Hospitalized Child 2

An adolescent tells the nurse that he would like to lose weight and asks the nurse's opinion on how to accomplish his goal. Which of the following suggestions would be most appropriate? 1. Exercising more often. 2. Severely limiting calorie intake. 3. Participating in an adolescent weight-reduction program. 4. Cutting down on sweets and other snacks.

3. Weight loss treatment modalities that include peer involvement have been proven to be the most successful approach with obese adolescents.

A parent says that her family will soon be traveling abroad and asks why the drinking water in many regions must be boiled. The nurse should explain that, in addition to various types of dysentery, contaminated drinking water is most commonly responsible for the transmission of which disease? 1. Yellow fever. 2. Brucellosis. 3. Poliomyelitis. 4. Typhoid fever.

4.

When administering an I.M. injection to a neonate, which of the following muscles should the nurse consider as the best injection site? 1. Deltoid. 2. Dorsogluteal. 3. Ventrogluteal. 4. Vastus Lateralis.

4. There is less danger of injuring nerves, blood vessels, or bony structures at this site.

When the nurse asks a child suspected of being physically abused how his shoulder was hurt, he replies "it was my fault. I was bad." What would be the nurse's best response? 1. Perhaps it wasn't your fault. Can we talk about what happened? 2. Tell me what you did that made your father hurt you. 3. We'll make you better and we won't let your father do this to you again. 4. You'll have to behave better so this won't happen again.

1.

The parents report that the child has a runny nose, fever, and cough and is irritable and constantly rubbing his ears. How should the nurse expect the child's tympanic membrane to appear? 1. Bulging and red. 2. Clear and inverted. 3. Pearly gray. 4. Scarred.

1. Based on the report of the child's signs and symptoms, the nurse should suspect otitis media.

Which of the following statements by an aolescent receiving gentamicin sulfate (Garamycin) should the nurse interpret as indicating drug toxicity? 1. I'm feeling dizzy. 2. I have no appetite. 3. I urinate a lot now. 4. I haven't moved my bowels in 3 days.

1. Gentamicin sulfate is a broad-spectrum aminoglycoside antibiotic that can cause nephrotoxicity and ototoxicity. Manifestations of ototoxicity include hearing problems and vestibular disturbances, such as dizziness.

A child with leukemia has petechiae; gums, lips, and nose that bleed easily; and bruising on various parts of her body. Which of the following laboratory test results should the nurse correlate with these findings? 1. Platelet count of 80. 2. Serum calcium level of 5 3. Fibrinogen level of 75. 4. Partial thromboplastin time of 38 seconds.

1. In leukemia, megakaryocytes, from which platelets are derived, are decreased. Normal counts range from 150 to 300.

Which of the following assessments would be the priority for a 2-year-old child after a bronchoscopy? 1. Cardiac rate. 2. Respiratory quality. 3. Sputum color. 4. Pulse pressure changes.

2.

Which of the following actions would be most appropriate for a charge nurse to take first when finding that nurse who is caring for a very sick infant is making inappropriate remarks and acting in a bizarre manner? 1. Report this nurse to the supervisor. 2. Remove this nurse from the client assignment. 3. Call the nurse's family to have someone take the nurse home. 4. Talk with the nurse to determine why this behavior is occurring.

2. Because client safety is the priority, the most appropriate first action by the charge nurse would be to remove the nurse who is acting bizarrely from the client assignment.

Which of the following suggestions would be most helpful to the parents of a 2-year-old child when managing separation anxiety during hospitalization? 1. Leave while the child is sleeping. 2. Bring the child's favorite toys from home. 3. Tell the child the time they are leaving and returning. 4. Keep the visit time short.

2. Bringing a child's favorite toys, security blanket, or familiar objects from home can make the transition from home to hospital less stressful.

As part of the annual health screening, the nurse visits the eight-grade physical education classes and asks each student to bend forward at the waist with the back parallel to the floor and the hangs together at midline. For which of the following is the nurse assessing? 1. Slipped epiphysis. 2. Developmental dysplasia of hip. 3. Idiopathic scoliosis. 4. Physical dexterity.

3.

For the child experiencing excessive vomiting secondary to pyloric stenosis, the nurse should assess the child for which of the following acie-base imbalances? 1. Respiratory alkalosis. 2. Respiratory acidosis. 3. Metabolic alkalosis. 4. Metabolic acidosis.

3.

Which of the following discharge instructions should the nurse give the parents of an infant with a temporary colostomy? 1. Flush the stoma with tap water at least once a day. 2. Allow the diaper to absorb the colostomy drainage. 3. Give the infant plenty of liquids to drink. 4. Expect the stoma to become dusky red within 2 weeks.

3.

After the nurse assesses a 2 1/2 year-old's teeth during the physical examination, which of the following instructions should the nurse give to the mother? 1. Make sure the child brushes his teeth after every meal and at bedtime. 2. Give the child a small, soft-bristled toothbrush to use. 3. Floss the child's teeth using dental floss. 4. Add a fluoride supplement to the child's milk.

3. For a toddler, a parent should clean and floss the toddler's teeth because the child does not have the cognitive or motor skills needed for effective cleaning.

A mother asks the nurse when she should wean her 4-month-old infant from breast feeding and begin using a cup. What should the nurse explain as the best indication of the infant's readiness to be weaned? 1. Taking solid foods well. 2. Sleeping through the night. 3. Shortening the nursing time. 4. Eating on a regular schedule.

3. Readiness for weaning is an individual matter but is usually indicated when an infant begins to decrease the time spent nursing.

The parents of an infant with congenital defects tell the nurse they will not come back to take their baby home. Which of the following actions should the nurse take next? 1. Determine why the parents will not pick their baby up. 2. Notify the physician so the physician can contact the parents. 3. Call the police to report an abandoned infant. 4. Refer the family to a social service agency.

1. The first action by the nurse would be to determine why the parents stated they would not pick up their baby.

The parents of a neonate with a cleft lip are shocked when they see their child for the first time. Which of the following nursing actions should the nurse include in the neonate's plan of care to help the parents accept their infant's anomaly? 1. Encouraging the parents to visit more frequently. 2. Reassuring them that surgery will correct the defect. 3. Showing them pictures of babies before and after corrective surgery. 4. Allowing them to complete their grieving process before seeing the infant again.

3.

A young child who has undergone a tonsillectomy refuses to let the nurse look at the tonsillar beds to check for bleeding. To assess whether the child is bleeding from the tonsillar beds, which of the following would be most appropriate? 1. Assess capillary refill. 2. Force open the mouth with a tongue blade. 3. Monitor for decreased blood pressure. 4. Observe for frequent swallowing.

4. Blood will go down the back of the throat causing the child to swallow frequently.

While attending a support group, the parents of a child with hemophilia become concerned because several of the families have had older children who have died from acquired immunodeficiency syndrome (AIDS). They ask the nurse how these children got the AIDS virus. The nurse bases the response on which of the following as the most likely route of transmission of AIDS to these children? 1. Contamination of the factor VIII replacement received during bleeding episodes. 2. Casual contact with a child testing positive for human immunodeficiency virus. 3. Use of a contaminated needle to obtain a blood sample for type and crossmatching. 4. Exposure in the waiting room to children with AIDS attending the same hematology clinic.

1.

Increased intracranial pressure is suspected in a 4-year-old child exhibiting a decreased level of consciousness. Which of the following assessment findings should also be of most concern to the nurse? 1. Blood pressure of 122/74. 2. Pulse of 86 beats/minute. 3. Respiratory rate of 24 breaths/minute. 4. Temperature of 100.2 F

1. A blood pressure of 122/74 is above the 95th percentile for a 4-year-old child. Increased blood pressure is a common sign of increased intracranial pressure.

A nurse is performing a Denver Developmental Screening Test (Denver II) on a 4-year old. The nurse determines that the test has resulted in a caution score when there are: 1. Failed or refused items intersected by the age line between the 25th and 75th percentiles. 2. A large number of refusals to the right of the age line. 3. More failures than passes along the age line. 4. Passed or failed items intersected by the age line in the 25th and 75th percentiles.

1. A caution score is given when there are failed or refused items intersected by the age line between the 25th and 75th percentiles.

In the initial assessment, which sign should the nurse expect as typical of esophageal atresia and tracheoesophageal fistula? 1. Continuous drooling. 2. Diaphragmatic breathing. 3. Bloody emesis. 4. Large amounts of frothy meconium.

1. Esophageal atresia and tracheoesophageal fistula may occur together or separately. Esophageal atresia prevents the passage of swallowed mucus and saliva into the stomach.

The nurse is teaching the parents of a 5-year-old child who has just received diphtheria, tetanus, and pertussis; inactivated polio; and measles, mumps, and rubella vaccines about commonly expected adverse effects. What should be included? Select all that apply. 1. Fever of 103 F. 2. Redness at the injection site. 3. Rash. 4. Anorexia. 5. Prolonged crying. 6 Diarrhea.

2, 3, 4.

A 16-year-old girl comes to the school nurse complaining of cramps, backache, and nausea with her periods. The nurse most likely would interpret these symptoms as which of the following? 1. Pathologic. 2. Physiologic. 3. Psychogenic. 4. Psychosomatic.

2.

A 6-month-old infant has a high fever and cold symptoms. She is pulling at her left ear. She is schedule to receive her 6-month immunizations. The mother asks the nurse if she will receive them. The nurse's best response would be: 1. She will receive just the hepatitis immunization today because she is so sick. 2. She can have them when she returns to have her ear rechecked. 3. She must be free of infection for 6 months before she can resume her immunizations. 4. She should have a pneumonia shot today instead.

2.

A mother expresses concern that picking up the infant whenever he cries will spoil him. What is the nurse's best response? 1. Allow him to cry for no longer than 45 minutes, then pick him up. 2. Babies need comforting and cuddling; meeting these needs will not spoil him. 3. Babies this young cry when they're hungry, try feeding him when he cries. 4. If it seems as if nothing is wrong, don't pick him up; the crying will stop eventually.

2.

An abused child is admitted to the hospital, and the nurse is aware that a court appearance may be necessary. To plan for this eventuality, what should be the priority? 1. Remembering the parent's and child's behavior when the child was admitted. 2. Documenting physical findings and behaviors observed during the child's admission. 3. Formulating subjective opinions about the cause of any injuries. 4. Preparing answers to questions that may be asked by the attorneys.

2.

At the day care center, one of the toddlers bites another child. Which of the following actions by the teacher would be most appropriate? 1. Bite the child who did the biting. 2. Place the child who did the biting in "time-out." 3. Spank the child who did the biting. 4. Call the parents to pick up the child who did the biting.

2.

The mother of a 4-year-old child is concerned about her child's masturbating. When responding to the mother, which of the following facts would the nurse need to keep in mind? 1. The child needs counseling for the abnormal behavior. 2. Masturbation is normal in children of this age. 3. The child is expressing some unmet needs. 4. Masturbation at this age provides sexual release.

2.

Which of the following statements made by a mother of a 3-year-old child with unexplained injuries should the nurse determine as supportive of suspicions about abuse? 1. A good friend and I go shopping at least weekly. 2. I'm disappointed that my child can't tie his shoes. 3. My mother helps me with the children. 4. My child helps dress himself.

2.

Which of the following suggestions would be most appropriate in helping parents to prepare their children for starting school? 1. Have an older sibling tell the child about school. 2. Orient the child to the school's physical environment. 3. Offer to stay with the child for the first few days of school. 4. Discuss school with the child if he asks about it.

2.

After staying several hours with her 9-year-old daughter who is admitted to the hospital with an asthma attack, the mother leaves to attend to her other children. The child exhibits continued signs and symptoms of respiratory distress. Which of the following findings should lead the nurse to make a nursing diagnosis of Anxiety related to respiratory distress? 1. Complaints of an inability to get comfortable. 2. Frequent requests for someone to stay in the room. 3. Inability to remember her exact address. 4. Verbalization of a feeling of tightness in her chest.

2. A 9-year-old child should be able to tolerate being alone. Frequently asking for someone to be in the room indicates a degree of psychological distress that, at this age, suggests anxiety.

A 5-month-old infant is brought to the clinic by his parents because he "cries too much" and "vomits a lot." The infant's birth weight was 6 lb, 10 oz, and his current weight is 7 lb, 4 oz, falling below the 5th percentile on a standard growth chart. Which of the following data should the nurse identify as the priority. 1. Frequency of regular check-ups/ 2. Feeding pattern. 3. Pattern of weight gain. 4. Family dynamics.

2. Because the infant falls below the 5th percentile on a standard growth chart, the nurse should consider failure to thrive.

A child with appendicitis is being readied for surgery. What should be the nurse's first action? 1. Administer an enema. 2. Insert a nasogastric tube. 3. Obtain vital signs. 4. Administer antibiotics.

3.

A mother, concerned about her infant's surgery for inguinal hernia repair, asks the nurse if her infant would have been scheduled for surgery even if the hernia had been asymptomatic. Which of the following statements offers the best explanation of why the surgical repair should be done at this time? 1. An infant is better able to tolerate the physical stress of surgery than an older child is. 2. The experience of surgery is less frightening for the younger child. 3. Less danger and fewer complications result when surgery is an elective procedure. 4. Doing surgery near the genital organs is preferred before a child becomes conscious of sexual identity.

3.

A mother brigs her child to the emergency department after the child has taken "some white pills just a short while ago." What should lead the nurse to determine that the pills taken were most probably acetaminophen? 1. Nosebleed. 2. Seizure activity. 3. Nausea and vomiting. 4. Deep, rapid respirations.

3. Acetaminophen is a common drug poisoning agent in children. Symptoms seen in the first 4 hours include nausea and vomiting, anorexia, malaise, and palor.

After surgical repair of a cleft lip, an infant exhibits difficulty breathing. Which of the following measures should the nurse institute first? 1. Raising the infant's head. 2. Turning the infant onto the abdomen. 3. Administering oxygen by mask. 4. Exerting downward pressure on the infant's chin.

4. After the repair of a cleft lip, the infant must become accustomed to nasal breathing. If the infant is having difficulty breathing, it would be best to open the mouth by exerting downward pressure on the chin.

A 10-month-old child with bronchiolitis is taken out of the 30% oxygen tent for breakfast because he refuses to eat unless in a high chair. During the feeding, the nurse notes that the child's respiratory rate has increased, he is becoming more irritable, and he is using accessory muscles to breathe. The first action of the nurse should be to: 1. Discontinue the feeding and place the child back in the tent. 2. Assess the pulse rate and respirations and notify the physician. 3. Perform postural drainage and then complete the feeding. 4. Suction the child's nose with a bulb syringe.

1.

A 7-month-old female infant is admitted to the hospital with a tentative diagnosis of Hirschsprung's disease. When obtaining the infant's initial health history from the parents, which of the following statements made by the mother would be most important? 1. She gets constipated often. 2. Sometimes she gets colds. 3. She spits up occasionally. 4. Her rectal temperature is 99.4

1.

A child is receiving methylprednisolone (Solu-Medrol) I.V. as treatment for a severe asthmatic attack. The nurse closely monitors the flow rate of the I.V. infusion to prevent the development of which of the following? 1. Hypertension. 2. Nausea. 3. Flushing of the skin. 4. Seizures.

1.

A 14-year-old boy brought to the emergency department complaining of right lower quadrant pain is tentatively diagnosed with acute appendicitis. When assessing the boy, what should the nurse expect to find? 1. Costovertebral angle tenderness. 2. Widening pulse pressure. 3. Oral temperature of 100 F. 4. Gross hematuria.

3. The most common manifestations of appendicitis include right lower quadrant pain, localized tenderness, and a fever of 99 F to 102 F.

After teaching the mother of a toddler with iron deficiency anemia about diet modifications, the nurse determines that the teaching was initially effective when the mother verbalizes dietary changes involving which of the following? 1. Ingestion of equal amounts of iron-rich solids and milk products. 2. Increased intake of iron-rich solids and decreased milk intake. 3. Provision of several meals per day to the child. 4. Twice-daily offerings of dairy food snacks to the child.

2. The child's intake of iron-rich solids needs to be increased, while the intake of milk, which is low in iron, needs to be decreased to 1 quart per day.

A mother of an ill child is concerned because the child "isn't eating well." Which of the following strategies devised by the mother to help increase the child's intake should the nurse advise against using? 1. Allowing the child to choose his meals from an acceptable list of foods. 2. Letting the child substitute items on his tray for other nutritious foods. 3. Asking the child to say why he is not eating. 4. Telling the child he must eat or else he will not get better.

4.

The mother says that the infant's physician recommends certain foods, but the infant refuses to eat them after breast-feeding. The nurse should suggest that the mother alter the feeding plan by doing which of the following? 1. Offering dessert followed by some vegetables and meat. 2. Offering breast milk as long as the infant refuses to eat solid foods. 3. Mixing pureed food with some breast milk in a bottle with a large-hole nipple. 4. Allowing the infant to nurse for a few minutes and then offering solid foods.

4.

A community health nurse has taught a parent in the clinic about the ages that children receive immunizations and the reason why certain immunizations, such as the measles, mumps, rubella and polio vaccines, are given at different times. The nurse should judge the teaching as successful when she overhears this parent tell another parent: 2. My 6-month-old child will have to wait for the MMR vaccine. 2. My child has a cold and will have to wait 2 weeks to receive immunizations. 3. Children must wait 2 months between the MMR and polio vaccines. 4. Children receive their MMR vaccine and then have to wait 1 month for the tuberculin skin test.

1.

The nurse should explain that the most common cause for the unhappiness some children experience when first entering school is due to which of the following? 1. Feelings of insecurity. 2. Social isolation. 3. Emotional maladjustment. 4. Poor language development.

1.

When performing a physical assessment on an 18-month old child, which of the following would be best? 1. Have the mother hold the toddler on her lap. 2. Assess the ears and mouth first. 3. Carry out the assessment from head to toe. 4. Assess motor function by having the child run and walk.

1.

When teaching a group of parents of school-age children about growth and development, which of the following characteristics about children of this age should the nurse include? 1. Desire to carry a task to completion. 2. Ability to imagine possibilities. 3. Feeling that others are focused on them. 4. Ability to consider hypothetical risks and benefits.

1.

Which of the following information during a health history should the nurse correlate as consistent with the diagnosis of failure to thrive in an infant? 1. Fussiness during feedings. 2. Fear of strangers. 3. Being quiet when held. 4. Needing to be awakened for feedings.

1.

Which of the following should the nurse do next after noting that an 8-month-old child's posterior fontanel is slightly open? 1. Check the child's head circumference. 2. Document this as a normal finding. 3. Question the mother about the child's delivery. 4. Schedule an x-ray of the child's head.

1.

For a child receiving steroids in therapeutic doses over a long period, the nurse should: 1. Monitor the child's serum glucose level. 2. Decrease the child's ingestion of potassium-rich foods. 3. Give the drug on an empty stomach. 4. Monitor the child's temperature to asses for infection.

1. Steroid use tends to elevate glucose levels. The child should be monitored for increases.

A parent reports that his 2-year-old child often falls when running. The nurse interprets this as indicating which of the following as a normal aspect of a toddler's vision? 1. Nearsightedness. 2. Farsightedness. 3. Binocular vision. 4. Strabismus.

1. Until age 7 years, children are normally myopic (nearsighted).

The mother of a child with tetralogy of Fallot asks the nurse why her child has clubbed fingers. The nurse bases the response on the understanding that clubbing is due to which of the following? 1. Anemia. 2. Peripheral hypoxia. 3. Delayed physical growth. 4. Destruction of bone marrow.

2. Clubbing of the fingers is one common finding in the child with persistent hypoxia, which leads to tissue changes in the body because of the low oxygen content of the blood.

Two adolescents come to the school nurse's office to talk about their friend. They are concerned because he seems to be using several different drugs. One of the adolescents asks how he would be able to tell if his friend was using cocaine. The nurse replies: 1. His eyes would be red and bloodshot. 2. His pupils would be large. 3. His pupils would be constricted to to pinpoints. 4. His eyes would look tired.

2. Cocaine use causes pupils to dilate.

A parent groupis discussing different types of punishment. The parents ask the nurse to discuss corporal punishment. The nurse tells the group that corporal punishment: 1. Does not physically harm the child. 2. Can result in children becoming accustomed to spanking. 3. Reinforces the idea that violence is not acceptable. 4. Can be beneficial in teaching children what they should do.

2. Corporal punishment is an aversion technique that teaches children what not to do.

Which of the following assessment findings should the nurse expect in an infant with colic? 1. Failure to gain weight. 2. Expulsion of flatus. 3. Soft abdomen. 4. Difficulty with burping.

2. Infants with colic have paroxysmal pain or cramping caused by the production and accumulation of gas.

Which of the following measures should the nurse expect to perform for a child who is receiving high-dose methotrexate (amethopterin) therapy? 1. Keeping the child in a fasting state. 2. Obtaining a while blood cell (WBC) count. 3. Preparing for radiography of the spinal canal. 4. Collecting a specimen for urinalysis.

2. Methotrexate is not highly toxic in low doses but may cause severe leukopenia at higher doses.

What is appropriate to include in a teaching plan for a 9-year-old child who has had diabetes for several years? 1. Beginning to recognize the signs and symptoms of hypoglycemia. 2. Learning to measure insulin accurately in a syringe. 3. Beginning to be able to self-administer injections with adult supervision. 4. Assuming responsibility for self care.

3.

After teaching the parents of an infant who has had a pyloromyotomy about proper postoperative feeding techniques, the nurse determines that they have understood the teaching when they position the infant in the crib after feeding with head elevated and lying on: 1. Left side. 2. Abdomen. 3. Right side. 4. Back.

3. Positioning the infant on the right side with the head elevated facilitates passage of food through the pyloric sphincter in to the intestine.

When obtaining a health history from the mother of a 7-year-old child diagnosed with acute rheumatic fever, the nurse should focus questions to determine if the child was recently ill with which of the following? 1. Vomiting. 2. Earache. 3. Sore throat. 4. Dysuria.

3. Rheumatic fever is an inflammatory collagen disease that typically follows an infection by group A beta-hemolytic streptococci, ordinarily occurring in the throat.

After having surgery to reduce the invagination of intussusception, an infant has a nasogastric tube in place, is receiving I.V. fluids, and is allowed nothing by mouth. In addition to body weight, which of the following parameters should the nurse use to calculate the amount of I.V. fluid and electrolyte solution to infuse over the next 24 hours? 1. Stool output. 2. Urine output. 3. Gastric output. 4. Degree of temperature elevation.

3. The volume of parenteral fluids needed is based on fluid requirements determined according to body weight and, in this situation, gastric output. If these fluids are not replaced with an appropriate I.V. solution, serious fluid and electrolyte imbalances could develop.

A nurse caring for a 15-month old girl suspects that she has been sexually abused. What rule should guide the nurse to the decision to report the abuse? 1. The parents need to be notified before suspected abuse can be reported. 2. Physicians are primarily responsible for reporting suspected abuse. 3. A nurse can be sued when reporting abuse on suspicions only. 4. A nurse who suspects child abuse is legally required to report the suspicions.

4.

When talking with grandparents of a toddler, which of the following toys should the nurse recommend as the most appropriate? 1. Tricycle. 2. Wheelbarrow. 3. Sled. 4. Blocks.

4. As toddlers begin imaginative play, blocks are an excellent toy choice.

A 5-year-old child asks the nurse if it will hurt to have his tonsils and adenoids taken out. Which of the following responses by the nurse would be best? 1. It won't hurt because we put you to sleep. 2. It won't hurt because you're such a big boy. 3. It will hurt because of the incisions made in the throat. 4. It will hurt, but we have medicine to help you feel better.

4. Truthful but simple explanations will minimize distorted fears and reduce anxiety.

After receiving report, the nurse is making out assignments. Which of the following clients would be appropriate to assign to unlicensed assistive personnel? 1. A 6-year-old with a femur fracture and a fever. 2. a 13-year-old adolescent with fluctuating vital signs and a new central line. 3. A 7-year-old transferred from the cardiac intensive care unit. 4. An 8-month-old with pneumonia who will be discharged today.

4. Unlicensed assistive personnel can care for a client with pneumonia who will be discharged.

A mother tells the nurse that her 4 1/2-year-old child "doesn't seem to know the difference between right and wrong." The nurse responds to the mother, basing the explanation on the fact that this behavior is typical of which of the following levels as described by Kohlberg's theory of levels of moral development? 1. Autonomous. 2. Conventional. 3. Preconventional. 4. Principled.

3. This stage is typical of the preschool-aged child.

After an appendectomy, an adolescent is alert and oriented. Parenteral fluids are infusing and a nasogastric tube is attached to low intermittent suction. Which of the following nursing measures would be most appropriate for the adolescent during this early postoperative period? 1. Irrigating the nasogastric tube every hour. 2. Testing the urine for protein. 3. Removing the nasogastric tube when the adolescent is fully alert. 4. Encouraging the adolescent to urinate frequently.

4. After an appendectomy, the adolescent should be encouraged to void frequently to prevent bladder distention which could cause strain on the incision.

Which of the following demonstrates the nurse's compliance with the Centers for Disease Control and prevention guidelines concerning sterile glove use? 1. As an optional precautionary measure. 2. When delivering care involving touching a child. 3. Upon entering a child's room. 4. When giving direct care to burned areas.

4. Sterile gloves must be worn when giving any care to a burn area.

After teaching the parents of a 15-month-old child who has undergone cleft palate repair how to use elbow restraints, which of the following statements by the parents indicates effective teaching? 1. We'll keep the restraints in place continuously until the doctor says it's okay to remove them. 2. We can take off the restraints while our child is playing but we'll make sure to put them back on at night. 3. The restraints should be taped directly to our child's arms so that they will stay in one place. 4. We'll remove the restraints temporarily at least three times a day to check his skin then put them right back on.

4. Elbow restraints help to keep the child from placing fingers or any other object in the mouth that would cause injury to the operative site.

A child with rheumatic fever has chorea. Which of the following actions should the nurse consider to be most important? 1. Explain to the child and family that the chorea will disappear over time. 2. Institute measures to keep the child in a warm environment. 3. Perform neurologic checks every 4 hours until the chorea subsides. 4. Encourage ambulation by giving aspirin 30 minutes before walking.

1. Because the clumsiness and uncontrolled actions can be upsetting to both the child and family, they need to understand that chorea associated with rheumatic fever is not permanent.

When assessing the child with asthma for allergic rhinitis, which of the following should the nurse expect to find? 1. Nasal crease. 2. Abdominal pain. 3. Fever. 4. Mouth breathing.

1. In the child with asthma and allergic rhinitis, the allergic reaction to inhaled particles generally causes frequent nose rubbing, subsequently leading to a nasal crease.

The physician orders 250mg of an antibiotic every 6 hours for a child weighing 25kg who had infected burns. The normal dosage for this antibiotic and condition is 20 to 50 mg/kg per 24 hours. Which of the following actions would be most appropriate? 1. Carry out the order because the ordered dose is acceptable. 2. Give the dose recommended by the pharmacy reference material. 3. Question the order because the dose is too low. 4. Question the order because the dose is a toxic amount.

1. The ordered dose equals 1000 mg in 24 hrs. The recommended dose is 500 to 1250 mg in 24 hrs.

A mother brings her 2-year-old adopted Korean child to the clinic for an initial checkup. The child has been living with the adopted family for several weeks. The nurse notes an irregular area of deep blue pigment on the child's buttocks extending into the sacral area. The nurse should: 1. Do nothing concerning this finding. 2. Ask the mother in private how the bruise occurred. 3. Notify social services of a case of possible child abuse. 4. Question the mother about the family's discipline style.

1. This lesion is a mongolian spot, which is common in children of Asian or African American heritage.

After uncomplicated abdominal surgery, which of the following would be most appropriate when determining if an alert school-aged child is ready to drink oral fluids? 1. Ask if the child wants something to drink. 2. Auscultate the child's abdomen for bowel sounds. 3. Determine that the child has a gag reflex. 4. Palpate the epigastric area for discomfort.

2. Before giving fluids, the nurse needs to auscultate the child's abdomen for bowel sounds, which indicate the return of peristalsis and a functioning GI tract.

The father of a 3-year old child expresses a concern about the child's fear of the dark. Using Piaget's concepts of cognitive development which of the following would be the most appropriate explanation as the basis for the child's fear of darkness? 1. Reversibility. 2. Animism. 3. Conservation of matter. 4. Object permanence.

2. The child attributes the quality of conscious thought to inanimate objects. It is a peculiarity of preconceptual thought, part of the preoperational stage, lasting from age 2 to 4 years.

The nurse explains to the mother of a child receiving digoxin (Lanoxin) that which of the following is the primary reason for giving this drug? 1. To relax the walls of the heart's arteries. 2. To improve the strength of the heartbeat. 3. To prevent irregularities in ventricular contractions. 4. To decrease inflammation of the heart wall.

2. Digitalis prepariations such as digoxin act to improve and strengthen the heartbeat.

A child with Down syndrome has an IQ of about 40. The nurse should expect which of the following as the type of environment and interdisciplinary program to most likely benefit this child? 1. Custodial. 2. Institutional. 3. Task analysis. 4. Vocational training.

3. Habit-training task analysis, a step-by-step process in which each step is taught before moving onto the next step, would be most beneficial.

A child admitted to the hospital with a serum sodium level of 160 mmol/L is receiving 5% dextrose with 0.45 normal saline solution. The mother asks the child's nurse why the child is receiving sodium. The nurse's best reply would be: 1. Your child's sodium is high; I'll stop the infusion and check with the physician. 2. Your child's sodium is high; but if the serum sodium level is decreased too rapidly, it may cause seizures. 3. Your child's sodium is low; we need to give some more sodium I.V. 4. Your child's sodium is normal; the solution will maintain the level.

2. The normal serum sodium level for a child is 138-146 mmol/L. A rapid decrease in serum sodium level can cause fluid shifts that will result in a rapid increase in intracranial pressure, increasing the risk of seizure.

A 10-year-old child with a history of bronchial asthma triggered by exposure to cold, smoke, and nuts is brought to the hospital's emergency department by his mother. Appearing restless and anxious, the child has a respiratory rate of 36 breaths/minute and pulse rate of 160 beats/minute. Which of the following findings should be of greatest concern to the nurse? 1. Increased respiratory effort. 2. Moist, loose cough. 3. Absence of wheezing. 4. Prolonged expiratory phase.

3. Knowing that this child is most likely experiencing an asthma attack, the nurse should expect to hear wheezing and note some shortness of breath with a prolonged expiratory phase.

Which of the following behaviors by a neonate attempting an initial feeding should indicate to the nurse that the neonate may have tracheoesophageal fisula? 1. Sucking attempts that are too poorly coordinated to effective. 2. Projectile vomiting that occurs after drinking 4 oz. 3. Coughing, choking, and cyanosis that occur after several swallows of formula. 4. Sleeping that occurs after taking 10ml of formula with an inability to be stimulated to take more.

3. The newborn with tracheoesophageal fistula swallows normally, but the fluids quickly fill the blind pouch.

The mother of a 4-year-old child asks about dental care for her child. "I help brush her teeth every day, and her teeth look healthy," the mother states. "When should I take her to see a dentist?" Which of the following responses would be most appropriate? 1. Because you help brush her teeth, there's no need to see a dentist right now. 2. Ideally she should have seen a dentist already, but it's still not too late. 3. Your child doesn't need to see the dentist until she starts school. 4. A dental checkup is a good idea even if no problems are noticeable.

4.

The parents of teenagers express concerns about the types and large quantities of food their children eat and their refusal to eat foods served at family meals. Which of the following suggestions would be most helpful for the parents? 1. Carefully evaluate the adolescents' nutritional intake. 2. Inform the adolescents about the adverse effects of fad diets. 3. Give the adolescents responsibility for grocery shopping for 1 month. 4. Incorporate the adolescents' preferences into meal planning.

4. Preventing food intake from becoming the center of an independence-dependence struggle is important.

Which of the following activities should the nurse include in the teaching plan for a mother to help channel her 4-year-old child's energy? 1. Participation in parallel play. 2. Play involving a game such as Simon Says. 3. Bicycle riding. 4. Stringing large beads.

2. Simon Says requires the preschooler to use a variety of motor skills, can help channel activity and meet developmental needs.

Which of the following instructions should the nurse include in the teaching plan about skin care for the mother of a child with atopic dermatitis? 1. Soaking the child in a tub for 30 minutes to soften the skin. 2. Using a mild soap followed by patting the skin to dry it. 3. Using an antibacterial soap two times a week. 4. Washing clothes in a strong detergent to prevent infections.

2.

Assessment of a 6-week-old infant reveals weight and length in the 50th percentile for his age and a head circumference at the 95th percentile. What should the nurse do first? 1. Assess motor and sensory function of the legs. 2. Examine the fontanels and sutures. 3. Advise the mother of the need for follow-up in 1 month. 4. Obtain a written consent for transillumination.

2. Head circumference usually parallels the percentile for length. The discrepancy found requires close and immediate attention because it could indicate hydrocephalus with its potential for brain damage.

Which of the following should the nurse do first when a neonate with myelomeningocele experiences urine retention with overflow incontinence? 1. Apply pressure to the suprapubic area. 2. Initiate an intermittent clean catheterization program. 3. Insert an indwelling urinary catheter. 4. Collect a urine specimen.

2. Overflow incontinence with constant dribbling is common in neonates with myelomeningocele.

An infant's skin is inelastic and the upper abdomen is distended. To palpate the olivelike mass most easily, the nurse should palpate the epigastrium just to the right of the umbilicus at which of the following times? 1. Just before the infant vomits. 2. While the infant is eating. 3. When the infant is lying on the left side. 4. When the stomach is empty

2. The pyloric, olivelike mass is most easily palpated when the abdominal muscles are relaxed, the stomach is empty and the infant is quiet. During eating, the stomach is still empty and the infant is relaxed and comfortable.

A nurse overhears a fellow staff member talking about the mother of a child for whom the staff nurse is caring. The nurse is telling others private information that the mother had shared. Which of the following responses by the nurse overhearing the conversation would be best? 1. Reporting this incident to their nurse-manager. 2. Telling the mother what was being said about her. 3. Talking to the staff member privately about this. 4. Talking to the staff in general about confidentiality.

3.

Which of the following would be best to help prepare a preschool-aged child for an injection? 1. Having an older child explain that shots do not hurt. 2. Helping the child to imagine she is in a different place. 3. Giving the child a play syringe and a bandage to give a doll injections. 4. Giving the child a pounding board to encourage expressions of anger.

3.

After the nurse instructs the parents of a 5-month-old infant about the purpose of the Denver Developmental Screening Test (DDST), which of the following statements by the parents about what the test measures would indicate that the teaching was effective? 1. This test measures a child's IQ. 2. This test measures a child's emotional development. 3. This test measures a child's social and physical abilities. 4. This test measures a child's potential for future development.

3. DDST measures a child's social, language, and fine and gross motor skills by testing abilities that usually occur at a given age.

Which of the following methods should the nurse use to feed an infant after surgical repair of a cleft lip? 1. Gastric gavage. 2. I.V. fluids. 3. Bottle with a cross-cut nipple. 4. Bottle with a lamb's nipple.

3. Feeding methods should produce the least ension possible on the sutures to promote effective healing of the cleft lip repair.

A nurse observes a family in the waiting room of a well-child clinic. Which of the following behaviors would be considered to be an example of social affective play? 1. An 8-year-old child is taking turns playing a handheld video game with another child. 2. A 4-year-old child is listening to the mother's chest with a stethoscope. 3. An infant is making happy noises in response to her father speaking to her. 4. A 2-year-old child is sitting in her mother's lap hugging a teddy bear.

3. Social affective play occurs when infants take pleasure in relationships with people.

During a home visit, the nurse notices that a 1-month-old infant has esotropia. The nurse should advise the parents to do which of the following? 1. Call the baby's health care provider immediately. 2. Mention this finding at the baby's 6-month checkup. 3. Do nothing because this condition is normal for the infant's age. 4. Call the clinic for a referral to an optometrist.

3. The nurse should advise the parents to do nothing because esotropia, inward turning of the eyes, is a normal finding in infants of this age.

When preparing to admit an infant diagnosed with diarrhea to the pediatric unit, the nurse should expect to assign the infant to which of the following rooms? 1. A four-bed room with postoperative clients. 2. A two-bed room with an infant with respiratory disease. 3. A two-bed room with no roommate. 4. A room with other infants younger than age 1 year.

3. To reduce the risk of infection transmission, an infant with diarrhea of undetermined origin should be placed in a room alone until a causative organism can be identified.

When caring for terminally ill children and their families, which of the following is recommended as most important for the nurse to have? 1. Experience with the death of a loved one. 2. Development of a belief that accepts life after death. 3. Participation in a course examining how best to deal with death and grieving. 4. A working personal philosophy concerning life and death.

4.

When completing an assessment of a healthy adolescent client, which of the following would be most appropriate? 1. Obtain a detailed account of the adolescent's prenatal and early developmental history. 2. Discuss sexual preferences and behaviors with the parents present for legal reasons. 3. Discuss the client's smoking with parents present in the room. 4. Gather information from the parents and adolescent; then assess the adolescent in private.

4.

While planning interventions with the nurse that will allow the diabetic child to participate in an early morning tennis program at school, the mother offers several interventions. What should the nurse recommend eliminating? 1. Injecting the morning insulin dose in an area away from major muscles used in playing tennis. 2. Having the child eat more calories for breakfast on tennis days. 3. Having the child carry a source of quickly absorbed carbohydrate to the program. 4. Teaching the other children in the class the signs and symptoms of hyperglycemia.

4.

During a routine health assessment, a mother tells the nurse that her 2-year old child is using a potty seat but is still having problems toilet training. Which of the following suggestions would be most appropriate? 1. Offer the child more praise each time. 2. Use a potty chair instead of a potty seat. 3. Focus on the "accidents" that occur during training. 4. Defer training until the child is developmentally ready.

4. The most common reason for failed toilet training is that the child is simply not developmentally ready for training.