will catch up developmentally by age 1 year. c. Developmental milestones vary from infant to infant. d. Each infant is an individual with unique development.

a. The infant's age is adjusted because of prematurity.

he nurse in an acute care pediatric facility is preparing to assume care of multiple patients at the change of shift. Which patient will the nurse plan to assess first? a. The toddler who prefers a tripod position instead of lying down b. The preschooler who exhibits clubbing of the fingertips c. The teenager who can sleep only with the head of the bed elevated d. The school-age child with pneumonia who has poor skin turgor

a. The toddler who prefers a tripod position instead of lying down

The nurse assesses the pain level of a school-age patient who is receiving end-of-life care and determines a need for pain medication. The physician has prescribed morphine sulfate to be administered either orally or rectally. For which reason will the nurse decide to administer the medication orally? a. To prevent the patient from being embarrassed by rectal administration b. To avoid stimulation of rectal spasms during insertion of the medication c. To decrease the risk of respiratory suppression d. To ensure the pain medication is absorbed as quickly as possible

a. To prevent the patient from being embarrassed by rectal administration

The nurse is preparing to teach to parents the importance of play in the infant's life. Which information will the nurse plan to include? Select all that apply. a. Toys can help with physical and fine motor development. b. Toys should provide a means of sensory stimulation for the infant. c. Older siblings are encouraged to share their toys with the infant. d. Play is how infants learn about their environment and themselves. e. Infants may be frightened by their own images in a reflective toy.

a. Toys can help with physical and fine motor development. b. Toys should provide a means of sensory stimulation for the infant. d. Play is how infants learn about their environment and themselves.

The nurse receives the shift report of multiple pediatric clients. Which pediatric client will the nurse see first? a. a toddler with tetralogy of Fallot squatting quietly in the corner of the room b. an adolescent with coarctation of the aorta with reports of coughing and coryza c. an infant whose parents report difficulty feeding with a temperature of 100.1°F (38°C) d. a child with history of hypertension and a current blood pressure of 130/90 mm Hg

a. a toddler with tetralogy of Fallot squatting quietly in the corner of the room

A child diagnosed with a ventricular septal defect (VSD) is seen in the clinic. The nurse conducts an assessment and reviews the child's recent laboratory results. The nurse suspects the child may have developed heart failure. Which finding is the best indicator of the nurse's suspicion? a. crackles on lung auscultation b. reports of increased fatigue c. poor weight gain d. low hematocrit

a. crackles on lung auscultation

The parents of an adolescent are distressed about the psychological changes in their child. Which example does the nurse validate as being a source of concern? a. Presents self in a constantly changing personae b. Comfortable with doing what the crowd does c. Regularly tests family limits and rules d. Constantly compares their body with others

b. Comfortable with doing what the crowd does

The nurse is caring for a 1-year-old patient after surgery for an intracranial shunt replacement. The nurse selects the FLACC scale for assessment because of the toddler's inability to participate in pain evaluation. The nurse will recognize which assessment finding as an indication of some level of pain? Select all that apply. a. Answers to name, sucks thumb, and holds toy b. Cries steadily and loudly, sometimes screams or sobs c. Constantly frowns, clenched jaw, quivering chin d. Squirms, shifting back and forth, tense e. Legs are positioned normally and appear relaxed

b. Cries steadily and loudly, sometimes screams or sobs c. Constantly frowns, clenched jaw, quivering chin d. Squirms, shifting back and forth, tense

The nurse is preparing to administer medications to school-aged patients. The nurse is aware the pediatric patient doses are different than medication doses for adults. Which factor does the nurse apply to administering pediatric medications? a. Children's bodies are smaller and need half of the adult dose. b. Doses of medications are ordered according to the child's weight. c. The first dosage consideration is based on the age of the child. d. The metabolic rate of a child is slower and can cause overdosing.

b. Doses of medications are ordered according to the child's weight.

The nurses on a pediatric unit are concerned about developmental delays in patients who are hospitalized frequently and for extended periods of time. Which interventions do the nurses initiate to alleviate these concerns? Select all that apply. a. Provide nurses with allotted time to play with confined children. b. Have age-appropriate educational TV channels available. c. Design a play/recreational area with age-appropriate sections. d. Encourage family to bring favorite toys and books from home. e. Extend the services of the child-life specialists to all patients.

b. Have age-appropriate educational TV channels available. c. Design a play/recreational area with age-appropriate sections. e. Extend the services of the child-life specialists to all patients.

Parents bring a toddler who is 2-1/2 years old to the hospital because of observed difficulty with breathing and a barky cough. The toddler is diagnosed with laryngotracheobronchitis. Which assessment finding does the nurse expect related to the diagnosis? a. Elevated temperature and pallor b. Inspiratory stridor heard in the upper airway c. Snoring sounds throughout respirations d. Fever accompanied by a congested cough

b. Inspiratory stridor heard in the upper airway

The nurse is aware the neonate's blood circulation is different before birth than after birth. Which circulation pattern does the nurse recognize as occurring prior to birth? a. For a short time after birth, the neonate continues to depend on the mother for oxygen supply. b. Oxygenated blood flows from the right atrium to the left atrium through the foramen ovale. c. Once the neonate takes a first breath, the ductus venosus closes and blood goes to the lungs. d. Oxygenated blood flows from the right ventricle to the lungs and then to the left ventricle.

b. Oxygenated blood flows from the right atrium to the left atrium through the foramen ovale.

The nurse in a pediatric clinic is counseling a parent who expresses concern about a toddler who plays alone at daycare and does not interact with the other children who are present. Which information does the nurse understand to respond to the parent's concern? a. The toddler is likely to grow into a shy, introverted adult. b. Parallel play is being exhibited and is normal at this age. c. It is important for the child to learn to be alone at this age. d. The toddler is exhibiting the normal behavior of solitary play.

b. Parallel play is being exhibited and is normal at this age.

The nurse is preparing a 13-year-old patient for a full physical examination by the primary care provider (PCP). The patient asks that her mother leave the room because of the sensitive nature of the examination. What is the best course of action to be taken by the nurse to protect the interested parties? a. Ask the mother to leave the room, and allow the patient to discuss her concerns privately with the PCP. b. Reassure the mother that the nurse will remain as a chaperone while she leaves the room. c. Allow the mother to stay in the room, and explain that she has the right to witness any care provided by the PCP. d. Act as a chaperone and remain with the patient and mother in the room during the full examination.

b. Reassure the mother that the nurse will remain as a chaperone while she leaves the room.

The nurse is evaluating the language skills of a 2-year-old patient. Which assessment finding causes the nurse to suspect a developmental delay? a. States, "Want mommy!" b. Repeats sounds but not words said by the nurse c. Converses using two short sentences d. Points to objects named by the nurse

b. Repeats sounds but not words said by the nurse

The nurse in a pediatric clinic is checking the developmental milestones for a 3-year-old patient. Which finding causes the nurse to perform additional assessments? a. The patient jumps with both feet about 2 inches high. b. The patient loses balance when kicking a ball. c. The patient draws a circle that is closed but oblong. d. The patient's tee-shirt is on backward.

b. The patient loses balance when kicking a ball.

The nurse is providing care to an 11-month-old child who is hospitalized with pneumonia. Which nursing interventions are appropriate for this child? Select all that apply. a. Allow the child to tour the facility before treatments. b. Use a singsong wide-eyed approach to interact. c. Promote a sense of security with use of gentle touch. d. Communicate primarily with parents regarding treatment. e. Use simple terminology when talking to the child.

b. Use a singsong wide-eyed approach to interact. c. Promote a sense of security with use of gentle touch. d. Communicate primarily with parents regarding treatment.

he nurse in a pediatric office is preparing to remove stitches from an 8-year-old child's arm. Which approach by the nurse before the procedure is most effective? a. Provide information in advance of how the procedure is performed. b. Have a coworker in the room to assist if the patient becomes uncooperative. c. Bring the instruments to the room and announce, "Let's get those stitches out." d. Tell the patient, "I will be back in fifteen minutes to take out your stitches."

c. Bring the instruments to the room and announce, "Let's get those stitches out."

The RN in a pediatric office is preparing to administer oral medication to an infant. Before the actual administration of the medication, which initial action does the nurse take? a. Acquire a calibrated syringe for administration. b. Assist the caregiver in holding the infant supine. c. Obtain an accurate weight of the infant. d. Provide the caregiver with written information.

c. Obtain an accurate weight of the infant.

The pediatric nurse is providing care for a school-age patient diagnosed with rheumatic heart disease. When developing a plan of care for the patient's hospital stay, which interventions does the nurse include? Select all that apply. a. Assess for the presence of strep throat or other throat infections. b. Begin patient/family teaching about the possibility of surgery. c. Organize daily care and treatments to provide for rest and relief of joint pain. d. Administer anti-inflammatory and antibiotic medications as prescribed. e. Include assessment for chest pain when obtaining vital signs.

c. Organize daily care and treatments to provide for rest and relief of joint pain. d. Administer anti-inflammatory and antibiotic medications as prescribed. e. Include assessment for chest pain when obtaining vital signs.

The nurse is providing care for a neonate diagnosed with tetralogy of Fallot who is receiving Prostaglandin E1 therapy. Which information is accurate for the nurse to understand when administering this therapy? a. Monitor for and document the expected findings of flushing, bradycardia, and irritability. b. Monitor for respiratory distress or apnea after adding the medication to the breathing tube. c. Prostaglandin E1 therapy is prescribed to keep the ductus arteriosus open. d. Prostaglandin E1 therapy should be given through a Y-connector added to the IV tubing.

c. Prostaglandin E1 therapy is prescribed to keep the ductus arteriosus open.

The school nurse in a high school setting expresses concern to school administration regarding the increase in student complaints about bullying, physical violence, and rejection. Which concern related to psychosocial development does the nurse share as being most important? a. Students are preoccupied with how they are seen in the eyes of others. b. Students who are bullied will develop issues related to sexual orientation. c. Students may be unable to provide a meaningful definition of self. d. Students who are aggressive will develop a strong sense of guilt as adults.

c. Students may be unable to provide a meaningful definition of self.

The nurse is providing postoperative teaching to the parents of a preschool child after a tonsillectomy. For which events does the nurse prompt the parents to contact the physician? Select all that apply. a. The child keeps an emesis basin close by. b. The child is asking for ice chips and popsicles. c. The child is frequently swallowing without food or fluids. d. Bright red blood is noticed in the child's mouth. e. The child refuses pain pills because it hurts to swallow.

c. The child is frequently swallowing without food or fluids. d. Bright red blood is noticed in the child's mouth. e. The child refuses pain pills because it hurts to swallow.

The nurse is providing care to a child in the home care setting. The nurse often provides the mother with advice that varies from how to perform the child's medical care to marital advice. The nurse has stated that this is her favorite patient and has made this child's home the last stop of her shift to use her free time for visits. What is the relationship status between the nurse and family? a. This is not a therapeutic relationship, as the nurse has not included the whole family in the care. b. This is a therapeutic relationship based on family-centered care, with a focus on empathy. c. This is not a therapeutic relationship, as the nurse has become enmeshed within the family. d. This is a therapeutic relationship, with the nurse focusing on the well-being of the whole family.

c. This is not a therapeutic relationship, as the nurse has become enmeshed within the family.

The nurse is providing care for a pediatric patient who is 11 years of age. The patient is diagnosed with an aggressive form of cancer and is scheduled to begin chemotherapy. The patient tells the nurse, "I think I am going to die, but I also think I will get much sicker first." Which communication by the nurse is most appropriate for this patient? a. Encourage the patient to ask the doctor to explain what is going to happen. b. Provide information about the different options that can be considered for the patient. c. Use basic terms to explain the disease progression and side effects of treatment. d. Explain to the patient the importance of maintaining a hopeful outlook.

c. Use basic terms to explain the disease progression and side effects of treatment.

The medical-surgical float nurse is assigned to the pediatric unit for the first time and states that the skills are "the same as general nursing since children are little adults with smaller bodies." What component of pediatric nursing contraindicates this statement? a. pediatric nursing is based on prevention of infectious diseases. b. pediatric nursing involved cultural sensitivity in patient care. c. pediatric nursing involved care based on the developmental level of the patient. d. pediatric nursing involves the patient's family in the plan of care.

c. pediatric nursing involved care based on the developmental level of the patient.

The nurse in an acute pediatric care setting is providing care for a 15-year-old patient. The patient is recovering from abdominal surgery. Which nursing intervention is appropriate for this patient? a. Discourage long visits by peers by reinforcing the need for rest. b. Tell the patient that IM injections will feel like a small pinch. c. Use FACES pain scale to show the patient a sense of humor. d. Ask if the patient wants to learn how to care for the incision.

d. Ask if the patient wants to learn how to care for the incision.

The nurse in a pediatric clinic is assessing a female adolescent who is 15 years of age. When the nurse performs a sexuality assessment, the patient states, "I have never had anything but safe sex." Which approach does the nurse take next? a. Inquire about treatment of an STI. b. Provide birth-control options. c. Ascertain the number of sex partners. d. Ask the patient to define "safe sex."

d. Ask the patient to define "safe sex."

The nurse is providing care for a school-age patient who received a head injury while playing sports. Which initial assessment finding causes the nurse greatest concern? a. Confusion and disorientation b. Immediate loss of consciousness c. Headache with periods of nausea d. Changes in breathing and heart rates

d. Changes in breathing and heart rates

The school nurse is attending a meeting with the teachers, school counselors, and parents of a student who has recently refused to attend school. The parents share that the student is either pretending to be ill or being untruthful about going to classes. Which initial intervention by the nurse is best? a. Explain the impact of missing school to the student. b. Ask the parents if they have noticed physical injuries. c. Suggest homeschooling until the problem is resolved. d. Inquire about the student's feelings regarding school.

d. Inquire about the student's feelings regarding school.

The parents are preparing to take their newborn, who was diagnosed with tetralogy of Fallot with pulmonary atresia, home. The nurse is developing a teaching sheet regarding care of the newborn for the parents. Which information is important for the nurse to include in the teaching plan? a. The newborn has immunity to infections from the mother. b. There is no need to limit activities. c. Monitor for signs and symptoms of bacterial pneumonia. d. It is necessary to maintain caloric intake.

d. It is necessary to maintain caloric intake.

The nurse is evaluating the motor development of a preschooler at age 5 years. Which assessment finding is essential in order for the child to be considered ready for school? a. Draws stick figures with two or more body parts b. Throws overhand and catches a bounced ball c. Dresses appropriately without assistance d. Uses the toilet without assistance

d. Uses the toilet without assistance