MCN 374 Exam 1 - Ch 1, 2, 4-9, 11, 12, 15, 20

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

1. 18 months 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

The charge nurse on a hospital unit is developing plans of care related to separation anxiety. The charge nurse recognizes that which hospitalized child at highest risk to experience separation anxiety when parents cannot stay? 1. 6-month-old 2. 18-month-old 3. 3-year-old 4. 4-year-old

2. 18-month-old While all of these children can experience separation anxiety, the young toddler is at highest risk. Toddlers are the group most at risk for a stressful experience when hospitalized. Separation from parents increases this risk greatly.

409. The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the health care provider did not prescribe antibiotics. Which response should the nurse make? 1. "The child may be allergic to antibiotics." 2. "The child is too young to receive antibiotics." 3. "Antibiotics are not indicated unless a bacterial infection is present." 4. "The child still has the maternal antibodies from birth and does not need antibiotics."

3. "Antibiotics are not indicated unless a bacterial infection is present." Laryngotracheobronchitis (croup) is the inflammation of the larynx, trachea, and bronchi and is the most common type of croup. It can be viral or bacterial. Antibiotics are not indicated in the treatment of croup unless a bacterial infection is present. Options 1, 2, and 4 are incorrect. In addition, no supporting data in the question indicate that the child may be allergic to antibiotics.

A child is being prepared for an invasive procedure. The mother of the child has legal custody but is not present. After details of the procedure are explained, who can provide legal consent on behalf of a minor child for treatment? 1. The divorced parent without custody 2. A cohabitating unmarried boyfriend of the childs mother 3. A grandparent who lives in the home with the child 4. A babysitter with written proxy consent

A babysitter with written proxy consent A parent may grant proxy consent in writing to another adult so that children are not denied necessary health care. In the case of divorced parents, the parent with custody may be the only parent allowed by some states to give informed consent. Residence in the same household with a child does not authorize an adult to sign consent for treatment.

Which legal or ethical offense would be committed if a nurse tells family members the condition of a newborn baby without first consulting the parents? 1. A breach of privacy 2. Negligence 3. Malpractice 4. A breach of ethics

A breach of privacy A breach of privacy would have been committed in this situation, because it violates the right to privacy of this family. The right to privacy is the right of a person to keep his or her person and property free from public scrutiny, including other family members. Negligence and malpractice are punishable legal offenses and are more serious. A breach of ethics would not apply to this situation.

Which nursing role is not directly involved when providing family-centered approach to the pediatric population? 1. Advocacy 2. Case management 3. Patient education 4. Researcher

A researcher is not involved in the family-centered approach to patient care of children and their families. Advocacy, case management, and patient education are all roles directly involved in the care of children and their families.

A father brings his 4-year-old to the doctor's office for a well child visit. The father is embarrassed by his child's behavior during the visit. The father states that every time the child comes for an immunization she begins to cry and scream. An appropriate response to this father is: A. "All children have a major fear of needles; preschoolers often believe pain is a punishment." B. "Your child most likely had a traumatic experience at an early age." C. "Next time the mother should accompany the child for an immunization." D. "It is best to ignore this type of behavior as the child is seeking attention."

A. "All children have a major fear of needles; preschoolers often believe pain is a punishment." The preschooler is in Piaget's stage of pre-operational thought. They often feel that they did something wrong that caused them to be sick or in pain.

The nurse providing anticipatory guidance education to the parents of a toddler shares that the most representative type of play usually seen in toddlers would be: A. Two children sitting side by side, each playing with a toy truck B. Two children putting a puzzle together C. A child who sits on the floor by himself, playing with blocks D. The child who dresses up like a fireman

A. Two children sitting side by side, each playing with a toy truck Two toddlers tend to play with similar objects side by side, occasionally trading toys and words

Individualized education plan (IEP)

Developed for a child with cognitive, motor, social, and communication impairment who needs special education services.

Individualized health plan (IHP)

Developed for the child with medical conditions that need to be managed within the school setting.

Individualized family service plan (IFSP)

Developed for the early intervention process for infants with special healthcare needs and their families.

Prescreening developmental questionnaire

Helps identify children who need Denver II assessment.

A 12-year-old pediatric client is in need of surgery. Which member of the health care team is legally responsible for obtaining informed consent for an invasive procedure? 1. Nurse 2. Physician 3. Unit secretary 4. Social workeR

Physician Informed consent is legal preauthorization for an invasive procedure. It is the physicians legal responsibility to obtain this, because it consists of an explanation about the medical condition, a detailed description of treatment plans, the expected benefits and risks related to the proposed treatment plan, alternative treatment options, the clients questions, and the guardians right to refuse treatment.

Ages and stages questionnaire

Questionnaire of specific ages, 10 to 15 items in each area: fine motor, gross motor, communication, adaptive, personal, and social skills.

217. A 2-year-old child is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home? 1. "We will be sure not to leave hot liquids unattended." 2. "I guess our children need to understand what the word hot means." 3. "We will be sure that the children stay in their rooms when we work in the kitchen." 4. "We will install a safety gate as soon as we get home so the children cannot get into the kitchen."

1. "We will be sure not to leave hot liquids unattended." Toddlers, with their increased mobility and development of motor skills, can reach hot water or hot objects placed on counters and stoves and can reach open fires or stove burners above their eye level. The nurse should encourage parents to remain in the kitchen when preparing a meal, use the back burners on the stove, and turn pot handles inward and toward the middle of the stove. Hot liquids should never be left unattended or within the child's reach, and the toddler should always be supervised. The statements in options 2, 3, and 4 do not indicate an understanding of the principles of safety.

The telephone triage nurse at a pediatric clinic knows each call is important. Which call would require extra attentiveness from the registered nurse because of an increased risk of mortality? 1. A 3-week-old infant born at 35 weeks gestation with gastroenteritis 2. A term 2-week-old infant of American Indian descent with an upper respiratory infection 3. A post term 4-week-old infant non-Hispanic black descent with moderate emesis after feeding 4. A 1-week-old infant born at 40 weeks gestation with symptoms of colic

1. A 3-week-old infant born at 35 weeks gestation with gastroenteritis The leading causes of death in the neonatal period (birth to 28 days of age) are short gestation, low birth weight, and congenital malformations. The preterm infant experiencing gastroenteritis at 3 weeks of age is at the greatest risk for mortality; therefore, would require extra attentiveness from the registered nurse.

221. The mother of a 3-year-old asks a clinic nurse about appropriate and safe toys for the child. The nurse should tell the mother that the most appropriate toy for a 3-year-old is which? 1. A wagon 2. A golf set 3. A farm set 4. A jackset with marbles

1. A wagon Rationale: Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, large trucks, and dolls are some of the appropriate toys. A farm set, a golf set, and jacks with marbles may contain items that the child could swallow.

Which nursing diagnosis is most appropriate for an infant with acute bronchiolitis due to respiratory syncytial virus (RSV)? 1. Activity Intolerance 2. Decreased Cardiac Output 3. Pain, Acute 4. Tissue Perfusion, Ineffective (peripheral)

1. Activity Intolerance Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory-disease process.

A child is admitted to the hospital with the diagnosis of laryngotracheobronchitis (LTB). Which nursing intervention is the priority for this child? 1. Administer nebulized epinephrine and oral or IM dexamethasone. 2. Administer antibiotics and assist with possible intubation. 3. Swab the throat for a throat culture. 4. Obtain a sputum specimen.

1. Administer nebulized epinephrine and oral or IM dexamethasone. Nebulized epinephrine and dexamethasone are given for LTB. Antibiotic administration and possible intubation are associated with epiglottitis. Throat cultures are not obtained for LTB because it is viral and swabbing the throat could cause complete obstruction to occur. Sputum specimens will not assist in the diagnosis of LTB.

During the nurses initial assessment of a school-age child, the child reports a pain level of 6 out of 10. The child is lying quietly in bed watching television. Which action by the nurse is most appropriate? 1. Administer prescribed analgesic. 2. Ask the childs parents if they think the child is hurting. 3. Reassess the child in 15 minutes to see if the pain rating has changed. 4. Do nothing, since the child appears to be resting.

1. Administer prescribed analgesic. School-age children are old enough to accurately report their pain level. A pain score of 6 is an indication for prompt administration of pain medication. The child may be trying to be brave or may be lying still because movement is painful.

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.

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. Administering flu vaccines, discussion of feeding schedules, and instructions to adolescents are all health-promotion and/or 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 is working with a school-age child who is hospitalized. Which action by the nurse will promote a sense of industry in this child? 1. Allow the child to assist with her care. 2. Encourage parents to participate in the childs care. 3. Give the child a detailed scientific explanation of the illness. 4. Speak to the child in a high-pitched voice.

1. Allow the child to assist with her care. Allowing the child to participate in her care will decrease the sense of loss of control and increase a sense of industry. While parents can certainly participate in their childs care, it does not increase the childs sense of control. School-age children in general will not understand detailed scientific explanations. Change in voice tone is appropriate when talking to very young children.

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.

1. Allow the child to participate in the exam. 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 childs decision whether he is ready for immunization, so do not ask this question.

A nurse is assessing an 11-month-old infant and notes that the infants height and weight are at the 5th percentile on the growth chart. Family history reveals that the infants 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

1. Alteration in Growth Pattern Related to Parental Anxiety 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.

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

1. Assessment 3. Education 4. Intervention 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.

The adolescent is 6-hours postappendectomy and refuses pain medications. The nurse would like to walk the child in the hall but is concerned that the child has unrelieved pain. The nurse knows that unrelieved pain causes physiologic consequences such as (Select all that apply.) 1. Atelectasis 2. Pneumonia 3. Ileus 4. Lethargy 5. Hypoactive bowel sounds

1. Atelectasis 2. Pneumonia 3. Ileus 1. Unrelieved pain causes physiologic consequences, such as atelectasis. 2. Unrelieved pain causes physiologic consequences, such as pneumonia. 3. Unrelieved pain causes physiologic consequences, such as ileus.

A neonatal nurse who encourages parents to hold their baby and provides opportunities for Kangaroo Care most likely is demonstrating concern for which aspect of the infant's psychosocial development? 1. Attachment 2. Assimilation 3. Centration 4. Resilience

1. Attachment Attachment is a strong emotional bond between a parent and child that forms the foundation for the fulfillment of the basic need of trust in the infant. Assimilation describes the child's incorporation of new experiences, centration is the ability to consider only one aspect of a situation at a time, and resilience is the ability to maintain healthy function even under significant stress and adversity.

It is important that parents of adolescents with special needs transition care of the adolescent so they can learn to make good decisions on their own. Which items are considered transitional needs? Select all that apply. 1. Attending school 2. Discussing sexual matters 3. Letting most friends know of the medical condition 4. Socialization beyond the family 5. To write his or her own individualized healthcare plan

1. Attending school 2. Discussing sexual matters 4. Socialization beyond the family Transitional needs toward independence include attending school, discussion of sexual matters, and socialization beyond the family. The other areas are not transitional needs.

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

1. Avoid naps in the late afternoon and evening 3. Avoid caffeine, tea, coffee, carbonated beverages and energy drinks for several hours before sleep. 5. Go to bed and get up at the same time each day, including weekends 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 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

1. Avoiding nursing or giving the infant a bottle at bedtime 3. Using a soft moist gauze for cleaning 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 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.

1. Bring hands to eyes and mouth. 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.

The nurse is working with a child with a chronic condition. The nurse observes that over time, the parents have experienced a pattern of periodic grieving alternating with denial. What are the parents currently experiencing based on this assessment finding? 1. Chronic sorrow 2. Compassion fatigue 3. Dysfunctional parenting 4. Pathological grieving

1. Chronic sorrow Parents experience chronic sorrow as they grieve when their child does not meet developmental milestones or participate in activities of "normal" children. The time between periods of grieving may be times of parental denial, which allows the family to function. Compassion fatigue is experienced by caregivers as their ability to feel compassion is exhausted. Dysfunctional parenting involves inadequately meeting the needs of children. Pathological grieving results when persons do not move through the stages of grief to resolution.

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

1. Client who does not make eye contact 2. Client with visible bruises in various stages of healing 5. Client who appears red in the face while walking to exam room 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.

The nurse is assigned to a child in a spica cast for a fractured femur suffered in an automobile accident. The childs teenage brother was driving the car, which was totaled. The nurse learns that the father lost his job three weeks ago and the mother has just accepted a temporary waitress job. Which nursing diagnosis will the nurse use when planning care for this child and family? 1. Compromised Family Coping Related to the Effects of Multiple Simultaneous Stressors 2. Impaired Social Interaction (Parent and Child) Related to the Lack of Family or Respite Support 3. Interrupted Family Processes Related to Child with Significant Disability Requiring Alteration in Family Functioning 4. Risk for Caregiver Role Strain Related to Child with a Newly Acquired Disability and the Associated Financial Burden

1. Compromised Family Coping Related to the Effects of Multiple Simultaneous Stressors Compromised Family Coping Related to the Effects of Multiple Simultaneous Stressors best fits the multiple crises to which this family is responding. The spica cast may require alteration in family functioning; however, fractures are generally not considered a significant long-term disability. Lack of family members and lack of respite support was not mentioned in the scenario.

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.

1. Decreased ability to perform visual tracking. 2. Decreased auditory stimulation. 3. Decreased muscle tone. 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 school nurse completes an assessment of a school-age client to determine the services this child will need in the classroom. The client is a newly diagnosed with type I diabetes mellitus. Based on this information, which special healthcare need category is the most appropriate? 1. Dependent on medication or special diet 2. Dependent on medical technology 3. Increase use of healthcare services 4. Functional limitations

1. Dependent on medication or special diet A child recently diagnosed with type I diabetes mellitus with no other medical diagnoses would be placed in the dependent on medication or special diet category. The other categories of care are not appropriate for this client.

The nurse in a pediatric acute-care unit is assigned the following tasks. Which task is not appropriate for the registered to nurse complete? 1. Diagnose an 8-year-old with acute otitis media and prescribe an antibiotic. 2. Listen to the concerns of an adolescent about being out of school for a lengthy surgical recovery. 3. Provide information to a mother of a newly diagnosed 4-year-old diabetic about local support-group options. 4. Diagnose

1. Diagnose an 8-year-old with acute otitis media and prescribe an antibiotic. The role of the pediatric nurse includes providing nursing assessment, directing nursing care interventions, and educating client and family at developmentally appropriate levels; client advocacy, case management, minimization of distress, and enhancement of coping. Advanced practice nurse practitioners perform assessment, diagnosis, and management of health conditions

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 of the childs 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

1. Discuss of the childs developmental status 2. Observe interactions among the family members 3. Discuss concerns with the parents In order to assess the child and family, the nurse would plan to discuss the childs 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 providing care to a preschool-age client who was admitted to the medicalsurgical unit after an acute asthma attack. Which interventions foster a family-centered focus to client care? Select all that apply. 1. Discussing rooming in with the parents of the client 2. Allowing the client to cry it out after the parents leave for the evening 3. Providing comfort items from home, such as a blanket 4. Maintaining strict visitation for the family 5. Discussing what to expect during the hospital stay

1. Discussing rooming in with the parents of the client 3. Providing comfort items from home, such as a blanket 5. Discussing what to expect during the hospital stay Family-centered care principles that are used in the hospital setting include rooming in, providing comfort items from home, and discussing what to expect. Allowing the child to cry it out and maintaining strict visitation for the family are not family-centered principles.

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

1. Discussing the growth of the toddler as compared to the growth chart 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.

211. A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears? 1. Encourage the child's parents to stay with the child. 2. Encourage play with other children of the same age. 3. Advise the family to visit only during the scheduled visiting hours. 4. Provide a private room, allowing the child to bring favorite toys from home.

1. Encourage the child's parents to stay with the child. Although the preschooler already may be spending sometime away from parents at a day care center or preschool, illness adds a stress or that makes separation more difficult. The child may ask repeatedly when parents will be coming for a visit or may constantly want to call the parents. Options 3 and 4 increase stress related to separation anxiety. Option 2 is unrelated to the subject of the question and, in addition, may not be appropriate for a child who may be immunocompromised and at risk for infection

A nurse is working with the family of a pediatric client. When planning to obtain an accurate family assessment, which initial step is the most appropriate? 1. Establish a trusting relationship with the family. 2. Select the most relevant family-assessment tool. 3. Focus primarily upon the mother, while learning her greatest concern. 4. Observe the family in the home setting, since this step always proves indispensable.

1. Establish a trusting relationship with the family. Establishment of a trusting relationship between the family and the nurse is the essential preliminary step in obtaining an accurate family assessment. There is benefit when the tool used matches the familys strengths and resources; however, selecting the most relevant family-assessment tool is not indispensable to accuracy in the assessment. Focusing primarily upon the mother while learning her greatest concern is counterproductive and prevents the nurse from acknowledging multiple perceptions held by the familys members. Observing the family in the home setting is only recommended in some cases.

The nurse is assessing a toddler's development of communication skills. The nurse recognizes that a toddler communicates in what ways? Select all that apply. 1. Expressive jargon 2. Interpersonal skills and contact with other children 3. Uses all parts of speech 4. Temper tantrums 5. Enjoys talking

1. Expressive jargon 2. Interpersonal skills and contact with other children 4. Temper tantrums 5. Enjoys talking 1. Toddlers use expressive jargon as a communication skill. 2. Toddlers learn interpersonal skills while being in contact with other children. 4. Toddlers use temper tantrums occasionally as a communication skill. 5. Toddlers enjoy talking.

A young school-age client is hospitalized with a fractured femur. Which assessment tools are appropriate for this client? Select all that apply. 1. FACES pain scale 2. Oucher scale 3. Visual Analog Scale 4. CRIES Scale 5. Poker-chip tool

1. FACES pain scale 2. Oucher scale 5. Poker-chip tool A young school-age client should be able to use the FACES Scale and Oucher scale to choose which face best matches the childs pain level. The child should also be able to count and understand the concepts of the poker-chip tool. The CRIES Scale was developed for preterm and full-term neonates. A young school-age client is not old enough to use the Visual Analog Scale.

The nurse is caring for a toddler client in the postoperative period. Which pain assessment tool is most appropriate for this client? 1. FLACC Behavioral Pain Assessment Scale 2. FACES pain scale 3. Oucher scale 4. Poker-chip tool

1. FLACC Behavioral Pain Assessment Scale The FLACC scale is an appropriate tool for infants and young children who cannot self-report pain. The FACES Scale, Oucher scale, and poker-chip tool are all self-report scales.

The nurse is assessing a familys effective coping strategies and ineffective defensive strategies. Which family-social-system theory is the nurse using in this assessment of the family? 1. Family-stress theory 2. Family-development theory 3. Family-systems theory 4. Family life-cycle theory

1. Family-stress theory Family-stress theory indicates an array of coping strategies that effectively help reduce stress, in contrast with the defensive strategies of dysfunctional families. Family-development theory suggests developmental tasks for families in each stage. Family-systems theory looks at the relationships among and between family members and the environment. The family life cycle is not a family social system theory.

Which stressor is common in the hospitalized toddler with a chronic disorder? Select all that apply. 1. Fear of painful procedures 2. Self-concept 3. Interruption of normal routines 4. Unfamiliarity of caregivers 5. Isolation

1. Fear of painful procedures 3. Interruption of normal routines 4. Unfamiliarity of caregivers 1. This is a stressor common in the hospitalized toddler with a chronic disorder. 3. This is a stressor common in the hospitalized toddler with a chronic disorder. 4. This is a stressor common in the hospitalized toddler with a chronic disorder.

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

1. Feeding pattern 2. Jaundice 5. Sleep pattern 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.

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

1. Financial accessibility 2. Consistent, ongoing care 3. Coordination of care 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 nurse is working with an adolescent client who will be admitted to the hospital in two days. Which nursing approach is most appropriate to prepare this client for hospitalization? 1. Have teens who have had similar experiences talk to the adolescent about hospitalization. 2. Provide an opportunity for the child to talk with an adult who has had a similar experience. 3. Teach parents what to expect so the information can be shared with the adolescent. 4. Provide an opportunity for the teen to try on surgical attire

1. Have teens who have had similar experiences talk to the adolescent about hospitalization. Adolescents benefit from a different approach than younger children when being prepared for hospitalization. Written materials, anatomically correct dolls, and talking to peers who have had similar experiences are all appropriate for the adolescent. The adolescent should be taught first-hand what to expect during the hospitalization. Dressing up in surgical attire is appropriate for the younger child.

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

1. Head circumference 2. Body length 3. Weight 4. Length of pregnancy 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 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

1. Hearing 2. Height and weight 3. Blood-pressure measurement 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.

An adolescent reports the following: I get up at 6 am, I attend early-morning band classes three times each week, I play sports for two hours each day after school, and homework takes me three 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?

1. How many hours of sleep do you get each night? The data in this scenario reveals very little time for sleep; therefore, the history should focus on sleep patterns.

There are many healthcare needs of children with chronic conditions. What nursing strategy would best help parents with continuity of care? 1. Include the family and older child in decision making. 2. Assist the family in gaining transportation to healthcare appointments. 3. Provide the family with resources such as social services. 4. Recognize and respect the cultural needs of the family.

1. Include the family and older child in decision making. Continuity of care involves the family and child's participation in their health care. Access to transportation involves access to care, not continuity. Providing resources such as social services is related to comprehensiveness of care, not to continuity. Recognizing and respecting cultural needs are part of the degree to which healthcare services, not continuity of care, are provided.

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.

1. Interview to obtain an updated health history. 2. Performing an age-appropriate development assessment. 4. Performing age-appropriate screening examinations. 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/or physical findings, not at each routine visit.

The nurse is working with a preschool-age client in Bryant traction for a fractured femur. Why is the Oucher Scale useful to the nurse caring for this child? 1. It provides continuity and consistency in assessing and monitoring the childs pain. 2. It decreases anxiety in the child. 3. It increases the childs comfort level. 4. It reduces the childs fear of painful procedures.

1. It provides continuity and consistency in assessing and monitoring the childs pain. Pain assessment scales are used to assess and monitor pain. Using an assessment scale cannot reduce the childs anxiety or fear, nor can it increase the childs comfort level. The nurse can reduce anxiety or fear and increase the childs comfort level by implementing appropriate nursing interventions based on assessment scale data.

A 5-year-old sibling of a 9-year-old child with cystic fibrosis tells the nurse, "I wish I had a breathing disease, too." The nurse knows the parents strive to spend quality time with each child and with both children together. What is the sibling currently experiencing? 1. Jealousy 2. Isolation 3. Loneliness 4. Anger

1. Jealousy The child with cystic fibrosis has something the younger child does not have. Cystic fibrosis brings the affected child more attention from others. Even if parents strive to spend more time with siblings of ill children, the well-child will be jealous because the situation can never be equal. The 5-year-old child does not understand the complications of the disease and only sees the 9-year-old child treated differently. Siblings of ill children may experience loneliness, isolation, or anger; but the child's comment does not support these feelings.

The nurse is measuring an abdominal girth on a child with abdominal distension. Identify the area on the childs 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

1. Just above the umbilicus, around the largest circumference of the abdomen 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.

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

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 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.

A school nurse is planning care for a school-age child recently diagnosed with asthma. Which items will the school nurse include in the plan of care at the school? Select all that apply. 1. Maintain a log of quick-relief medication administration. 2. Call the parents if quick-relief medications work appropriately. 3. Assess for symptoms of exercise-induced bronchospasm. 4. Coordinate education of the childs teachers. 5. Conduct a support group for all children with asthma.

1. Maintain a log of quick-relief medication administration. 3. Assess for symptoms of exercise-induced bronchospasm. 4. Coordinate education of the childs teachers. 5. Conduct a support group for all children with asthma. Appropriate interventions for the school nurse to include in the plan of care include: keeping a log of the quick-relief medications administered; assessing the child for exercise-induced bronchospasms and reporting, if needed; coordinating education of the childs teachers; and conducting a support group for all children in the school with asthma. The nurse would only call the parents if the quick-relief mediation was not effective in treating the childs symptoms.

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.

1. Monitor feeding behaviors. 2. Perform a hearing screening. 3. Perform a heel stick to obtain blood for the newborn screen. The nurse should assess feeding behaviors of the infant whether the infant is breast-fed 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 is assessing a school-age client who experienced blunt force trauma to the chest when an airbag deployed following a motor vehicle crash. Which areas of assessment are essential for this client? Select all that apply. 1. Monitor responsiveness and behavior. 2. Monitor SpO2. 3. Auscultate the lungs for crackles, wheezes, decreased breath sounds. 4. Document input and output. 5. Note changes in voice quality or coughing.

1. Monitor responsiveness and behavior. 2. Monitor SpO2. 3. Auscultate the lungs for crackles, wheezes, decreased breath sounds. 4. Document input and output. The areas of assessment that are essential for this client include: monitoring for responsive and behavior in order to detect hypoxia and the potential for airway obstruction; monitoring SpO2 frequently to identify changes indicating deterioration in condition; auscultating the lungs for crackles, wheezes, decreased breath sound; and noting changes in voice quality or coughing. Documenting input and output is not a priority for this client.

The nurse in the long-term care clinic is reviewing the charts of a group of children with chronic physical, psychological, functional, and social limitations. Which conditions are most likely to lead to chronic limitations? Select all that apply. 1. Near drowning 2. Congenital heart defect 3. Sinusitis 4. Fetal insult when the mother contracted rubella in the first trimester of pregnancy 5. Sepsis contracted as a neonate

1. Near drowning 2. Congenital heart defect 4. Fetal insult when the mother contracted rubella in the first trimester of pregnancy 5. Sepsis contracted as a neonate All of these conditions or events except sinusitis can leave a child with a permanent chronic condition.

While assessing the development of a 9-month-old infant, the nurse asks the mother if the child actively looks for toys when they are placed out of sight. Which developmental task is the nurse assessing this infant for? 1. Object permanence 2. Centration 3. Transductive reasoning 4. Conservation

1. Object permanence A child who has developed object permanence has the ability to understand that even though something is out of sight, it still exists. In centration, a child focuses only on a particular aspect of a situation. Transductive reasoning happens when a child connects two events in a cause-effect relationship because they have occurred at the same time. Conservation describes when a child knows that matter is not changed when its form is altered.

The nurse is planning activities for a toddler with a birth injury of a torn brachial plexus that resulted in muscle atrophy and weakness of his right arm. Which nursing intervention is most appropriate for this client? 1. Offering the toddler a choice of clothing 2. Asking the toddler if he would like to take his medicine 3. Dressing the toddler 4. Feeding the toddler

1. Offering the toddler a choice of clothing Toddlers are developing autonomy, self-control, and independence. Offering the toddler a choice contributes to their sense of autonomy. However, taking medicine is not within the toddler's realm of choice. Dressing and feeding the toddler does not encourage independence and will eventually cause frustration for both parent and toddler. The toddler must learn how to do these activities despite the physical limitations of the right arm.

The nurse is performing an assessment of the ecological systems of childhood. What will the nurse include when assessing mesosystems? Select all that apply. 1. Parental involvement in school 2. Local political influences 3. Libraries in the community 4. Influences of the religious community 5. Age of each family member

1. Parental involvement in school 4. Influences of the religious community When assessing a child's mesosystem, the nurse will assess parental involvement in school and the influences of the religious community on the child and family. Local political influences and the libraries in the community are assessed in an exosystem assessment. The age of each family member is assessed during chronosystem assessment.

A toddler is hospitalized with a fractured femur. In addition to pain medication, which will best provide pain relief for this child? 1. Parents presence at the bedside 2. Age-appropriate toys 3. Deep-breathing exercises 4. Videos for the child to watch

1. Parents presence at the bedside Parents presence at the bedside reduces anxiety and subsequently reduces pain. Although play and other methods of distraction might be somewhat effective, they do not equal the comfort that parents presence provides, especially in a 2-year-old, who is also at high risk for separation anxiety

411. The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply. 1. Place the infant in a private room. 2. Ensure that the infant's head is in a flexed position. 3. Wear a mask at all times when in contact with the infant. 4. Place the infant in a tent that delivers warm humidified air. 5. Position the infant on the side, with the head lower than the chest. 6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.

1. Place the infant in a private room. 6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children. RSV is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands. Use of contact and standard precautions during care (wearing gloves and a gown) reduces nosocomial transmission of RSV. A mask is unnecessary. In addition, it is important to ensure that nurses caring for a child with RSV do not care for other high-risk children to prevent the transmission of the infection. An infant with RSV should be isolated in a private room or in a room with another infant with RSV infection. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. Cool humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea.

408. The clinic nurse reads the results of a tuberculin skin test (TST) on a 3-year-old child. The results indicate an area of induration measuring 10 mm. The nurse should interpret these results as which finding? 1. Positive 2. Negative 3. Inconclusive 4. Definitive and requiring a repeat test

1. Positive Induration measuring 10 mm or more is considered to be a positive result in children younger than 4 years of age and in children with chronic illness or at high risk for exposure to tuberculosis. A reaction of 5 mm or more is considered to be a positive result for the highest risk groups, such as a child with an immunosuppressive condition or a child with human immunodeficiency virus (HIV) infection. A reaction of 15 mm or more is positive in children 4 years or older with- out any risk factors.

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 adolescents role in the family

1. Possible domestic violence 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.

222. Which interventions are appropriate for the care of an infant? Select all that apply. 1. Provide swaddling. 2. Talk in a loud voice. 3. Provide the infant with a bottle of juice at nap time. 4. Hang mobiles with black and white contrast designs. 5. Caress the infant while bathing or during diaper changes. 6. Allow the infant to cry for at least 10 minutes before responding.

1. Provide swaddling. 4. Hang mobiles with black and white contrast designs. 5. Caress the infant while bathing or during diaper changes. Holding, caressing, and swaddling provide warmth and tactile stimulation for the infant. To provide auditory stimulation, the nurse should talk to the infant in a soft voice and should instruct the mother to do so also. Additional interventions include playing a music box, radio, or television, or having a ticking clock or metronome nearby. Hanging a bright shiny object in midline within 20 to 25 cm of the infant's face and hanging mobiles with contrasting colors, such as black and white, provide visual stimulation. Crying is an infant's way of communicating; therefore, the nurse would respond to the infant's crying. The mother is taught to do so also. An infant or child should never be allowed to fall asleep with a bottle containing milk, juice, soda pop, sweetened water, or another sweet liquid because of the risk of nursing (bottle-mouth) caries.

The nurse is working with a hospitalized preschool-age child. The nurse is planning activities to reduce anxiety in this child. Which action by the nurse is the most appropriate? 1. Provide the child with a doll and safe medical equipment. 2. Read a story to the child. 3. Use an anatomically correct doll to teach the child about the illness. 4. Talk to the child about the hospitalization.

1. Provide the child with a doll and safe medical equipment. Therapeutic play is a means of anxiety reduction in the hospitalized child. Allowing the child to play with safe medical equipment is an age-appropriate method through which the child can express her feelings, thereby reducing anxiety. Anatomically correct dolls are not age appropriate. Reading a story to the child does not allow for expression of feelings. Talking to the child may be beneficial, but it does not allow for active release of frustration and anxiety as active play does.

The nurse is planning care for a preschool-age client who has cerebral palsy (CP). Which interventions are appropriate for this client? Select all that apply. 1. Providing heath supervision 2. Collaborating with physical therapy 3. Assisting with planning educational services 4. Prescribing medication for spasticity 5. Promoting growth and development

1. Providing heath supervision 2. Collaborating with physical therapy 3. Assisting with planning educational services 5. Promoting growth and development Appropriate interventions for the nurse who is providing care to a client with a chronic condition include providing health supervision, collaborating with other specialties, assisting with planning educational services, and promoting growth and development. It is outside the scope of nursing practice to prescribe medication. The nurse could, however, administer prescribed medications if appropriate.

A 3-year-old has been diagnosed with cystic fibrosis. The guardians asked the nurse what respiratory symptoms they should expect to see. What will the nurse tell the guardians? Select all that apply. 1. Purulent nasal discharge 2. Frequent infections 3. Mottled nail beds 4. Chronic moist, productive cough 5. Increased fertility

1. Purulent nasal discharge 2. Frequent infections 4. Chronic moist, productive cough Respiratory symptoms the guardians will see are: nasal polyps, chronic sinusitis, frontal headaches, purulent nasal discharge, postnasal discharge, cough (chronic, moist, productive), wheezing, coarse crackles, frequent infections, shortness of breath, decreased exercise tolerance, barrel chest, and clubbing of fingers and toes.

Which of the following are components of family-centered care? Select all that apply. 1. Recognizing and building on family strengths 2. Meeting the emotional, social, and developmental needs of the child and family 3. Respect all parenting practices 4. Support all cultural practices 5. Encourage parent-to-parent support

1. Recognizing and building on family strengths 2. Meeting the emotional, social, and developmental needs of the child and family 5. Encourage parent-to-parent support Recognizing and building on family strengths are one of the components of family-centered care. 2. Meeting the emotional, social, and developmental needs of the child and family are included in the components of family-centered care. 5. Encouraging parent-to-parent support is one of the components of family-centered care.

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.

1. Screening tests are administered at the ages when a child is most likely to develop a condition. 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 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.

1. Select one topic and present a brief amount of information on the topic. 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.

A new parent group inquires about the stages through which their children will progress as they grow older. The nurse is discussing Piaget's developmental stages. In what order would the nurse expect the child to progress through Piaget's stages of development? 1. Sensorimotor 2. Formal operational 3. Preoperational 4. Concrete operational

1. Sensorimotor 2. Formal operational 3. Preoperational 4. Concrete operational Sensorimotor (birth to 2 years), preoperational (2 to 7 years), concrete operational (7 to 11 years), formal operational (11 years to adulthood).

A parent of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. Using Erikson's psychosocial development theory, which instructions should the nurse provide to the parent? Select all that apply. 1. Set limits on the child's behavior. 2. Ignore the child when this behavior occurs. 3. Allow the behavior, because this is normal at this age period. 4. Provide a simple explanation of why the behavior is unacceptable. 5. Punish the child every time the child says "no" to change the behavior.

1. Set limits on the child's behavior. 4. Provide a simple explanation of why the behavior is unacceptable. According to Erikson, the child focuses on gaining some basic control over self and the environment and indepen- dence between ages 1 and 3 years. Gaining independence often means that the child has to rebel against the parents'wishes. Say- ing things like "no" or "mine" and having temper tantrums are common during this period of development. Being consistent andsettinglimitsonthechild'sbehaviorarenecessaryelements. Providing a simple explanation of why certain behaviors are unacceptable is an appropriate action. Options 2 and 3 do not address the child's behavior. Option 5 is likely to produce a negative response during this normal developmental pattern.

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

1. Sexual activity 2. Cigarette smoking 4. Use of alcohol The nurse must maintain the nurseclient 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.

The nurse educator is teaching a group of nursing students how to perform a respiratory assessment for a newborn in the newborn intensive care unit (NICU) diagnosed with respiratory distress syndrome (RDS). Which normal characteristics of the newborns respiratory system increase the risk for obstruction? Select all that apply. 1. Shorter and narrower airway 2. Higher trachea 3. Bronchial branching at different angles 4. Inadequate smooth muscle bundles 5. Diaphragmatic breather

1. Shorter and narrower airway 2. Higher trachea 3. Bronchial branching at different angles Normal characteristics of the pediatric respiratory system that increase the risk for obstruction include a shorter and narrower airway, a higher trachea, and a different angle for bronchial branching. Inadequate smooth muscle bundles and being diaphragmatic breathers are characteristics that do not increase the risk of obstruction.

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

1. Skateboarding 2. Playing football 4. Playing lacrosse 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.

While in the pediatrician's office for their child's 12-month well-child exam, the parents ask the nurse for advice on age-appropriate toys for their child. Based on the child's developmental level, which types of toys would the nurse suggest? Select all that apply. 1. Soft toys that can be manipulated 2. Small toys that can pop apart and go back together 3. Jack-in-the-box toys 4. Toys with black and white patterns 5. Push-and-pull toys

1. Soft toys that can be manipulated 3. Jack-in-the-box toys 5. Push-and-pull toys Both gross and fine motor skills are becoming more developed, and children at this age enjoy toys that can help them refine these skills. They tend to enjoy more colorful toys at this age and are more mobile and thus have less interest in placing toys in their mouths and more interest in toys that can be manipulated.

The nurse is counseling the parents of a 6-1/2-month-old infant. Which age-appropriate toy is most appropriate for the nurse to suggest to these parents? 1. Soft, fluid-filled ring that can be chilled in the refrigerator 2. Colorful rattle 3. Jack-in-the-box toy 4. Push-and-pull toy

1. Soft, fluid-filled ring that can be chilled in the refrigerator Teething toys would be appropriate for this age. The rattle might be better enjoyed by a 3- to 6-month-old infant, and the jack-in-the-box and push-and-pull toys are better suited for a 9- to 12-month-old child.

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? Standard Text: 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

1. Stop, drop and roll if clothes catch fire 2. Never go into the road alone. 4. Safe meeting place outside the house in case of fire 5. Car seat safety 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.

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

1. Sucking pads in the mouth 2. A rounded chest 3. Hearing breath sounds over the entire chest 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 nurse is providing care to an infant who is diagnosed with bronchiolitis. Which breath sounds indicate the infant is experiencing respiratory distress? Select all that apply. 1. Tachypnea 2. Wheezing 3. Grunting 4. Retractions 5. Eupnea

1. Tachypnea 2. Wheezing 3. Grunting Wheezing and grunting are adventitious respiratory sounds that indicates respiratory distress in the neonate. Tachypnea is the term used to indicate a respiratory rate of greater than 60 breaths per minute in an infant. While this does indicate respiratory distress, tachynpea is not a type of breath sound. Retractions, or the use of accessory muscles, are indicative of respiratory distress in the neonate, but this is not a type of breath sound. Eupnea is the medical term for normal breathing.

While inspecting a 5-year-old childs 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

1. Temperature 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.

The nurse is describing Piaget's cognitive developmental theory to pediatric nursing staff. The nurse should tell that staff that which child behavior is characteristic of the formal operations stage? 1. The child has the ability to think abstractly. 2. The child begins to understand the environment. 3. The child is able to classify, order, and sort facts. 4. The child learns to think in terms of past, present, and future.

1. The child has the ability to think abstractly. In the formal operations stage, the child has the ability to think abstractly and logically. Option 2 identifies the sensorimotor stage. Option 3 identifies the concrete oper- ational stage. Option 4 identifies the preoperational stage.

Several children arrived at the emergency department accompanied only by their fathers. Which father may legally sign emergency medical consent for treatment? 1. The divorced one from the binuclear family 2. The stepfather from the blended or reconstituted family 3. The divorced one when the single-parent mother has custody 4. The nonbiologic one from the heterosexual cohabitating family

1. The divorced one from the binuclear family The divorced father from the binuclear family may sign informed consent because he has equal legal rights with the mother under joint-custody arrangements. The nonbiologic stepfather from the blended or reconstituted family, the divorced biologic father when the single-parent mother has custody, and the nonbiologic father from the heterosexual cohabitating family are without legal authority to seek emergency medical care for the child.

The preschool-age child has been back from surgery for removal of a Wilm's tumor for 6 hours, the nurse anticipates the preschooler will need pain medication very soon. The nurse is aware that the preschool-age child may not complain of pain because Select all that apply. 1. The preschooler cannot give a description of his pain. 2. The preschooler may assume the nurse knows he has pain. 3. The preschooler may be afraid it may hurt more to have the pain treated. 4. The preschooler believes he must be brave. 5. The preschooler uses sleeping to deal with pain.

1. The preschooler cannot give a description of his pain. 2. The preschooler may assume the nurse knows he has pain. 3. The preschooler may be afraid it may hurt more to have the pain treated. 4. The preschooler believes he must be brave. This is why the preschooler may not complain of pain. Children may not complain of pain for several reasons: young children cannot give a description of their pain because of a limited vocabulary or few pain experiences; some children believe they need to be brave and not worry their parents; preschoolers may assume the nurse knows they have pain, and some children are afraid that it will hurt more to have the pain treated.

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 preschooler? 1. Toddlers play side by side, while preschoolers play cooperatively. 2. Toddlers play house and imitate adult roles, while preschoolers become the Mom or Dad while playing house. 3. Toddlers play cooperatively, while preschoolers play interactive games. 4. There are no differences between toddlers and preschoolers since both groups play cooperatively

1. Toddlers play side by side, while preschoolers play cooperatively. 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.

A child is showing signs of acute respiratory distress. Which position will the nurse place this child? 1. Upright 2. Side-lying 3. Flat 4. In semi-Fowlers

1. Upright Upright is correct because it allows for optimal chest expansion. Side-lying, flat, and semi-Fowlers (head up slightly) do not allow for as optimal chest expansion as the upright position.

The nurse is admitting a school-age Vietnamese client who hit a parked car while riding a bike. The child has a fracture of the left radius and femur in addition to a fractured orbit. The child is stoic and denies pain. Which nursing actions are most appropriate in this situation? Select all that apply. 1. Use the FLACC scale to determine the childs pain level. 2. Tell the child to ring the call bell if the leg starts hurting. 3. Administer pain medication now and continue on a regular basis. 4. Ask the childs parents to notify the nurse if the child complains of pain. 5. Use the NIPS scale to determine the childs pain level.

1. Use the FLACC scale to determine the childs pain level. 3. Administer pain medication now and continue on a regular basis. 4. Ask the childs parents to notify the nurse if the child complains of pain. Based on the type of injuries the child has, pain will be present. Analgesics should be given on a scheduled basis so that the pain does not get out of control. The FLACC scale is the most appropriate tool to use with an 8-year-old. The childs stoic expression is likely to be culturally related, and the child may not admit hurting. While asking the parents to call the nurse is not inappropriate, it is not the most appropriate initial action. The NIPS scale is appropriate for a newborn, not a 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

1. Varicella 2. Human papillomavirus 5. Hepatitis B 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 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

1. Vegetables 3. Rice cereal 4. Fruits 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.

Following parental teaching, the nurse is evaluating the parents understanding of environmental control for their childs asthma management. Which statement by the parents indicates appropriate understanding of the teaching? 1. We will replace the carpet in our childs bedroom with tile. 2. Were glad the dog can continue to sleep in our childs room. 3. Well be sure to use the fireplace often to keep the house warm in the winter. 4. Well keep the plants in our childs room dusted.

1. We will replace the carpet in our childs bedroom with tile. Control of dust in the childs bedroom is an important aspect of environmental control for asthma management. When possible, pets and plants should not be kept in the home. Smoke from fireplaces should be eliminated.

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. Lets 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.

1. What do you usually do or say during a temper tantrum? 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.

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

1. Wheezing 3. Decreased vocal resonance 4. Decreased tactile fremitus 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.

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 one week of discharge 3. Within two weeks of discharge 4. When the infant is 1 month old

1. Within 48 hours of discharge Newborns discharged before 48 hours old should be seen within 48 hours of discharge. Waiting one week and/or two 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 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

2. 24 months 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.

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

2. 8 pounds, 2 ounces Rationale 1: In the first week of life, most infants lose about one-tenth of their birth weight; therefore, this infants 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.

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

2. A child who has stridor 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.

219. The mother of a 3-year-old is concerned because her child still is insisting on a bottle at nap time and at bedtime. Which is the most appropriate suggestion to the mother? 1. Allow the bottle if it contains juice. 2. Allow the bottle if it contains water. 3. Do not allow the child to have the bottle. 4. Allow the bottle during naps but not at bedtime.

2. Allow the bottle if it contains water. A toddler should never be allowed to fall asleep with a bottle containing milk, juice, soda pop, sweetened water, or any other sweet liquid because of the risk of nursing (bottle-mouth) caries. If a bottle is allowed at nap time or bed- time, it should contain only water.

The parents of a critically injured child wish to stay in the room while the child is receiving emergency care. Which action by the nurse is the most appropriate? 1. Escort the parents to the waiting room and assure them that they can see their child soon. 2. Allow the parents to stay with the child. 3. Ask the physician if the parents can stay with the child. 4. Tell the parents that they do not need to stay with the child.

2. Allow the parents to stay with the child. Parents should be allowed to stay with their child if they wish to do so. This position is supported by the Emergency Nurses Association and is a key aspect of family-centered care.

The child was just transferred to the postanesthesia unit (PACU) and report given. The nurse has performed baseline vital signs, the child is stable and pain is under control. What should the nurse do next? 1. Document 2. Allow the parents to visit the child 3. Discharge the child 4. Look for signs of infection 5. Offer clear liquids

2. Allow the parents to visit the child If the child is stable and pain is under control, the nurse should allow the parents to visit with the child.

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 parents 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, since the parent is not able to control the toddlers behavior.

2. Allow the toddler to sit on the parents lap and begin the assessment. 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 nurse is preparing to assessment 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 parents 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

2. Allowing the client to sit in the parents lap 4. Handing the client a stethoscope while taking the health history 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 toddlers 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.

A hospitalized toddler-age client needs to have an IV restarted. The child begins to cry when carried into the treatment room by the mother. Which nursing diagnosis is most appropriate? 1. Ineffective Individual Coping Related to an Invasive Procedure 2. Anxiety Related to Anticipated Painful Procedure 3. Fear Related to the Unfamiliar Environment 4. Knowledge Deficit of the Procedure

2. Anxiety Related to Anticipated Painful Procedure At this age, the child is not old enough to understand the need for an IV infusion. The stem indicates that the child has been through this painful procedure before, and his reaction to entering the treatment room is based on anticipation of repeat discomfort. The childs behavior is appropriate for a child of this age.

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.

2. Ask the child to repeat his address. 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.

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 childs speech articulation. 4. Have the child point to various parts of the body as you name them.

2. Ask the child to repeat his address. Repeating the name of an object after 510 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.

The nurse is planning care for an adolescent client who will be hospitalized for several weeks following a traumatic brain injury. Which interventions will enhance family-centered care for this client and family? Select all that apply. 1. Making all ADL decisions for the adolescent and family 2. Asking the adolescent what foods to include during meal time 3. Allowing the family time to pray each day with the adolescent 4. Encouraging the adolescents friends to visit during visiting hours 5. Leaving all questions for the healthcare provider

2. Asking the adolescent what foods to include during meal time 3. Allowing the family time to pray each day with the adolescent 4. Encouraging the adolescents friends to visit during visiting hours Interventions that will enhance family-centered care for this client and family include asking the adolescent to be an active member of care by making food choices, allowing the family to pray each day with the adolescent, and encouraging the adolescents friends to visit during visiting hours. These interventions each promote the concepts of family-centered care. Making all decisions for the adolescent and family and leaving all questions for the healthcare provider do not promote the concepts of family-centered care.

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-and-family interactions 3. Modeling infant-nurturing behaviors 4. Informing the parents of the infants gains in height and weight

2. Assessing the newborn-and-family interactions 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 infants gains in height and weight, this activity does not take priority.

The nurse is working on parenting skills with a group of mothers. Which mother would need the fewest discipline-related suggestions? 1. Authoritarian one 2. Authoritative one 3. Indifferent one 4. Permissive one

2. Authoritative one The parenting style that results in positive outcomes for the behavior and learning of its children is the authoritative style. Nurses have observed that children from homes using this parental style more frequently have personalities manifesting self-reliance, self-control, and social competence. These parents should be praised for using the preferred approach. Children in the authoritarian parenting family are denied opportunity to develop some skills in the areas of self-direction, communication, and negotiation. Under the permissive parenting style, children do not learn the socially acceptable limits of behaviors. The indifferent parenting style results in children who often exhibit destructive behaviors and delinquency.

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

2. Autism screening 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

The nurse, talking with the parents of a toddler who is struggling with toilet training, reassures them that their child is demonstrating a typical developmental stage. According to Erikson, which developmental stage will the nurse document in the medical record for this toddler? 1. Trust versus mistrust 2. Autonomy versus shame and doubt 3. Initiative versus guilt 4. Industry versus inferiority

2. Autonomy versus shame and doubt Erikson's stage of "autonomy versus shame and doubt" marks a period of time when the toddler is trying to gain some independence while still wanting to please adults.

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.

2. Avoid breastfeeding or drinking from a bottle when sleeping. 4. Cleanse gums 1 to 2 times a day. 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.

A child is admitted to the hospital with pneumonia. The childs oximetry reading is 88 percent upon admission to the pediatric floor. Which is the priority nursing intervention for this child? 1. Obtain a blood sample to send to the lab for electrolyte analysis. 2. Begin oxygen per nasal cannula. 3. Medicate for pain. 4. Begin administration of intravenous fluids.

2. Begin oxygen per nasal cannula. Pulse oximetry reading should be 92 or greater. Oxygen by nasal cannula should be started initially. Medicating for pain, administering IV fluids, and sending lab specimens can be done once the childs oxygenation status has been addressed.

213. Which car safety device should be used for a child who is 8 years old and 4 feet tall? 1. Seatbelt 2. Booster seat 3. Rear-facing convertible seat 4. Front-facing convertible seat

2. Booster seat All children whose weight or height is above the forward-facing limit for their car safety seat should use a belt- positioning booster seat until the vehicle seat belt fits properly, typically when they have reached 4 feet, 9 inches in height (145 cm) and are between 8 and 12 years of age. Infants should ride in a car in a semi reclined, rear-facing position in an infant- only seat or a convertible seat until they weigh at least 20 pounds (9 kg) and are at least 1 year of age. The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat but is generally at a body weight of 9 kilograms (20 pounds) and 1 year of age.

The nurse is providing care to an infant in the emergency department. Upon assessment, the infant is noted to have to be experiencing tachypnea, wheezing, retractions, and nasal flaring. The infant is irritability and the parents state the infant has had poor fluid intake for two days. Pulse ox reading is currently at 85% on room air. The infants blood gas is pending. Which diagnosis does the nurse anticipate for this infant? 1. Bronchitis 2. Bronchiolitis 3. Pneumonia 4. Active pulmonary tuberculosis

2. Bronchiolitis The nurse anticipates the infant will be diagnosed with bronchiolitis. Symptoms of bronchiolitis include mild respiratory symptoms that progress to tachypnea, wheezing, retractions, nasal flaring, irritability, poor fluid intake, hypoxia, cyanosis, and decreased mental status. Symptoms of bronchitis include a dry hacking cough, increases in severity at night, painful chest and ribs. Symptoms of pneumonia include initial rhinitis and cough, followed by fever, crackles, wheezes, dyspnea, tachypnea, restlessness, diminished breath sounds. Symptoms of active pulmonary tuberculosis include persistent cough, decreased appetite, weight loss or failure to gain weight, low-grade fever, night sweats, chills, enlarged lymph nodes.

A 7-year-old child is admitted for acute appendicitis. The parents are questioning the nurse about expectations during the childs recovery. Which information tool would be most useful in answering a parents questions about the timing of key events? 1. Healthy People 2020 2. Clinical pathways 3. Child mortality statistics 4. National clinical practice guidelines

2. Clinical pathways Clinical pathways are interdisciplinary documents provided by a hospital to suggest ideal sequencing and timing of events and interventions for specific diseases to improve efficiency of care and enhance recovery. This pathway serves as a model outlining the typical hospital stay for individuals with specified conditions. Healthy People 2020 contains objectives set by the U.S. government to improve the health and reduce the incidence of death in the twenty-first century. Child mortality statistics can be compared with those from other decades for the evaluation of achievement toward health-care goals. National clinical practice guidelines promote uniformity in care for specific disease conditions by suggesting expected outcomes from specific interventions.

As an advocate for the child undergoing bone-marrow aspiration, which intervention would the nurse suggest to decrease the pain experienced due to the procedure? 1. General anesthesia 2. Conscious sedation 3. Intravenous narcotics ten minutes before the procedure 4. Oral pain medication for discomfort after the procedure

2. Conscious sedation For the child undergoing repeated procedures, it is important for the child to be sedated prior to and during the initial procedure. General anesthesia is not necessary for bone-marrow aspiration. Narcotics alone will not provide appropriate sedation to keep the child from remembering the procedure. While oral pain medication postprocedure is not inappropriate if discomfort exists, it is not the best answer. The child will have great anxiety and discomfort during the procedures and prior to future procedures.

402. A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? 1. Warm, dry skin 2. Decreased wheezing 3. Pulse rate of 90 beats/minute 4. Respirations of 18 breaths/minute

2. Decreased wheezing Asthma is a chronic inflammatory disease of the airways. Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With treatment, increased wheezing actually may signal that the child's condition is improving. Warm, dry skin indicates an improvement in the child's condition because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats/ minute. The normal respiratory rate in a 10-year-old is 16 to 20 breaths/minute.

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?

2. Do you have any concerns about your weight? The only question that addresses the adolescents 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.

215. The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate? 1. Increase oral fluids. 2. Document the finding. 3. Notify the health care provider (HCP). 4. Elevate the head of the bed to 90 degrees.

2. Document the finding. The anterior fontanel is diamond-shaped and located on the top of the head. The fontanel should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. The nurse would document the finding because it is normal. There is no useful reason to increase oral fluids, notify the HCP, or elevate the head of the bed to 90 degrees.

214. The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. On the basis of this finding, which action is most appropriate? 1. Administer oxygen. 2. Document the findings. 3. Notify the health care provider. 4. Reassess the respiratory rate in 15 minutes

2. Document the findings. The normal respiratory rate in a 12-month-old infant is 20 to 40 breaths/minute. The normal apical heart rate is 90 to 130 beats/minute, and the average blood pressure is 90/56 mm Hg. The nurse would document the findings.

A parent asks the nurse if there is anything that can be done to reduce the pain that his 3-year-old experiences each morning when blood is drawn for lab studies. Which intervention would the nurse implement based on the parents concern? 1. Intravenous sedation 15 minutes prior to the procedure 2. EMLA cream (lidocaine 2.5% and prilocaine 2.5%) applied to skin at least one hour prior to the procedure 3. Use of guided imagery during the procedure 4. Use of muscle-relaxation techniques

2. EMLA cream (lidocaine 2.5% and prilocaine 2.5%) applied to skin at least one hour prior to the procedure Sedation is not generally used with quick minor procedures such as venipuncture. A 3-year-old is too young to participate in techniques such as muscle relaxation and guided imagery. EMLA cream is shown to be effective in providing topical anesthesia if applied at least one hour prior to the procedure.

The nurse is planning care for a school-age client and family who have expressed wanting to use complementary and alternative modalities (CAM) in the treatment plan. Which interventions can the nurse safely implement into the plan of care? Select all that apply. 1. Substituting an herbal remedy for a prescribed medication 2. Encouraging the parents to share which modalities they would like to implement 3. Educating on the benefits and risks for each modality 4. Using essential oils to decrease nausea 5. Discouraging the use of faith-based therapies

2. Encouraging the parents to share which modalities they would like to implement 3. Educating on the benefits and risks for each modality 4. Using essential oils to decrease nausea Appropriate interventions for this client and family include encouraging the parents to share which modalities they want to implement, educating about the risks and benefits of each modality, and using modalities that are safe, such the use of essential oils to decrease nausea. An herbal remedy should not be substituted for a prescribed medication, but can be used if deemed safe with the prescribed medication. Discouraging the use of faith-based therapies does not support the client and family who want to use CAM in the treatment plan.

In working with parents of children with chronic diseases, the nurse is concerned with helping the parents to protect themselves from compassion fatigue. Which activities are appropriate for the nurse to encourage? Select all that apply. 1. Sleeping more than 9 hours per 24-hour period 2. Exercising 3. Fostering social relationships 4. Developing a hobby 5. Moving away

2. Exercising 3. Fostering social relationships 4. Developing a hobby Exercising, fostering social relationships, and developing a hobby all contribute to physical, spiritual, social, and mental rest and restoration. Sleeping more than the body requires and moving away are avoidance behaviors that do not address exhaustion from overwhelming caregiving responsibilities.

A school-age client tells you that Grandpa, Mommy, Daddy, and my brother live at my house. Which type of family will the nurse identify in the medical record based on this description? 1. Binuclear family 2. Extended family 3. Gay or lesbian family 4. Traditional nuclear family

2. Extended family An extended family contains a parent or a couple who share the house with their children and another adult relative. A binuclear family includes the divorced parents who have joint custody of their biologic children, while the children alternate spending varying amounts of time in the home of each parent. A gay or lesbian family is comprised of two same-sex domestic partners; they may or may not have children. The traditional nuclear family consists of an employed provider parent, a homemaking parent, and the biologic children of this union.

The nurse recognizes that the pediatric client is from a cultural background different from that of the hospital staff. Which goal is most appropriate for this client when planning nursing care? 1. Overlook or minimize the differences that exist. 2. Facilitate the familys ability to comply with the care needed. 3. Avoid inadvertently offending the family by imposing the nurses perspective. 4. Encourage complementary beneficial cultural practices as primary therapies.

2. Facilitate the family's ability to comply with the care needed. The incorporation of the familys cultural perspective into the care plan is most likely to result in the familys ability to accept medical care and comply with the regimen prescribed. Since culture develops from social learning, attempts to ignore or minimize cultural consideration will result in mistrust, suspicion, or offenses that can have negative effects upon the health of children by reducing the resources available to promote health and prevent illness. Complementary therapy may be used later if other primary therapies prove to be ineffective.

The nurse is teaching a group of mothers of infants about the benefits of immunization. Which immunization will the nurse teach to the mothers that can assist in preventing the life-threatening disease epiglottitis? 1. Measles, mumps, and rubella (MMR) 2. Haemophilus influenzae type B (HIB) 3. Hepatitis B 4. Polio

2. Haemophilus influenzae type B (HIB) The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

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

2. Health promotion 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.

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

2. Health promotion 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 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

2. III 3. IV 5. VI 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.

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

2. Inadequate dental care 3. Inadequate diet 4. Inadequate brushing 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.

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.

2. Leave intrusive procedures such as ear and eye examinations until the end. 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.

Parents of a preschool 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. Lets 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 childs behavior? 4. I think you are not parenting your child properly, so lets talk about ways to improve your parenting skills.

2. Lets talk about other forms of discipline that have a more positive effect on the child. 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 nurses 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.

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

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

There are several tools that help with obtaining a cultural assessment of a client and his family. Which tool would be appropriate to gather 12 major concepts of cultural assessment? 1. Sunrise enabler 2. Model for cultural competence 3. Transcultural assessment model 4. Health traditions model

2. Model for cultural competence The sunrise enabler examines influences on care and culture. The model for cultural competence will gather information on 12 major concepts. The transcultural assessment model is based on 6 phenomena. The health traditions model is predicated on holistic health.

410. The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action? 1. Initiate strict enteric precautions. 2. Move the infant to a room with another child with RSV. 3. Leave the infant in the present room because RSV is not contagious. 4. Inform the staff that they must wear a mask, gloves, and a gown when caring for the child.

2. Move the infant to a room with another child with RSV. RSV is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands. Use of contact and standard precautions during care is necessary. Using good hand-washing technique and wearing gloves and gowns are also necessary. Masks are not required. An infant with RSV is isolated in a single room or placed in a room with another child with RSV. Enteric precautions are unnecessary.

A family actively participates in school functions. One of the children is paraplegic and requires a wheelchair for mobility. Which process does the nurse determine the family is working on based on these assessment findings? 1. Stagnation 2. Normalization 3. Isolation 4. Interaction

2. Normalization The family is normalizing life with the children through activities. The family is not staying at home because one member cannot walk; rather, the family is moving on to full participation in life. The family is interacting with others through the process of normalization.

Which health promotion activities can the nurse recommend to the parents of a preschool-age child in order to enhance the childs 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.

2. Praise the child for staying dry at night. 4. Set aside time for the child each day. 5. Discuss appropriate activities to engage in with the daycare provider 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 childs unique characteristics. Health maintenance seeks to avoid the poor self-image that can occur with constant criticism or expectations not in alignment with the toddlers or preschoolers developmental capabilities.

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 go 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 parentchild relationship during these stressful times

2. Promoting healthy mental-health outcomes 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 parentchild relationship should not be used as a substitute for the development of new peer relationships.

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

2. Review health-promotion and health-maintenance activities. 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.

Which of these developmental milestones should the nurse expect to find in children who are between 2 and 3 years old? Standard Text: 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

2. Scribbles and draws on paper 3. Kicks a ball 5. Goes up and down stairs 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 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

2. Secondary prevention Secondary prevention includes developmental, hearing and vision screenings.

The nurse is counseling the parents of a 13-year-old regarding the behaviors they may encounter after telling the child about their plans to divorce. Which behaviors could the child demonstrate? Select all that apply. 1. Sorrow 2. Skipping school 3. Risk-taking 4. Withdraw from friends and activities 5. Temper tantrums

2. Skipping school 3. Risk-taking Adolescent behaviors include: panic, fear, depression, guilt, risk-taking, fear of loneliness and abandonment, denial, anger, sadness, aggressiveness, skipping or dropping out of school, use of drugs and alcohol, and sexual acting out.

The nurse is preparing to perform a heel stick on a neonate. Which complementary therapy is appropriate for the nurse to use decrease pain during this quick but painful procedure? 1. Swaddling 2. Sucrose pacifier 3. Massage 4. Holding the infant

2. Sucrose pacifier Sucrose provides short-term natural pain relief and is most appropriate for use in neonates to decrease pain associated with a quick procedure. The other measures are more appropriate following the procedure or as an adjunct to pain medication for ongoing pain or distress.

A nurse and the family of an 8-year-old with acute renal failure are reviewing family strengths helpful in managing stressors. Which family strengths should the nurse recommend this family utilize? Select all that apply. 1. Meeting member needs 2. Support by extended family 3. Effective communication 4. Receiving and giving love 5. Prior life experiences

2. Support by extended family 3. Effective communication 5. Prior life experiences 2. Support by extended family is one of the family strengths. 3. Effective communication is one of the family strengths. 5. Prior life experiences are one of the family strengths.

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. Its 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.

2. Teaching simple handwashing is a good topic at this age. 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 nurse is working with pediatric clients in a research facility. The nurse recognizes that federal guidelines are in place that delineate which pediatrics clients must give assent for participation in research trials. Based upon the clients age, the nurse would seek assent from which children? Select all that apply. 1. The precocious 4-year-old starting as a cystic fibrosis research-study participant. 2. The 7-year-old leukemia client electing to receive a newly developed medication, now being researched. 3. The 10-year-old starting in an investigative study for clients with precocious puberty. 4. The 13-year-old client beginning participation in a research program for ADHD treatments.

2. The 7-year-old leukemia client electing to receive a newly developed medication, now being researched. 3. The 10-year-old starting in an investigative study for clients with precocious puberty. 4. The 13-year-old client beginning participation in a research program for ADHD treatments. Federal guidelines mandate that research participants 7 years old and older must receive developmentally appropriate information about healthcare procedures and treatments and give assent.

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 five minutes each day.

2. The adolescent is not meeting the recommendations of the Healthy People 2020 initiative. 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 five minutes each day also is not consistent with current recommendations. Suggesting that something is better than nothing is not good practice.

406. The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction? 1. The child exhibits nasal flaring and bradycardia. 2. The child is leaning forward, with the chin thrust out 3. The child has a low-grade fever and complains of a sore throat. 4. The child is leaning backward, supporting himself or herself with the hands and arms.

2. The child is leaning forward, with the chin thrust out Epiglottitis is a bacterial form of croup. A primary concern is that it can progress to acute respiratory distress. Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward while supported by arms, chin thrust out, mouth open), nasal flaring, the use of accessory muscles for breathing, and the presence of stridor. Option 4 is an incorrect position. Options 1 and 3 are incorrect because epiglottitis causes tachycardia and a high fever.

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.

2. The child is obese and needs dietary counseling. These data show that the child is disproportionate in height and weight. This childs 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 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.

2. The infant has gained a significant amount of weight. 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.

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

2. Throw a ball 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 45 years, a child begins to throw a ball overhand.

A nurse caring for a school-age client notices some swelling in the childs 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

2. Urine output 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.

216. The nurse is evaluating the developmental level of a 2-year-old. Which does the nurse expect to observe in this child? 1. Uses a fork to eat 2. Uses a cup to drink 3. Pours own milk into a cup 4. Uses a knife for cutting food

2. Uses a cup to drink By age 2 years, the child can use a cup and spoon correctly but with some spilling. By age 3 to 4, the child begins to use a fork. By the end of the preschool period, the child should be able to pour milk into a cup and begin to use a knife for cutting.

The nurse is teaching the parents of a newly diagnosed cystic fibrosis patient how to administer the pancreatic enzymes. How often will the nurse teach the parents to administer the enzymes? 1. Two times per day 2. With meals and snacks 3. Every 6 hours around the clock 4. Four times per day

2. With meals and snacks Pancreatic enzymes are administered with meals and large snacks. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

The nurse has set up a group discussion for several families with chronically ill children. The nurse informs these parents that they may face which ethical issue? 1. Normalization 2. Withholding and refusal of treatment 3. Repeated hospital admissions 4. Lack of proper dietary needs

2. Withholding and refusal of treatment Withholding and refusal of treatment is an ethical issue involving the life and quality of life of the child. Normalization is a family process of adaptation as the family members cope with daily life with their child. Lack of dietary needs is not an ethical issue, nor is repeated hospital admissions.

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.

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. 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 parentchild conflict and/or make assumptions about household communication

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. hear a quiet but easily heard murmur. 2. hear a moderately loud murmur without a palpable thrill. 3. hear a very loud murmur with easily palpable thrill. 4. listen without a stethoscope and hear a murmur at chest wall.

2. hear a moderately loud murmur without a palpable thrill. 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.

A supervisor is reviewing the documentation of the nurses in the unit. Which client documentation is the most accurate and contains all the required part for a narrative entry? 1. 2/2/05 1630 Catheterized using an 8 French catheter, 45 mL clear yellow urine obtained, specimen sent to lab, squirmed and cried softly during insertion of catheter. Quiet in mothers arms following catheter removal. M. May RN 2. 1/9/05 2 pm NG tube placement confirmed and irrigated with 30 ml sterile water. Suction set at low, intermittent. Oxygen via nasal canal at 2 L/min. Nares patent, pink, and nonirritated. K. Earnst RN 3. 4:00 Trach dressing removed with dime-size stain of dry serous exudate. Site cleansed with normal saline. Dried with sterile gauze. New sterile trach sponge and trach ties applied. Respirations regular and even throughout the procedure. F. Luck RN 4. Feb. 05 Port-A-Cath assessed with Huber needle. Blood return present. Flushed with NaCl sol., IV gamma globins hung and infusing at 30cc/hr. Child smiling and playful throughout the procedure. P. Potter, RN

2/2/05 1630 Catheterized using an 8 French catheter, 45 mL clear yellow urine obtained, specimen sent to lab, squirmed and cried softly during insertion of catheter. Quiet in mothers arms following catheter removal. M. May RN The client record should include the date and time of entry, nursing care provided, assessments, an objective report of the clients physiologic response, exact quotes, and the nurses signature and title.

208. The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse should make which response? 1. "You need to be concerned." 2. "You need to monitor the child's behavior closely." 3. "At this age, the child is developing his own personality." 4. "You need to provide more praise to the child to stop this behavior."

3. "At this age, the child is developing his own personality." According to Erikson, during school-age years (6 to 12 years of age), the child begins to move toward peers and friends and away from the parents for support. The child also begins to develop special interests that reflect his or her own developing personality instead of the parents. Therefore options 1, 2, and 4 are incorrect responses.

At the conclusion of teaching parents about cerebral palsy, the nurse asks, "What is your hope for your toddler with cerebral palsy?" Which reply from a parent best indicates an understanding of a realistic achievement for the child? 1. "I hope my child qualifies for the Winter Olympics like I did." 2. "I hope my child just enjoys life." 3. "I hope my child will attend our neighborhood school." 4. "I hope my child is liked and accepted by other children."

3. "I hope my child will attend our neighborhood school." Expecting a child with cerebral palsy to do well in the local school is a realistic hope that the child can possibly achieve. A child with cerebral palsy does not have the gross motor skills to qualify for the Olympics; thus, this is unrealistic. A hope for the child to enjoy life is realistic, but is not an achievement for the child. A hope that the child is liked and accepted by other children is realistic, but this hope is also dependent on other children

Which statement by the nurse is most appropriate prior to giving an intramuscular injection to a 2-1/2-year-old child? 1. "We will give you your shot when your mommy comes back." 2. "This is medicine that will make you better. First we will hold your leg, then I will wipe it off with this magic cloth that kills the germs on your leg right here, then I will hold the needle like this and say 'one, two, three . . . go' and give you your shot. Are you ready?" 3. "It is all right to cry, I know that this hurts. After we are done you can go to the box and pick out your favorite sticker." 4. "This is a magic sword that will give you your medicine and make you all better."

3. "It is all right to cry, I know that this hurts. After we are done you can go to the box and pick out your favorite sticker." The most appropriate response would be to acknowledge the child's feelings and give her something to look forward to (picking out a sticker). Waiting for the mother to come back would be inappropriate because toddlers do not have an understanding of time. Giving elaborate descriptions and using colorful language are inappropriate. The instructions should not end with a "are you ready" statement because the toddler will say no. You also don't want to frighten and/or confuse the child by using statements such as use of a magic sword.

The parents of a 1-year-old infant are concerned that this baby seems more shy and scared of new situations than their other child and ask the nurse if this is normal. The nurse knows that the infant is exhibiting a characteristic of the "slow-to-warm-up." Which statement to the parents is most appropriate by the nurse? 1. "Your infant is showing a regularity in patterns of eating." 2. "Your infant displays a predominately negative mood." 3. "Your infant initially reacts to new situations by withdrawing." 4. "Your infant has intense reactions to the environment."

3. "Your infant initially reacts to new situations by withdrawing." Slow-to-warm-up" children adapt slowly to new situations and initially will withdraw. Showing regularity in patterns of eating is a characteristic of an "easy" child, and displaying a predominately negative mood and commonly having intense reactions to the environment are characteristics of "difficult" children.

A new mother is worried about a soft spot on the top of her newborn infants 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

3. 12 to 18 months of age 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 child is prescribed rifampicin for treatment of tuberculosis. For which length of time will the nurse tell the parents that this child must remain on the medication? 1. 2 months 2. 4 months 3. 6 months 4. 8 months

3. 6 months Active and latent TB are treated with isoniazid, rifampicin, pyrazinamide, and ethambutol. Therapy for active TB usually involves a 6-month regimen consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol for the first 2 months and isoniazid and rifampicin for the remaining 4 months. Therefore, the child will remain on rifampicin for a total of 6 months.

A nurse is assessing language development in all the infants presenting at the doctor's office for well-child visits. At which age range would the nurse expect a child to verbalize the words "dada" and "mama"? 1. 3 and 5 months 2. 6 and 8 months 3. 9 and 12 months 4. 13 and 18 months

3. 9 and 12 months Children should be able to verbalize "mama" or "dada" to identify their parents by 1 year of age.

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

3. A car seat with a harness approved for higher weights and heights 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 higherweight/height children so that she is protected from injury. Rear-facing seats and regular seat with lap and shoulder strap are not appropriate for a 3-year-old.

An adolescent female presents at a nurse practitioners 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

3. A health-supervision opportunity 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.

The nurse is caring for a client in the pediatric intensive-care unit (PICU). The parents have expressed anger over the nursing care their child is receiving. Which nursing intervention is most appropriate based on the situation? 1. Ask the physician to talk with the family. 2. Explain to the parents that their anger is affecting their child so they will not be allowed to visit the child until they calm down. 3. Acknowledge the parents concerns and collaborate with them regarding the care of their child. 4. Call the chaplain to sit with the family.

3. Acknowledge the parents concerns and collaborate with them regarding the care of their child. Hospitalization of the child in a pediatric intensive-care unit is a great stressor for parents. If the parents feel that they are not informed or involved in the care of their child, they may become angry and upset. Calling the physician or chaplain may be appropriate at some point, but the nurse must assume the role of supporter in this situation to promote a sense of trust. Telling the parents that they cannot visit their child will only increase their anger.

The nurse is working in an adolescent medical clinic. What can the nurse anticipate when comparing adolescents in the clinic with chronic conditions to their peers? 1. A high level self-esteem 2. A concern for their parents 3. An altered body image 4. A decreased concern about their appearance

3. An altered body image As adolescents develop a sense of identity, they are focused on themselves and the present. They have a heightened concern about their appearance but may have inaccurate assessments of their body image and low self-esteem when comparing their bodies with those of their peers.

The nurse is providing care to a school-age client who is admitted to the hospital after a motor vehicle accident. Which interventions are appropriate to prepare this client and family for their hospital stay? Select all that apply. 1. A hospital tour 2. A health fair brochure 3. An orientation to the unit 4. An age-appropriate explanation of procedures 5. A child life program consultation

3. An orientation to the unit 4. An age-appropriate explanation of procedures 5. A child life program consultation Interventions that are appropriate for this client and family are those that occur as the result of an unplanned hospital admission. The nurse would orient the client and family to the unit and provide age-appropriate explanation for all procedures. It is also appropriate for the nurse to consult with the child life program. A hospital tour and a health fair brochure are appropriate interventions for a planned hospitalization.

The nurse is caring for a child who has been sedated for a painful procedure. Which nursing activity is the priority for this child? 1. Allow parents to stay with the child. 2. Monitor pulse oximetry. 3. Assess the childs respiratory effort. 4. Place the child on a cardiac monitor.

3. Assess the childs respiratory effort. When the child is sedated for a procedure, it is very important for the nurse to actually visualize the child and his effort of breathing. Although equipment is important and is used routinely during sedation, it does not replace the need for visual assessment. Parents may be allowed to stay with the child, but assessment of breathing effort must take priority.

The nurse is working on parenting skills with a mother of three children. The nurse demonstrates a strategy that uses reward to increase positive behavior. Which strategy will the nurse document in the medical record based on this description? 1. Time out 2. Reasoning 3. Behavior modification 4. Experiencing consequences of misbehavior

3. Behavior modification Behavior modification identifies and gives rewards for desired behaviors. Time out and experiencing consequences of misbehavior show the child that unacceptable behavior brings undesirable outcomes. Reasoning attempts to use explanation to end misbehavior.

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 childs 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.

3. Call the parents and encourage them to bring the child for recommended care. 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 health care 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.

The camp nurse is assessing a group of children attending summer camp. The nurse will expect which children to most likely have problems perceiving a sense of belonging? 1. Children whose parents divorced recently 2. Children who gained a stepparent recently 3. Children recently placed into foster care 4. Children adopted as infants

3. Children recently placed into foster care Children in foster care are more likely to have problems perceiving a sense of belonging. Children whose parents divorce often fear abandonment. Children who gain a stepparent may have problems trusting the new parent. Infants who are adopted at birth can have minimal problems with acceptance when parents follow preadoption counseling about disclosure.

Cultures have many different childrearing practices. Which culture is known to value the male child more than the female child, and often teaches children to avoid displaying emotion? 1. Mexican 2. Amish 3. Chinese 4. Navajo

3. Chinese The Chinese culture values the male child more than the female child, and often teaches children to avoid showing emotion. The other cultures do not have this component

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

3. Coarctation of the aorta 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.

The nurse needs to administer a medication to a preschool-age child. The medication is only available in tablet form. Which action by the nurse is the most appropriate? 1. Place the tablet on the childs tongue and give the child a drink of water. 2. Break the tablet in small pieces and ask the child to swallow the pieces one by one. 3. Crush the tablet and mix it in a teaspoon of applesauce. 4. Crush the table and mix it in a cup of juice.

3. Crush the tablet and mix it in a teaspoon of applesauce. A 4-year-old is not mature enough to swallow a pill or pieces of a pill. The medication should be crushed and mixed with a very small amount of food, not juice.

A toddler recently diagnosed with a seizure disorder will be discharged home on an anticonvulsant. Which action by the mother best demonstrates understanding of how to give the medication? 1. Verbalizing how to give the medication 2. Acknowledging understanding of written instructions 3. Drawing up the medication correctly in an oral syringe and administering it to the child 4. Observing the nurse draw up the medication and administering it to the child.

3. Drawing up the medication correctly in an oral syringe and administering it to the child Verbalization of how to give the medication and acknowledging understanding of written instructions are methods that might be used, but they do not actually demonstrate understanding. Observing the nurse draw up and administer the medication may be used in the teaching process. The best way for the mother to demonstrate understanding is to actually draw up and give the medication.

223. The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 1. Discourage reminiscing. 2. Make the decisions for the family. 3. Encourage expression of feelings, concerns, and fears. 4. Explain everything that is happening to all family members. 5. Touch and hold the client's or family member's hand if appropriate. 6. Be honest and let the client and family know they will not be abandoned by the nurse

3. Encourage expression of feelings, concerns, and fears. 5. Touch and hold the client's or family member's hand if appropriate. 6. Be honest and let the client and family know they will not be abandoned by the nurse The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know they will not be abandoned. The nurse should touch and hold the client's or family member's hand, if appropriate.

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

3. Gastrointestinal This infants 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.

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

3. Gummy bears and licorice 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 babys temperature to rise. 4. When you leave the office, only put one layer of clothing on your baby.

3. I see that you have many layers of clothing on your baby. This may cause your babys temperature to rise. 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 in the pediatric clinic observes a parental lack of warmth and interest toward the child. Which family style will the nurse most likely document in this situation? 1. Authoritarian 2. Authoritative 3. Indifferent 4. Permissive

3. Indifferent Parents displaying the indifferent parenting style fail to demonstrate consistent warmth and interest in their children. Parents who favor the authoritarian style may exhibit a punitive attitude toward the child who is misbehaving but are not disinterested. Parents employing the authoritative style and the permissive style have children who report that my parent loves me and shows affection regularly.

The parents of an 8-year-old state that their son seems very interested in trying new activities. When the parents ask for suggested activities for this age child, the nurse recommends scouts as an activity that will foster growth and development. In which stage of Erikson's "psychosocial stages of development" is this child? 1. Trust versus mistrust 2. Initiative versus guilt 3. Industry versus inferiority 4. Identity versus role confusion

3. Industry versus inferiority Trust versus mistrust (birth to 1 year)—The task of the first year of life is to establish trust in the people providing care. Trust is fostered by provision of food, clean clothing, touch, and comfort. If basic needs are not met, the infant will eventually learn to mistrust others. Initiative versus guilt (3 to 6 years)—The young child initiates new activities and considers new ideas. This interest in exploring the world creates a child who is involved and busy. Constant criticism, on the other hand, leads to feelings of guilt and a lack of purpose. Identity versus role confusion (12 to 18 years)—In adolescence, as the body matures and thought processes become more complex, a new sense of identity or self is established. The self, family, peer group, and community are all examined and redefined. The adolescent who is unable to establish a meaningful definition of self will experience confusion in one or more roles of life. Industry versus inferiority (6 to 12 years)—The middle years of childhood are characterized by development of new interests and by involvement in activities. The child takes pride in accomplishments in sports, school, home, and community. If the child cannot accomplish what is expected, however, the result will be a sense of inferiority.

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. Lets 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?

3. Lets discuss some activities that you have done within the past few months that could possibly lead to pregnancy. 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.

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. Lets talk privately. Lets 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?

3. Lets talk privately. Lets discuss the way you speak with your child and possible ways to be more positive. 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. Since the child is only 6 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 newborn is suspected of having cystic fibrosis. As the child is being prepared for transfer to a pediatric hospital, the mother asks the nurse which symptoms made the practitioner suspect cystic fibrosis. Which response by the nurse is the most appropriate? 1. Steatorrheic stools 2. Constipation 3. Meconium ileus 4. Rectal prolapse

3. Meconium ileus Newborns with cystic fibrosis may present in the first 48 hours with meconium ileus. Steatorrhea, constipation, and rectal prolapse may be signs of cystic fibrosis seen in an older infant or child.

Two 3-year-olds are playing in a hospital playroom together. One is working on a puzzle while the other is stacking blocks. Which type of play are these children exhibiting? 1. Cooperative play 2. Associative play 3. Parallel play 4. Solitary play

3. Parallel play Parallel play describes when two or more children play together, each engaging in their own activities. Cooperative play happens when children demonstrate the ability to cooperate with others and play a part in order to contribute to a unified whole. Associative play is characterized by children interacting in groups and participating in similar activities. In solitary play, a child plays alone.

A child is being discharged from the hospital after a 3-week stay following a motor vehicle accident. The mother expresses concern about caring for the childs wounds at home. She has demonstrated appropriate technique with medication administration and wound care. Which nursing diagnosis is the priority in this situation? 1. Knowledge Deficit of Home Care 2. Altered Family Processes Related to Hospitalization 3. Parental Anxiety Related to Care of the Child at Home 4. Risk for Infection Related to Presence of Healing Wounds

3. Parental Anxiety Related to Care of the Child at Home While all of the diagnoses might have been appropriate at some point, the current focus is the mothers anxiety about caring for the child at home. The priority of the nurse is relieving this anxiety

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.

3. Position the infant on her back to sleep. 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 nurse educator is presenting a lecture about risks to developmental progression. Which items will the educator include in the lecture? Select all that apply. 1. Family support 2. Access to the Internet 3. Recent loss of employment 4. Terminal illness of a family member 5. Hazards within the home environment

3. Recent loss of employment 4. Terminal illness of a family member 5. Hazards within the home environment Risk factors that can inhibit developmental progression include financial problems, stresses and worries, family and job instability, neighborhood and home hazards, and lack of resources. Family support and access to the Internet are both considered protective factors

A mother of a school-age client who recently had surgery for the removal of tonsils and adenoids complains that the child has begun sucking his thumb again. Which coping mechanisms is the child using to cope with the surgery and hospitalization? 1. Repression 2. Rationalization 3. Regression 4. Fantasy

3. Regression The correct answer is regression, which is a return to an earlier behavior. Repression is the involuntary forgetting of uncomfortable situations, rationalization is an attempt to make unacceptable feelings acceptable, and fantasy is a creation of the mind to help deal with an unacceptable fear.

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

3. Remote memory 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 childs language development, and assessing how he interacts with others evaluates social-skill development.

The nurse can instruct parents to expect children in which age group to begin to assume more independent responsibility for their own management of a chronic condition, such as blood-glucose monitoring, insulin administration, intermittent self-catheterization, and appropriate inhaler use? 1. Toddlers 2. Preschool-age 3. School-age 4. Adolescents

3. School-age School-age children are developing a sense of industry and can begin assuming responsibility for self-care. Toddlers and preschool-age children do not have the cognitive and psychomotor skills for these tasks. Adolescents should already be well accomplished at self-care.

An adolescent client with cystic fibrosis suddenly becomes noncompliant with the medication regime. Which intervention by the nurse will most likely improve compliance for this client? 1. Give the child a computer-animated game that presents information on the management of cystic fibrosis. 2. Arrange for the physician to sit down and talk to the child about the risks related to noncompliance with medications. 3. Set up a meeting with some older teens with cystic fibrosis who have been managing their disease effectively. 4. Discuss with the child's parents the privileges that can be taken away, such as cell phone, if compliance fails to improve.

3. Set up a meeting with some older teens with cystic fibrosis who have been managing their disease effectively. Providing an adolescent with positive role models who are in his peer group is the intervention most likely to improve compliance. Interest in games may begin to wane, adults' opinions may be viewed negatively and challenged, and threatening punishment may further incite rebellion.

A school-age client is being discharged from the outpatient surgical center. Which statement by the parent would indicate the need for further teaching? 1. I can expect my child to have some pain for the next few days. 2. I will plan to give my child pain medicine around the clock for the next day or so. 3. Since my child just had surgery today, I can expect the pain level to be higher tomorrow. 4. I will call the office tomorrow if the pain medicine is not relieving the pain

3. Since my child just had surgery today, I can expect the pain level to be higher tomorrow. Increasing pain can be a sign of complication and should be reported to the physician; therefore, if the parent expects the pain to be higher the next day, the nurse should clarify expectations for pain control. The child is expected to have some pain for a few days after surgery and should receive pain medication on a scheduled basis. If prescribed medication is not relieving the pain to a satisfactory level, the physician should be notified.

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.

3. Tell me about the concerns that brought you to the clinic today. 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 parents 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 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 infants 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

3. Temperament during the visit 4. Feeding schedule 5. Sleep-wake patterns When addressing mental health issues, the nurse would assess the infants temperament during the visit, feeding schedule, and sleep-wake patterns. The infants 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 childs 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 infants mental health needs are being addressed.

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.

3. The child is permitted to target practice with a revolver, unsupervised. 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.

A preschool-age client is hospitalized following surgery for a ruptured appendix. During assessment of the child, the nurse notes that the child is sleeping. Vital signs are as follows: temperature 97.8 degrees F axillary, pulse 90, respirations 12, and blood pressure 100/60. Which conclusion by the nurse is appropriate based on the assessment findings? 1. The client is comfortable and the pain is controlled. 2. The client is in shock secondary to blood loss during surgery. 3. The client is experiencing respiratory depression secondary to opioid administration for postoperative pain. 4. The client is sleeping to avoid pain associated with surgery.

3. The client is experiencing respiratory depression secondary to opioid administration for postoperative pain. Respiratory depression secondary to opioid use is most likely to occur when the child is sleeping. A respiratory rate of 12 is well below normal for a preschool-age client. The other vital signs are within normal limits for a sleeping preschool-age client.

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.

3. The height and weight are disproportionate, and the toddler needs further evaluation. . 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.

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.

3. The height and weight are disproportionate, and the toddler needs further evaluation. 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 childs 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

The community-health nurse is assessing several families for various strengths and needs in regard to after-school and backup child-care arrangements. Which family type will benefit the most from this assessment and subsequent interventions? 1. The binuclear family 2. The extended family 3. The single-parent family 4. The traditional nuclear family

3. The single-parent family The single-parent family most typically lacks social, emotional, and financial resources. Nursing considerations for such families should include referrals to options that will enable the parent to fulfill work commitments while providing the child with access to resources that can support the childs growth and development. The binuclear family, the extended family, and the traditional nuclear family generally have at least two adults who can share in the care and the nurturing of its children.

Parents of a child admitted with respiratory distress are concerned because the child wont lie down and wants to sit in a chair leaning forward. Which response by the nurse is the most appropriate? 1. This helps the child feel in control of his situation. 2. The child needs to be encouraged to lie flat in bed. 3. This position helps keep the airway open. 4. This confirms the child has asthma.

3. This position helps keep the airway open. Leaning forward helps keep the airway open. The child is not in control just because he is leaning forward. Lying flat in bed will increase the respiratory distress. This position does not confirm asthma.

Despite the availability of Childrens Health Insurance Programs (CHIP), many eligible children are not enrolled. Which nursing intervention would be the most appropriate to help children become enrolled in CHIP? 1. Assessment of the details of the familys income and expenditures 2. Case management to limit costly, unnecessary duplication of services 3. To advocate for the child by encouraging the family to investigate its SCHIP eligibility 4. To educate the family about the need for keeping regular well-childvisit appointments

3. To advocate for the child by encouraging the family to investigate its SCHIP eligibility In the role of an advocate, a nurse will advance the interests of another; by suggesting the family investigate its SCHIP eligibility, the nurse is directing their action toward the childs best interest. Financial assessment is more commonly the function of a social worker. The case-management activity mentioned will not provide a source of funding nor will the educational effort described.

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

3. Transfers objects from one hand to the other 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.

A preschool-age client is seen in the clinic for a sore throat. In this childs mind, what is the most likely causative agent for the sore throat? 1. Was exposed to someone else with a sore throat. 2. Did not eat the right foods. 3. Yelled at his brother. 4. Did not take his vitamins.

3. Yelled at his brother. Preschoolers understand some concepts of being sick but not the cause of illness. They are likely to think that they are sick as a result of something that they have done. They will frequently view illness as punishment. A child of this age does not yet understand that he can become sick from exposure to someone else who is sick. The other two answers, while not causes of sore throat, can be factors in some illnesses but are beyond the thinking of a 4-year-old.

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

4,2,3,1 In examining a toddler, it is usually best to go from least invasive to most invasive examination in order to build her 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.

The nurse is working with a group of parents who have children with chronic conditions. Which statement by a parent would indicate a risk for a caregiver burden that could become overwhelming? 1. "My mother moved in and helped us take our quadruplets home." 2. "Our health insurance sent us a rejection letter for my child's brand-name medication, and we must fill out forms to get the generic." 3. "I chose to quit my job to be home with my child, and my husband helps in the evening when he can." 4. "I have to care for my child day and night, which leaves little time for me."

4. "I have to care for my child day and night, which leaves little time for me." No respite time from caregiving responsibilities may lead to overwhelming caregiver burden. The family's pitching in to help indicates family support. Substituting generic for brand-name medications will not result in caregiver burden. The mother's choosing to care for the child and receiving help from the husband indicates family support.

405. The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent? 1. "The immunization schedule will need to be altered." 2. "The child should not receive any hepatitis vaccines." 3. "The child will receive all of the immunizations except for the polio series." 4. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."

4. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination." Cystic fibrosis is a chronic multisystem disorder (autosomal recessive trait disorder) characterized by exocrine gland dysfunction. The mucus produced by the exocrine glands is abnormally thick, tenacious, and copious, causing obstruction of the small passageways of the affected organs, particularly in the respiratory, gastrointestinal, and reproductive systems. Adequately protecting children with cystic fibrosis from communicable diseases by immunization is essential. In addition to the basic series of immunizations, a yearly influenza immunization is recommended for children with cystic fibrosis. Options 1, 2, and 3 are incorrect.

While trying to inform a young school-age client about what will occur during an upcoming CT scan, the nurse notices that the child is engaged in a collective monologue, talking about a new puppy. Which response by the nurse is the most appropriate in this situation? 1. "Please stop talking about your puppy. I need to tell you about your CT scan." 2. Ignore the child's responses and continue discussing the procedure. 3. "I'll come back when you are ready to talk with me more about your CT scan." 4. "You must be so excited to have a new puppy! They are so much fun. Now, let me tell you again about going downstairs in a wheelchair to a special room."

4. "You must be so excited to have a new puppy! They are so much fun. Now, let me tell you again about going downstairs in a wheelchair to a special room." When a child becomes engaged in a collective monologue, it is best to respond to the content of his or her conversation and then attempt to reinsert facts about the content that needs to be covered.

The nurse is working in a pediatric surgical unit. In discussing patient-controlled analgesia (PCA) in a preoperative parental meeting, which client would be a candidate for PCA? 1. Developmentally delayed 16-year-old, postoperative bone surgery 2. 5-year-old, postoperative tonsillectomy 3. 10-year-old who has a fractured femur and concussion from a bike accident 4. 12-year-old, postoperative spinal fusion for scoliosis

4. 12-year-old, postoperative spinal fusion for scoliosis Patient-controlled analgesia (PCA) is most appropriate in children 5 years and over. The child must be able to press the button and understand that she will receive pain medicine by pushing the button. PCA is generally prescribed for clients who will be hospitalized for at least 48 hours. Children who are developmentally delayed or have suffered head trauma are not candidates for PCA.

The nurse must perform a procedure on a toddler. Which technique is the most appropriate when performing the procedure? 1. Ask the mother to restrain the child during the procedure. 2. Ask the child if it is okay to start the procedure. 3. Perform the procedure in the childs hospital bed. 4. Allow the child to cry or scream.

4. Allow the child to cry or scream. While the toddler will need to be restrained, the parent should not be the one to do this. The nurse should avoid giving the child a choice if there is no choice. The treatment room should be utilized for the procedure so that the hospital bed remains a safe place. The child should be allowed to cry or scream during the procedure.

212. A 16-year-old client is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively? 1. Encourage the client to rest and read. 2. Encourage the parents to room in with the client. 3. Allow the family to bring in the client's favorite computer games. 4. Allow the client to interact with others in his or her (Adolescent) same age group.

4. Allow the client to interact with others in his or her (Adolescent) same age group. Adolescents often are not sure whether they want their parents with them when they are hospitalized. Because of the importance of their peer group, separation from friends is a source of anxiety. Ideally, the members of the peer group will support their ill friend. Options 1, 2, and 3 isolate the client from the peer group.

A young school-age client is in the playroom when the respiratory therapist arrives on the pediatric unit to give the child a scheduled breathing treatment. Which action by the nurse is the most appropriate? 1. Reschedule the treatment for a later time. 2. Show the respiratory therapist to the playroom so the treatment may be performed. 3. Escort the child to his room and ask the child-life specialist to bring toys to the bedside. 4. Assist the child back to his room for the treatment but reassure the child that he may return when the procedure is completed

4. Assist the child back to his room for the treatment but reassure the child that he may return when the procedure is completed Procedures should not be performed in the playroom. Scheduled respiratory treatments should be performed on time; however, the child should be allowed to return to the playroom as soon as the procedure is completed.

404. A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant? 1. Side or prone 2. Back or prone 3. Stomach with the face turned 4. Back rather than on the stomach

4. Back rather than on the stomach SIDS is the unexpected death of an apparently healthy infant younger than 1 year for whom an investigation of the death and a thorough autopsy fail to show an adequate cause of death. Several theories are proposed regarding the cause, but the exact cause is unknown. Nurses should encour- age parents to place the infant on the back (supine) for sleep. Infants in the prone position (on the stomach) may be unable to move their heads to the side, increasing the risk of suffoca- tion. The infant may have the ability to turn to a prone position from the side-lying position.

A school-age client has been receiving morphine every two hours for postoperative pain as ordered. The medication relieves the pain for approximately 90 minutes, and then the pain returns. Which action by the nurse is the most appropriate? 1. Tell the child that pain medication cannot be administered more frequently than every two hours. 2. Reposition the child and quietly leave the room. 3. Inform the parents that the child is dependent on the medication. 4. Call the healthcare provider to see if the childs orders for pain medication can be changed.

4. Call the healthcare provider to see if the childs orders for pain medication can be changed. The nurse has the responsibility of relieving the childs pain. The child has been receiving the prescribed medication on a regular basis. The healthcare provider should be called to see if the childs orders can be changed. This child might do well with patient-controlled analgesia (PCA). Oral medications such as acetaminophen and NSAIDs can be given with morphine to provide optimum pain relief.

An infant has been NPO for surgery for 4 hours and does not have an intravenous line. The nurse receives a call from the operating room with the information that the surgery has been postponed due to an emergency. Which action by the nurse is the most appropriate? 1. Feed the infant 4 ounces of formula. 2. Reassure the parents that it will not be much longer before surgery. 3. Allow the parents to feed the infant an ounce of oral rehydration solution. 4. Call the physician to see if the infant needs to have an intravenous line started.

4. Call the physician to see if the infant needs to have an intravenous line started. The infant who is NPO is at high risk for dehydration. The nurse does not know how much longer it will be before surgery. The nurse cannot independently make the decision to feed the infant. Feeding the infant could further postpone the surgery, should an operating room become available sooner than expected. It is best to keep the infant NPO and consult the physician to see if an intravenous line is needed.

The nurse is caring for a child who has a long leg cast. The child complains of increasing pain in the toes of the casted foot. Which initial action by the nurse is the most appropriate? 1. Call the healthcare provider to report increasing pain. 2. Administer pain medication. 3. Reposition the child in bed. 4. Check to see if the cast is too tight.

4. Check to see if the cast is too tight. While all of the actions are appropriate, the nurses initial action is to assess for external factors that might be causing pain.

The nurse is performing an assessment of a childs biologic family history. Which situation would necessitate the nurses asking the mother for information should use the term childs father instead of your husband? 1. Traditional nuclear family 2. Traditional extended family 3. Two-income nuclear family 4. Cohabitating informal stepfamily

4. Cohabitating informal stepfamily The mother from the cohabitating informal stepfamily does not have a husband; the nurse should be asking about the childs father. In the traditional nuclear family, the traditional extended family, and the two-income nuclear family, the childs father is the same person as the mothers husband.

A new pediatric hospital will open soon. While planning nursing care, the hospital administration is considering two models of providing health care: family-focused care and family-centered care. Which action best implements family-centered care? 1. Telling the family what must be done for the familys health 2. Assuming the role of an expert professional to direct the health care 3. Intervening for the child and family as a unit 4. Conferring with the family in deciding which healthcare option will be chosen

4. Conferring with the family in deciding which healthcare option will be chosen The benefit of employing the family-centered-care philosophy is that the priorities and needs as seen by the family are addressed as a partnership between a family and a nurse develops. In family-focused care, the healthcare worker assumes the role of professional expert while missing the multiple contributions the family brings to the healthcare meeting.

220. The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child? 1. A radio 2. A sports video 3. Large picture books 4. Crayons and a coloring book

4. Crayons and a coloring book In the preschooler, play is simple and imaginative, and includes activities such as crayons and coloring books, puppets, felt and magnetic boards, and Play-Doh. A radio or a sports video is most appropriate for the adolescent. Large picture books are most appropriate for the infant.

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

4. Developmental surveillance 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.

The practitioner changes the medications for the child with asthma to salmeterol (Serevent). The mother asks the nurse what this drug will do. The nurse explains that salmeterol (Serevent) is used to treat asthma because the drug produces which characteristic? 1. Decreases inflammation 2. Decreases mucous production 3. Controls allergic rhinitis 4. Dilates the bronchioles

4. Dilates the bronchioles Salmeterol (Serevent) is a long-acting beta2-agonist that acts by bronchodilating. Steroids are anti-inflammatory, anticholinergics decrease mucous production, and antihistamines control allergic rhinitis.

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

4. Do you keep books for your child readily available? Keeping books readily available will stimulate reading skills. This is the question that will provide the most information about learning/reading skills. Language and getting along with others are more communication skills. Rewards are more closely related to discipline.

A three-week-old infant is returned post-pyloromyotomy three hours ago. The father is refusing pain medication for the infant and states, "The baby is hungry. Can I give the baby a bottle?" How should the nurse best advocate for the infant? Select all that apply. 1. Call the physician to ask if the child can feed yet. 2. The FLACC scale rating is 8 out of 10; try swaddling and rocking the infant. 3. Ask the parent to obtain a FLACC scale rating and let the nurse know what rating they get. 4. Educate the parent about the surgery and why the infant should not have anything by mouth. 5. Inform the parent about the meaning of the pain scale and the need for pain medication.

4. Educate the parent about the surgery and why the infant should not have anything by mouth. 5. Inform the parent about the meaning of the pain scale and the need for pain medication. 4. Educating the parent about the surgery and why the infant should not have anything by mouth is a good way to advocate for the infant. 5. Informing the parent about the meaning of the pain scale and the need for pain medication is a good way to advocate for the infant.

The charge nurse is concerned with reducing the stressors of hospitalization. Which nursing intervention is most helpful in decreasing the stressors for the toddler-age client? 1. Assign the same nurse to the toddler as much as possible. 2. Let the child listen to an audiotape of the mothers voice. 3. Place a picture of the family at the bedside. 4. Encourage a parent to stay with the child.

4. Encourage a parent to stay with the child. While all of the interventions are appropriate for the hospitalized toddler, presence of a parent is most important. Separation from parents is the major stressor for the hospitalized toddler.

403. The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother? 1. Increase the dose of ibuprofen. 2. Increase the frequency of ibuprofen. 3. Encourage the child to lie on the left side. 4. Encourage the child to lie on the right side.

4. Encourage the child to lie on the right side. Pneumonia is an inflammation of the pulmonary parenchyma or alveoli, or both, caused by a virus, mycoplasmal agents, bacteria, or aspiration of foreign substances. Splinting of the affected side by lying on that side may decrease discomfort. It would be inappropriate to advise the mother to increase the dose or frequency of the ibuprofen. Lying on the left side would not be helpful in alleviating discomfort.

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.

4. Focus anticipatory guidance strategies on topics that the parent or child have expressed as an area of interest. 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.

A nurse is assessing a neonate. Which assessment finding indicates that the neonates respiratory status is worsening? 1. Acrocyanosis 2. Arterial CO2 of 40 3. Periorbital edema 4. Grunting respirations with nasal flaring

4. Grunting respirations with nasal flaring Grunting respirations with nasal flaring indicates respiratory status is becoming worse. Acrocyanosis (cyanosis of the extremities) is a normal finding in a neonate. CO2 of 40 is within a normal range. Periorbital edema does not necessarily mean deterioration in respiratory status.

218. A mother arrives at a clinic with her toddler and tells the nurse that she has a difficult time getting the child to go to bed at night. What measure is most appropriate for the nurse to suggest to the mother? 1. Allow the child to set bedtime limits. 2. Allow the child to have temper tantrums. 3. Avoid letting the child nap during the day. 4. Inform the child of bedtime a few minutes before it is time for bed.

4. Inform the child of bedtime a few minutes before it is time for bed. Toddlers often resist going to bed. Bedtime protests may be reduced by establishing a consistent before-bedtime routine and enforcing consistent limits regarding the child's bedtime behavior. Informing the child of bedtime a few minutes before it is time for bed is the most appropriate option. Most toddlers take an afternoon nap and, until their second birthday, also may require a morning nap. Firm, consistent limits are needed for temper tantrums or when toddlers try stalling tactics.

407. A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the most appropriate nursing action? 1. Tell the mother that the child must stay in the tent. 2. Place a toy in the tent to make the child feel more comfortable. 3. Call the health care provider and obtain a prescription for a mild sedative. 4. Let the mother hold the child and direct the cool mist over the child's face.

4. Let the mother hold the child and direct the cool mist over the child's face. Laryngotracheobronchitis (croup) is the inflammation of the larynx, trachea, and bronchi and is the most common type of croup. Cool mist therapy may be prescribed to liquefy secretions and to assist in breathing. If the use of a tent or hood is causing distress, treatment may be more effective if the child is held by the parent and a cool mist is directed toward the child's face (blow-by). A mild sedative would not be administered to the child. Crying would increase hypoxia and aggravate laryngospasm, which may cause airway obstruction. Options 1 and 2 would not alleviate the child's fear.

A group of children on one hospital unit are all suffering separation anxiety. Which child is experiencing the despair stage of separation anxiety? 1. Does not cry if parents return and leave again 2. Screams and cries when parents leave 3. Appears to be happy and content with staff 4. Lies quietly in bed

4. Lies quietly in bed Children in the despair stage appear sad, depressed, or withdrawn. A child who is lying in bed might be exhibiting any of these. Screaming and crying are components of the protest stage. The young child who appears to be happy and content with everyone is in the denial stage, as is the child who does not cry if parents return and leave again.

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.

4. Obtain a nutritional history for each of these adolescents. 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 nurse is reviewing the immunization record of an adolescent who will be seen later in the day. Which item in the clients history makes heptatis B status a priority? 1. Chronic acne 2. Overuse injuries from playing varsity sports 3. Chronic asthma 4. Plans to get a tattoo

4. Plans to get a tattoo 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.

The clinic nurse is working with a child with multiple disabilities. The parents have asked the nurse to help them in meeting with the school board to develop an Individualized Education Plan (IEP) and an Individualized Health Plan (IHP). Which nursing intervention is most appropriate? 1. Providing a written list of the child's medical diagnoses for the IEP meeting. 2. Offering to wait with the child while the parents attend the IEP meeting. 3. Listening to the parents' concerns and complaints about the school district. 4. Presenting verbally the child's cognitive, physical, and social skills to school officials at the IEP meeting.

4. Presenting verbally the child's cognitive, physical, and social skills to school officials at the IEP meeting. As an advocate for the child and a partner with the family, the nurse attends the IEP meeting and presents the child's functional skills to develop a comprehensive IEP. A list of medical diagnoses does not accurately inform school officials about the child's skills or needs. Waiting with the child and listening to parents' concerns may be kind and empathetic but does not contribute to an action plan for the child's educational needs.

While being comforted in the emergency department, a young school-age sibling of a pediatric trauma victim blurts out to the nurse, "It's my fault! When we were fighting yesterday, I told him I wished he was dead!" Which response is most appropriate by the nurse? 1. Asking the child if she would like to sit down and drink some water 2. Sitting the child down in an empty room with markers and paper so that she can draw a picture 3. Calmly discussing the catheters, tubes, and equipment that the patient requires and explaining to the sibling why the patient needs them 4. Reassuring the child that it is normal to get angry and say things that we do not mean but that we have no control over whether or not an accident happens

4. Reassuring the child that it is normal to get angry and say things that we do not mean but that we have no control over whether or not an accident happens Magical thinking" is the belief that events occur because of one's thoughts or actions, and the most therapeutic way to respond to this is to correct any misconceptions that children may have and reassure them that they are not to blame for any accidents or illness. 2. "Magical thinking" is the belief that events occur because of one's thoughts or actions, and the most therapeutic way to respond to this is to correct any misconceptions that children may have and reassure them that they are not to blame for any accidents or illness.

A nurse delegates the task of neonatal vital-sign assessment to a nurse technician. Which instruction will the nurse give to the technician prior to assign care? 1. Report any neonate using abdominal muscles to breathe. 2. Report any neonate with apnea for 10 seconds. 3. Count respirations for 15 seconds and multiply by 4 to get the rate for 1 minute. 4. Report any neonate with a breathing pause that lasts 20 seconds or longer.

4. Report any neonate with a breathing pause that lasts 20 seconds or longer. The abnormal assessment finding for vital signs that the nurse should instruct a nurse technician to report is any breathing pause by a neonate lasting longer than 20 seconds. This can indicate apnea and could lead to an apparent life-threatening event (ALTE). A breathing pause of 10 seconds or less is called periodic breathing and is a normal pattern for a neonate. Respirations should be counted for 1 minute, not 15 seconds. It is normal for neonates to use abdominal muscles for breathing.

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. Dont allow visitors for the first month. 2. Smoke outside only. 3. Take the newborn to weekly child-stimulation classes. 4. SIDS risk-reduction measures

4. SIDS risk-reduction measures 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 childs big brother. 3. Maintain appropriate immunizations. 4. Teach the child the proper method for brushing the teeth.

4. Teach the child the proper method for brushing the teeth. 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 of an outpatient clinic is sitting with the parents while their adolescent goes for a test. The parents are complaining about their childs 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 childs behavior.

4. Tell me what concerns you about your childs behavior. 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.

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.

4. Weight should triple by 1 year of age. An infant should triple its birth weight by 1 year of age. The other answers are not appropriate weight gains.

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.

4. asymmetric thigh and gluteal folds. 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.

Which stage of development is most unstable and challenging regarding development of personal identity? A. Adolescence B. Toddler hood C. Childhood D. Infancy

A. Adolescence Adolescence is the stage in which one forms a sense of identity. This can be very challenging due to the drastic physical changes, increasing cognitive development and psychosocial challenges during these years.

The nurse is preparing a 4-year-old for surgery. Which teaching technique is most appropriate? A. Allow the child to handle safe medical equipment B. Use an anatomically correct doll to explain the procedure. C. Explain to the child that she will be put to sleep for the procedure. D. Limit the teaching to one one-hour session.

A. Allow the child to handle safe medical equipment

A nurse is caring for a 17-year-old female with cystic fibrosis who has been admitted to the hospital to receive I.V. antibiotic and respiratory treatment for exacerbation of a lung infection. The adolescent has a number of questions about her future and the consequences of the disease. Which statements about the course of cystic fibrosis are true? (Select all that apply.) A. Despite a voracious appetite may have failure to thrive B. The adolescent is at risk for developing diabetes C. Pregnancy and child-bearing aren't affected D. Normal sexual relationships can be expected E. Only males carry the gene for the disease. F. By age 20, the frequency of respiratory treatment should be possible to decrease

A. Despite a voracious appetite may have failure to thrive B. The adolescent is at risk for developing diabetes D. Normal sexual relationships can be expected a. Despite the child's voracious appetite parents may have difficulty getting their child to eat enough calories for optimal nutrition and growth. b. Obstructions in the pancreatic ducts impede the natural enzyme flow that enables the body to digest fats, fat-soluble vitamins and proteins. As the child ages, the pancreas may stop producing sufficient insulin, leading to glucose intolerance and the development of cystic-fibrosis related diabetes mellitus. d. They need to develop normal relationships and establish intimacy with a partner. Information about infertility must be provided along with the guidelines for safe sexual practices to reduce the incidence of sexually transmitted infections. Females with CF may be able to conceive and should be offered contraception.

Which nursing intervention is most appropriate in order to foster the development of trust in a hospitalized infant? A. Encourage the parents to room in and participate in care B. Place pictures of the child's family at the bedside C. Offer the infant a pacifier D. Play tapes of the mother's voice

A. Encourage the parents to room in and participate in care The task of first the first year of life is to establish trust in the people providing care (the parents). Although the nurse may meet many of the hospitalized child's needs, continued parental involvement is necessary both during and after hospitalization to ensure progression through expected developmental stages. It is helpful to encourage the parents to room in. Page 69 and 70 table 4-3

The nurse knows that which represents the major stressor of hospitalization for children from middle infancy throughout the preschool years? A. Separation anxiety B. Loss of control C. Fear of bodily injury D. Fear of pain

A. Separation anxiety

A nurse is caring for a child immediately after removal of the endotracheal tube. What assessment would the nurse report immediately to the provider? A. Stridor B. Occasional pink-tinged sputum C. A few basilar lung crackles on the right D. Respiratory rate 24 breaths/min

A. Stridor Endotracheal intubation is done to protect the airway during epiglottitis. The tube is inserted between the vocal cords and after removal there can be inflammation. The nurse should be alert to signs and symptoms of airway narrowing post intubation such as stridor indicating upper airway constriction.

The nurse notes that a 6-month-old infant who weighed 7 pounds at birth now weighs 15 pounds. What is the nurse's evaluation of the infant's current weight? A. The infant's weight is appropriate for his age. B. The infant has been consuming more calories than needed. C. The infant needs weekly follow-up to assess weight. D. The infant should be hospitalized for failure to thrive.

A. The infant's weight is appropriate for his age. The infant doubles their birthweight at 5-6 months of age

Pediatric nurses have foundational knowledge obtained in nursing school and add specific competencies related to the pediatric client. Which would be considered an additional specific expected competency of the pediatric nurse? 1. Physical assessment 2. Anatomical and developmental differences 3. Nursing process 4. Management of healthcare conditions

Anatomical and developmental differences Assessing anatomical and developmental differences would be a specific expected competency for the pediatric nurse that would not be learned in nursing school. Physical assessment, nursing process, and management of health conditions are all foundational knowledge learned in nursing school.

A 4-year-old boy is hospitalized with a serious bacterial infection. He tells the nurse that he is sick because he was "bad." The nurse's best interpretation of this comment is that it is: A. A sign of stress. B. Common at this age. C. Suggestive of maladaptation. D. Suggestive of excessive discipline at home

B. Common at this age.

A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? A. Warm, dry skin, pink mucous membranes, clear rhinitis B. Decreased wheezing without concurrent improvement of respiratory function C. Pulse rate of 90 beats/minute, normal sinus rhythm, capillary refill of <3 seconds D. Respirations of 18 breaths/minute, unlabored, clear breath sounds

B. Decreased wheezing without concurrent improvement of respiratory function Some asthma episodes do not respond to repeated doses of albuterol and corticosteroids and progress ot protentially life-threatening episodes. The child has increased hypoxemia, decreased expiration due to air trapping and ineffective ventilation.

Whenever the parents of a 10-month-old leave their hospitalized child for short periods, he begins to cry and scream. The nurse explains that this behavior demonstrates that the child: A. Needs to remain with his parents at all times. B. Is experiencing separation anxiety. C. Is experiencing discomfort. D. Is extremely spoiled.

B. Is experiencing separation anxiety.

The mother of a 12-month-old infant who is hospitalized is upset that she must leave her baby to go home for a short time. What should the nurse suggest to this concerned parent? A. Return as soon as possible to attend to her daughter's needs. B. Leave a personal article with the child and reassure her that she will return. C. Call a family relative to stay at all times with the child when the mother leaves. D. Ask a nurse to sit at the child's bedside in her absence.

B. Leave a personal article with the child and reassure her that she will return.

The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the MOST APPROPRIATE nursing action? A. Initiate strict enteric precautions. B. Move the infant to a room with another child with RSV. C. Leave the infant in the present room because RSV is not contagious. D. Inform the staff that they only need to wear a mask when caring for the child.

B. Move the infant to a room with another child with RSV. The child is placed on respiratory and contact isolation when hospitalized to minimize the spread of infection to other hospitalized children. It is always appropriate to cohort same infections together in the same room.

A physician prescribes albuterol sulfate (Proventil) MDI for a patient with newly diagnosed asthma. When teaching the patient about this drug, the nurse should explain that it may cause: A. Nasal congestion B. Nervousness C. Lethargy D. Hyperkalemia

B. Nervousness Dose-related side effects include tachycardia, nervousness, nausea and vomiting, headaches Page 499 - Medications used to treat Asthma

The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the health care provider did not prescribe antibiotics. Which response should the nurse make? A. "The child may be allergic to antibiotics." B. "The child is too young to receive antibiotics." C. "Antibiotics are not indicated unless a bacterial infection is present." D. "The child still has the maternal antibodies from birth and does not need antibiotics."

C. "Antibiotics are not indicated unless a bacterial infection is present." Antibiotics are not prescribed for viral infections.

A mother of a 15-month-old brings her son to the clinic. While doing a nursing assessment, the mother makes the following comments. Which comment merits further investigation by the nurse? A. "My son cries sometimes when I leave him at his grandparent's house." B. "My son always takes his blanket with him." C. "My son is not crawling yet." D. "My son likes to eat mashed potatoes."

C. "My son is not crawling yet." Crawls or pulls whole body along floor by arms is expected between 8 and 10 months of age. Page 82 Toddlers should be showing growing ability to walk and finally walk with ease and begin to run

A 4-year-old who has been toilet-trained becomes incontinent when hospitalized for surgery. The most appropriate nursing diagnosis based on this assessment finding is: A. Coping, Defensive, related to stress of hospitalization. B. Growth and Development Altered, related to incontinence. C. Ineffective Individual Coping related to hospitalization D. Urinary Elimination, Altered, related to incontinence.

C. Ineffective Individual Coping related to hospitalization

A 14-year-old has been diagnosed with insulin-dependent diabetes. Which technique is most appropriate in order to facilitate coping with this diagnosis? A. Give the adolescent specific instructions. B. Encourage increased dependence on parents for several weeks. C. Introduce the adolescent to another teenager who is successfully managing his diabetes. D. Warn the teen of the consequences of noncompliance.

C. Introduce the adolescent to another teenager who is successfully managing his diabetes.

The nurse conducts developmental screenings at a community center for infants and young children. The nurse explains that the purpose of these screenings is to: A. Reverse degenerative processes that have occurred. B. Recognize early infection in order to prevent spread to individuals in close contact with the child. C. Recognize a disorder early so strategies can be developed to promote optimum development. D. Measure intelligence and readiness for school.

C. Recognize a disorder early so strategies can be developed to promote optimum development. : Developmental surveillance allows for early identification of any developmental concerns and also helps the nurse promote optimal growth and development through anticipatory guidance.

The mother of an infant diagnosed with bronchiolitis asks the nurse what causes this disease. The nurse's response would be based on the knowledge that the majority of infections that cause bronchiolitis are a result of: A. Ribavirin B. Mycoplasma pneumoniae C. Respiratory syncytial virus (RSV) D. Hemophilus influenzae

C. Respiratory syncytial virus (RSV) Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis. Page 488.

An 18-month-old child is seen in the emergency department with respiratory distress and is admitted with a diagnosis of pneumonia. Following the initial workup, the baby is still short of breath but is rubbing his eyes as if he is sleepy. The mother wants to lay the baby down for his nap. The infant refuses to lie down. The nurse would suggest: A. Rocking the baby until he is asleep and then lay him down. B. The mother hold him in her arms while he sleeps. C. The mother allow the baby to sleep in an upright position. D. A sleeping pill to help the baby rest

C. The mother allow the baby to sleep in an upright position. Position head of bed up or place the child in position of comfort on parent's lap, if crying or struggling in crib or bed. Upright position facilitates improved aeration and promotes decrease in anxiety (especially in infants) and energy expenditure.

Parents evaluation of developmental status

Consists of 10 questions for parent to answer in interview, based on research regarding parents' concerns.

Child development inventory

Consists of 60, yes-no descriptions for three separate instruments to identify child with developmental difficulties.

Denver II

Consists of observation of child in 4 domains; personal, social, fine-motor-adaptive, language, and gross motor.

Which nursing intervention is most developmentally appropriate for a hospitalized 10-year-old? A. Encourage dependency on parents while the child is hospitalized. B. Obtain a complete health history from the child. C. Encourage the child to play with safe medical equipment. D. Allow the child to assist with dressing changes.

D. Allow the child to assist with dressing changes.

A 16-year-old is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which of the following nursing interventions is most appropriate to facilitate normal growth and development? A. Allow the family to bring in the child's favorite computer games B. Encourage the parents to room-in with the child C. Encourage the child to rest and read D. Allow the child to participate in activities with other individuals in the same age group

D. Allow the child to participate in activities with other individuals in the same age group

A child is brought to the emergency department with suspected epiglottitis. Which nursing intervention would be considered unsafe? A. Allowing the child to remain in the position of choice. B. Placing intubation equipment at the bedside. C. Encouraging parents to comfort the child. D. Examining the throat.

D. Examining the throat. Throat cultures and visual inspection of the inner mouth and throat are contraindicated in children with LTB and epiglottitis. These procedures can cause laryngospasms (spasmodic vibrations that close the larynx) as a result of the child's anxiety or of probing this reactive and already compromised area. A complete airway obstruction may result.

A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the MOST APPROPRIATE nursing action? A. Tell the mother that the child must stay in the tent. B. Place a toy in the tent to make the child feel more comfortable. C. Call the health care provider and obtain a prescription for a mild sedative. D. Let the mother hold the child and direct the cool mist over the child's face.

D. Let the mother hold the child and direct the cool mist over the child's face. position child in position of comfort on parent's lap if crying or struggling in crib or bed. Incorporate parents into child's care. This will promote decreased anxiety (especially in infants). Nursing Care Plan the child with bronchiolitis

The nurse is discussing sexually transmitted infections (STIs) with a 17-year-old student. To correctly plan the teaching lesson, the nurse utilizes Piaget's theory to determine the adolescent's cognitive abilities. The educational plan should be based on the: A. Sensorimotor reactions. B. Limited cause and effect understanding. C. Concrete thinking. D. Mature abstract thinking.

D. Mature abstract thinking. The adolescent at this stage is able to discuss and reason abstract concepts. They can also think and act independently

An inexperienced mother is playing with her 6-month-old in the playroom. The nurse taught the mother about toys that are developmentally appropriate for the infant. The nurse will know the teaching has been successful when the mother selects: A. Blocks B. Tricycle C. Puzzles D. Rattles

D. Rattles The 6-month-old infant should be able to grasp rattles and other objects at will

A 4-year-old scores three "failures" on a developmental screening test. Which statement is the most accurate? A. The child is not as intelligent as expected for age and should be referred to a learning specialist. B. The child has a speech problem and should be referred to a speech therapist. C. The child is at risk for school problems and should be retested. D. The child should be referred for a further diagnostic developmental evaluation.

D. The child should be referred for a further diagnostic developmental evaluation. Failing multiple items on a developmental screening is of concern and the child should be referred for a diagnostic developmental evaluation. Every developmental screening tool has various pass/fail parameters. The guidelines for the screening used should be followed.

The parents of a 2-year-old arrive at a hospital to visit their child. The child is in the playroom when the parents arrive. When the parents enter the playroom, the child does not readily approach the parents. The nurse interprets this behavior as indicating that: A. The child is withdrawn B. The child is self-centered C. The child has adjusted to the hospitalized setting D. This is a normal pattern

D. This is a normal pattern

Individualized transition plan (ITP)

Helps individuals receive vocational training and move successfully from the home into other community settings.

What is the pediatric nurses best defense against an accusation of malpractice or negligence? 1. Following the physicians written orders 2. Meeting the scope and standards of practice for pediatric nursing 3. Being a nurse practitioner or clinical nurse specialist 4. Acting on the advice of the nurse manager

Meeting the scope and standards of practice for pediatric nursing Meeting the scope and standards of practice for pediatric nursing would cover the pediatric nurse against an accusation of malpractice or negligence because the standards are rigorous and cover all bases of excellent nursing practice. Following the physicians written orders or acting on the advice of the nurse manager are not enough to defend the nurse from accusations because the orders and/or advice may be wrong or unethical. Being a clinical nurse specialist or nurse practitioner does not defend the nurse against these accusations if he or she does not follow the Society of Pediatric Nurses standards of practice.

A 12-year-old child is admitted to the unit for a surgical procedure. The child is accompanied by two parents and a younger sibling. What is the level of involvement in treatment decision making for this child? 1. That of an emancipated minor. 2. That of a mature minor. 3. That of assent. 4. None.

That of assent Assent requires the ability to generally understand what procedure and treatments are planned, to understand what participation is required, and to make a statement of agreement or disagreement with the plan. Usually, in Piagets stage of formal operations, 11- to 13-year-olds should be able to problem solve using abstract concepts and are able to give valid assent when parents sign the informed consent. An emancipated minor is a self-supporting adolescent who is not subject to the control of a parent or guardian. A mature minor is a 14- or 15-year-old whom the state law designates as being able to understand medical risks and who is thus permitted to give informed consent for treatment.

Which nursing intervention is most appropriate when providing education to the pediatric client and family? 1. Giving primary care for high-risk children who are in hospital settings 2. Giving primary care for healthy children 3. Working toward the goal of informed choices with the family 4. Obtaining a physician consultation for any technical procedures at delivery

Working toward the goal of informed choices with the family The educator works with the family toward the goal of making informed choices through education and explanation