NCLEX Chapter 23 References
The 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 my 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" Rationale: Toddlers, with their increased mobility and development of motor skills, can reach hot water or hot objects placed on counter 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 childs 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 TTS: 3 and 4 are alike because they isolate the toddler
A 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 jack set with marbles
1. A wagon Rationale: Toys for 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
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 Rationale: Although the preschooler already may be spending some time away from parents at a day care center or preschool, illness adds a stressor 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 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 at risk for infection TTS: Note that the subject relates to the childs fear. Options 3 and 4 will increase anxiety and fear further and should be eliminated. Bearing the subject of the question in mind and considering the child's diagnosis will assist you in eliminating option 2
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
The mother of a 3-year-old is concerned because her child 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 Rationale: 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 bedtime, it should contain only water
Which car safety device should be used for a child who is 8 years old and is 4 feet tall? 1. Seat belt 2. Booster seat 3. Rear-facing convertible seat 4. Front-facing convertible seat
2. Booster seat Rationale: 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 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 car seat or a convertible seat until they weight at least 20 pounds 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 9kg (20 pounds) and 1 year of age
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 the finding, which nursing action is most appropriate? 1. Increase oral fluids 2. Document the findings 3. Notify the health care provider (HCP) 4. Elevate the head of the bed to 90 degrees
2. Document the findings Rationale: 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 TTS: Note the strategic words most appropriate, and the words soft and flat. This should provide you with the clue that this is a normal finding. A bulging or tense fontanel may result from crying or increased intracranial pressure
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 Rationale: 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 90/56mm Hg. The nurse would document the findings. TTS: Focus on the data in the question and note the strategic words most appropriate. Recalling the normal vital signs of an infant and noting that the respiratory rate identified in the question is within the normal range will direct you to the correct option
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 Rationale: 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 food
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 that 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 that they will not be abandoned by the nurse
A 16-year-old 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 child to rest and read 2. Encourage the parents to room in with the child 3. Allow the family to bring in the child's favorite computer games 4. Allow the child to interact with others in his or her same age group
4. Allow the child to interact with others in his or her same age group Rationale: 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 child from the peer groups
The nurse is preparing to care for a 5-year-old who has been placed in traction following a factor 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 Rationale: 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 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 Rationale: 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 TTS: Remember that preparing the toddler for an event will minimize resistive behavior
The nurse is caring for a hospitalized preschool child who is very apprehensive. What should the nurse do to assist in promoting comfort in the child?
When caring for a child who is apprehensive, the nurse should provide a safe and secure environment. The nurse should also take time for communication with the child; allow the child to express feelings such as anxiety, fear, or anger; accept any regressive behavior and assist the preschooler in moving from regressive to appropriate behaviors. Additional interventions include encouraging rooming in with the parents or leaving a favorite toy; allowing mobility and providing play and diversional activities; placing the preschooler with other children of the same age if possible; and encouraging the preschooler to be independent. The nurse should also explain procedures simply, on the preschooler's level, avoid intrusive procedures when possible, and allow the child to wear their underpants
