Pediatric Nursing Exam 1

Which comment should the parent of a 2-year-old expect from the toddler about a new baby brother? 1. "When the baby takes a nap, will you play with me?" 2. "Can I play with the baby?" 3. "The baby is so cute. I love him." 4. "It is time to put him away so we can play."

4. "It is time to put him away so we can play."

What can a nurse do to reinforce a 5-year-old's intellectual initiative when he asks about his upcoming surgery? 1. Answer the child's questions about his upcoming surgery in simple terms. 2. Provide the child with a book that has vivid illustrations about his surgery. 3. Tell the child he should wait and ask the doctor his questions. 4. Tell the child that she will answer his questions at a later time.

1. Answer the child's questions about his upcoming surgery in simple terms.

Which treatment would the nurse anticipate for a 2-week-old boy diagnosed with PKU? 1. There is no treatment or special diet. 2. A high-phenylalanine diet. 3. A low-phenylalanine diet. 4. The mother would be advised not to breastfeed the infant.

3. A low-phenylalanine diet. Rationale: PKU is inherited as an autosomal-recessive trait. The enzyme phenylalanine hydroxylase controlling the conversion of phenylalanine to tyrosine is missing. A low-phenylalanine diet is the treatment to prevent brain damage.

Which would be the best response to the mother of a 13-year-old who continues to ask to ride his 16-year-old cousin's all-terrain vehicle? 1. Emphasize the wearing of safety apparel and adults supervision. 2. Explain that he is developing increased physical skills; if he wears safety apparel and shows maturity should be fine. 3. All-terrain vehicles are not recommended for those younger than 16 years of age. 4. This is a stage where the child is seeking independence and should be allowed to participate in new physical activities.

3. All-terrain vehicles are not recommended for those younger than 16 years of age. Rationale: The teen may be at the developmental stage of seeking independence, but adolescents do not yet have the emotional or physical development to operate all-terrain vehicles. The American Academy of Pediatrics states that those younger than 16 years should not operate all-terrain vehicles.

How can the nurse best facilitate the trust relationship between infant and parents while the infant is hospitalized? The nurse should: 1. Encourage the parents to remain at their child's bedside as much as possible. 2. Keep parents informed about all aspects of their child's condition. 3. Encourage the parents to hold their child as much as possible. 4. Advise the parents to participate actively in their child's care.

3. Encourage the parents to hold their child as much as possible.

Which statement by the parent of a newborn diagnosed with galactosemia demonstrates successful teaching? 1. "This is a rare disorder that usually does not affect future children." 2. "Our newborn looks normal; he may not have galactosemia." 3. "Our newborn may need to take penicillin and other medications to prevent infection." 4. "Penicillin and other drugs that contain lactose as fillers need to be avoided."

4. "Penicillin and other drugs that contain lactose as fillers need to be avoided."

The parent of a 4-month-old with cystic fibrosis (CF) asks the nurse what time to begin the child's first chest physiotherapy (CPT) each day. Which is the nurse's best response? 1. "Thirty minutes before feeding the child breakfast." 2. "After deep-suctioning the child each morning." 3. "Thirty minutes after feeding the child breakfast." 4. "Only when the child has congestion or coughing."

1. "Thirty minutes before feeding the child breakfast." Rationale: CPT should be done in the morning prior to feeding to avoid the risk of the child vomiting.

Which intervention should the nurse implement for a newborn diagnosed with galactosemia? 1. Eliminate all milk and lactose-containing foods. 2. Encourage breastfeeding as long as possible. 3. Encourage lactose-containing formulas. 4. Avoid feeding soy-protein formula to the newborn.

1. Eliminate all milk and lactose-containing foods.

Expected nursing assessments of a newborn with suspected cystic fibrosis would include: 1. Observe frequency and nature of stools. 2. Provide chest physiotherapy. 3. Observe for weight gain. 4. Assess parent's compliance with fluid restrictions.

1. Observe frequency and nature of stools.

A school-age child has been diagnosed with nasopharyngitis. The parent is concerned because the child has had little or no appetite for the last 24-hours. Which is the nurse's best response? 1. "Do not be concerned; it is common for children to have a decreased appetite during a respiratory illness." 2. "Be sure your child is taking an adequate amount of fluids. The appetite should return soon." 3. "Try offering the child some favorite food. Maybe that will improve the appetite." 4. "You need to force your child to eat whatever you can; adequate nutrition is essential."

2. "Be sure your child is taking an adequate amount of fluids. The appetite should return soon."

Which is the nurse's best response to parents who ask what impact asthma will have on the child's future in sports? 1. "As long as your child takes prescribed asthma medication, the child will be fine." 2. "The earlier a child is diagnosed with asthma, the more significant the symptoms." 3. "The earlier a child is diagnosed with asthma, the better has of growing out of the disease." 4. "Your child should avoid playing contact sports and sports that require a lot of running."

2. "The earlier a child is diagnosed with asthma, the more significant the symptoms." Rationale: When a child is diagnosed with asthma at an early age, the child is more likely to have significant symptoms on aging.

16. Which laboratory result will provide the most important information regarding the respiratory status of a child with an acute asthma exacerbation? 1. CBC. 2. ABG. 3. BUN. 4. PTT.

2. ABG.

How does the nurse interpret the laboratory analysis of a stool sample containing excessive amounts of azotorrhea and steatorrhea in a child with cystic fibrosis (CF)? The values indicate: 1. Not compliant with taking her vitamins. 2. Not compliant with taking her enzymes. 3. Eating too many foods high in fat. 4. Eating too many foods high in fiber.

2. Not compliant with taking her enzymes. Rationale: If the child were not taking enzymes, the result would be a large amount of undigested food, azotorrhea, and steatorrhea in the stool. Pancreatic ducts in CF patients becomes clogged with thick mucus that blocks the flow of digestive enzymes from the pancreas to the duodenum. Therefore, patients must take digestive enzymes with all meals and snacks to aid in absorption of nutrients.

Which assessment is most important after any injury in a child? 1. History of consciousness and length of time unconscious. 2. Serial assessments of level of consciousness. 3. Initial neurological assessment. 4. Initial vital signs and oxygen saturation level.

2. Serial assessments of level of consciousness. Rationale: Serial assessments of level consciousness are the most important observations of a child after any injury. That information tells you if the child's condition is changing.

Which reaction would a nurse expect when giving a preschooler immunizations? 1. The child remains silent and still. 2. The child cries and tells the nurse that it hurts. 3. The child tries to stall the nurse. 4. The child remains still while telling the nurse that she is hurting him.

2. The child cries and tells the nurse that it hurts. Rationale: The common response of a 5-year-old is to cry and protest during an immunization.

The parent of a child with CF is excited about the possibility of the child receiving a double lung transplant. What would the parent understand? 1. The transplant will cure the child of CF and allow the child to lead a long and healthy life. 2. The transplant will not cure the child of CD but will allow the child to have a longer life. 3. The transplant will help reverse the multi system damage that has been caused by CF. 4. The transplant will be the child's only chance at surviving long enough to graduate college.

2. The transplant will not cure the child of CD but will allow the child to have a longer life.

The parent of an infant with cystic fibrosis asks the nurse how to meet the child's increased nutritional needs. Which is the nurse's best suggestion? 1. "You may need to increase the number of fresh fruits and vegetables you give to your child." 2. "You may need to advance your child's diet to whole cow's milk because it is higher in fat than formula." 3. "You may need to change your child to a higher-calorie formula." 4. "You may need to increase your child's carbohydrate intake."

3. "You may need to change your child to a higher-calorie formula."

9. A 7-month-old has a low-grade fever, nasal congestion, and a mild cough. What should the nursing care management of this child include? 1. Maintaining strict bedrest. 2. Avoiding contact with family members. 3. Instilling saline nose drops and bulb suctioning. 4. Keeping the head of the bed flat.

3. Instilling saline nose drops and bulb suctioning.

Which assessment of an 18-month-old with burns on his feet would cause suspicion of child abuse? 1. Splash marks on his right lower leg. 2. Burns noted on right arm. 3. Symmetrical burns on both feet. 4. Burns mainly noted on right foot.

3. Symmetrical burns on both feet.

What is the most important piece of information that the nurse must ask the parents of a child in status asthmaticus? 1. "What time did your child last eat?" 2. "Has your child been exposed to any of the usual asthma triggers?" 3. "When was your child last admitted to the hospital for asthma?" 4. "When was your child's last dose of medication?"

4. "When was your child's last dose of medication?"

A 2-year old has just been diagnosed with CF. The parents ask the nurse what early respiratory systems they should expect to see in their child. Which is the nurse's best response? 1. "You can expect your child to develop a barrel-shaped chest." 2. "You can expect your child to develop a chronic productive cough." 3. "You can expect your child to develop bronchiectasis." 4. "You can expect your child to develop wheezing respirations."

4. "You can expect your child to develop wheezing respirations." Rationale: Wheezing respirations and a dry, nonproductive cough are commonly early symptoms in CF.

Which nursing intervention would be of highest priority for a 2-year old suspected of ingesting digoxin? 1. Provide supplemental oxygen. 2. Establish intravenous access. 3. Draw blood for a STAT digoxin level 4. Provide continuous cardiac monitoring.

4. Provide continuous cardiac monitoring. Rationale: Bradycardia and cardiac dysrhythmias are common signs of digoxin toxicity in children. Continuous cardiac monitoring is the highest priority to detect dysrhythmias before they became lethal. How

Which would the nurse explain to the parents about the inheritance of cystic fibrosis? 1. CF is an autosomal-dominant trait passed on from the child's mother. 2. CF is an autosomal-dominant trait passed on from the child's father. 3. The child of parents who are both carriers of the gene for CF has a 50% chance of acquiring CF. 4. The child of a mother who has CF and a father is a carrier of the gene for CF has a 50% chance of acquiring CF.

4. The child of a mother who has CF and a father is a carrier of the gene for CF has a 50% chance of acquiring CF.

A 3-year-old boy has been hospitalized because he fell down the stairs. His mother is crying and states, "This is all my fault." Which is the nurse's best response? 1. "Accidents happen. You shouldn't blame yourself." 2. "Falls are one of the most common injuries in this age group." 3. "It may be a good idea to put a baby gate on the stairs." 4. "Your son should be proficient at walking down the stairs by now."

2. "Falls are one of the most common injuries in this age group."

The mother of an 11-month-old with iron deficiency anemia tells the nurse that her infant is currently taking iron and a multivitamin. Which statement made by the mother should be of concern to the nurse? 1. "I give the iron and multivitamin at the same time each morning." 2. "I give the iron and multivitamin in the morning 6-oz bottle." 3. "I give the iron and multivitamin 2 hours before I feed the morning bottle." 4. "I five the iron and multivitamin in oral syringes toward the back of the cheek."

2. "I give the iron and multivitamin in the morning 6-oz bottle." Rationale: Medications should never be mixed in a large amount of food or formula because the parent cannot be sure that the child will take the entire feeding. Formula decreases the absorption of iron.

Which statement by an infant's mother leads the nurse to believe she needs further education about the nutritional needs of a 6-month-old? 1. "I will continue to breastfeed my son and will give him rice cereal three times a day." 2. "I will start my son on fruits and gradually introduce vegetables." 3. "I will start my son on carrots and will introduce one new vegetable every few days." 4. "I will not give my son any more than 8 ounces of baby juice per day."

2. "I will start my son on fruits and gradually introduce vegetables." Rationale: Infants should be started on vegetables prior to fruits. The sweetness of fruits may inhibit infants from taking vegetables. ** As a parent, this is true! Trust me 😂

The mother of a newborn asks the nurse when the infant will receive the first hepatitis B immunization. Which is the nurse's best response? 1. "Babies receive the hepatitis B vaccine only if their mother is hepatitis B-positive." 2. "The first dose of hepatitis B vaccine will be given prior to discharge today." 3. "The first dose of hepatitis B vaccine is given at 1 year of age." 4. "Babies receive their first hepatitis B vaccine at 6-months of age."

2. "The first dose of hepatitis B vaccine will be given prior to discharge today."

Which teaching would be important to discuss with the family of a newborn with PKU? 1. Studies have shown that children with PKU outgrow the disease. 2. Consumption of decreased amounts of protein and dairy products is advised. 3. High-protein and high-dairy products consumption must be maintained. 4. Exclusive breastfeeding is encouraged for maximal nutrition for the child.

2. Consumption of decreased amounts of protein and dairy products is advised. Rationale: Many high-protein foods such as meats and dairy products are restricted or eliminated from the diet due to the high phenylalanine content.

A 5-year-old boy has always been one of the shortest children in class. His mother tells the school nurse that her husband is 6' tall and she is 5' 7". What should the nurse tell the child's mother? 1. He is expected to grow about 3 inches every year from ages 6 to 9 years. 2. He is expected to grow about 2 inches every year from ages 6 to 9 years. 3. He should be seen by an endocrinologist for growth-hormone injections. 4. His growth should be re-evaluated when he is 7 years old.

2. He is expected to grow about 2 inches every year from ages 6 to 9 years.

Which intervention might the nurse anticipate in a 2-day-old infant diagnosed with maple syrup urine disease? 1. High-protein, high-amino-acid diet. 2. Low-protein, low-amino-acid diet. 3. Low-protein, low-sodium diet. 4. Phenylalanine-restricted diet.

2. Low-protein, low-amino-acid diet.

An 18-month-old is discharged from the hospital after having a febrile seizure secondary to exanthem subitum (roseola). On discharge, the mother asks the nurse if her 6-year-old twins will get sick. Which teaching about the transmission of roseola would be most accurate? 1. The child should be isolated in the home until the vesicles have dried. 2. The child does not need to be isolated from the older siblings. 3. Administer acetaminophen to the older siblings to prevent seizures. 4. Monitor older children for seizure development.

2. The child does not need to be isolated from the older siblings.

Which would be the priority intervention for the newborn of a mother positive for hepatitis antigen? 1. The newborn should be given the first dose of hepatitis B vaccine by 2 months of age. 2. The newborn should receive the hepatitis B vaccine and hepatitis immune globulin within 12 hours of birth. 3. The newborn should receive the hepatitis B vaccine and hepatitis immune globulin within 24 hours of birth. 4. The newborn should receive the hepatitis B immune globulin within 12 hours of birth.

2. The newborn should receive the hepatitis B vaccine and hepatitis immune globulin within 12 hours of birth.

A mother requests that her child receive the varicella vaccine at the 9-month well-child checkup. The nurse tells the mother that: 1. Children who are vaccinated will likely develop a mild case of the disease. 2. The vaccine cannot be given at that visit. 3. The vaccine will be administered after the physician examines the child. 4. A booster vaccination will be needed at 18 months of age.

2. The vaccine cannot be given at that visit. Rationale: The nurse should not give the vaccine. The varicella vaccine is usually not administered prior to 1 year of age.

A 6-month old male is at his well-child checkup. The nurse weighs him, and his mother asks if his weight is normal for his age. The nurse's best response is: 1. "At 6 months his weight should be approximately three times his birth weight." 2. "Each child gains weight at his or her own pace." 3. "At 6 months his weight should be approximately twice his birth weight." 4. At 6 months a child should weigh about 10 lb more than his or her birth weight."

3. "At 6 months his weight should be approximately twice his birth weight." Rationale: Infants should double their weight by 4-6-months of age.

The nurse is assessing the pain level in an infant who just had surgery. The infant's parents ask which vital sign changes are expected in a child experiencing pain. The nurse's best response is: 1. "We expect to see a child's heart rate decrease and respiratory rate increase." 2. "We expect to see a child's heart rate and blood pressure decrease." 3. "We expect to see a child's heart rate and blood pressure increase." 4. "We expect to see a child's heart rate increase and blood pressure decrease."

3. "We expect to see a child's heart rate and blood pressure increase."

What should parents understand is one of the most common causes of injury and death for a 7-month-old infant? 1. Poisoning. 2. Child abuse. 3. Aspiration. 4. Dog bites.

3. Aspiration. Rationale: Aspiration is a common cause of injury and death among children of this age. These children often find small objects lying on the floor and place them in their mouths. Older siblings are often responsible for leaving small objects around.

The best method to explain a procedure to a hospitalized preschool-age child is to: 1. Show the child a pamphlet with pictures showing the procedure. 2. Have the 5-year-old next door tell the 4-year-old about the experience. 3. Demonstrate the procedure on a doll. 4. Show the child a video of the procedure.

3. Demonstrate the procedure on a. doll.

Which medication is most important to have available in all clinics and offices if immunizations are administered? 1. Benadryl (diphenhydramine) injection 2. Benadryl (diphenhydramine) liquid 3. Epinephrine 1:1000 injection 4. Epinephrine 1:10,000 injection

3. Epinephrine 1:1000 injection

An 8-day-old was admitted to the hospital with vomiting and dehydration. The newborn's heart rate is 170, respiratory rate is 44, blood pressure is 85/52, and temperature is 99℉ (37.2℃). What is the nurse's best response to the parents who ask if the vital signs are normal? 1. "The blood pressure is elevated, but the other vital signs are within normal limits." 2. "The temperature is elevated, but the other vital signs are within normal limits." 3. "The respiratory rate is elevated, but the other vital signs are within normal limits." 4. "The heart rate is elevated, but the other vital signs are within normal limits."

4. "The heart rate is elevated, but the other vital signs are within normal limits."

Which statement by the mother of an 18-month-old would lead the nurse to believe that the child should be referred for further evaluation for developmental delay? 1. "My child is able to stand but is not yet taking steps independently." 2. "My child has a vocabulary of approximately 15 words." 3. "My child is still sucking his thumb." 4. "My child seems to be quite wary of strangers."

1. "My child is able to stand but is not yet taking steps independently."

Which should the nurse recommend to the parents of a 9-year-old hospitalized following a bicycle injury? To prevent future injury, their child should: 1. Wear safety equipment while riding bicycles. 2. Read educational material on bicycle safety. 3. Watch a video on bicycle safety. 4. Ride his bike in the presence of adults.

1. Wear safety equipment while riding bicycles.

Which stressor is common in hospitalized toddlers? (Select all that apply) 1. Social isolation. 2. Interrupted routine. 3. Sleep disturbances. 4. Self-concept disturbances. 5. Fear of being hurt.

2, 3, & 5 Rationale: Social isolation is a stressor of the hospitalized teen. Common stressors of the hospitalized toddler include interrupted routine, sleep pattern disturbances, and fear of being hurt. Self-concept disturbance is a stressor of the hospitalized teen.

A first-time mother brings in her 5-day-old baby for a well-child visit. The nurse weighs the infant and reports a weight of 7 lbs 5 oz to the mother. The mother looks concerned and tells the nurse that her baby weighed 7 lb 10 oz when she was discharged 4 days ago. The nurse's best response to the mother is: 1. "I will let the doctor the doctor know, and he will talk with you about the possible causes of our infant's weigh loss." 2. "A weight loss of a few ounces is common among newborns, especially for breastfeeding mothers." 3. I can tell you are a first-time mother. Don't worry; we will find out why she is losing weight." 4. "Maybe she isn't getting enough milk. How often are you breastfeeding her?"

2. "A weight loss of a few ounces is common among newborns, especially for breastfeeding mothers."

Which should the nurse do to prevent separation anxiety in a hospitalized toddler? 1. Assume the parental role when parents are not able to be at the bedside. 2. Encourage the parents to always remain at the bedside. 3. Establish a routine similar to that of the child's home. 4. Rotate nursing staff so the child becomes comfortable with a variety of nurses.

3. Establish a routine similar to that of the child's home.

During an adolescents initial physical assessment, the nurse notes signs and symptoms of nutritional deficit. Which assessment let the nurse to this initial conclusion? 1. Protein level WNL 2. Blood pressure is 110/66 3. Hair and nails are brittle and dry. 4. Teeth appear to be eroded

3. Hair and nails are brittle and dry.

The mother of a 3-week-old tells the nurse she is residing in a homeless shelter and is concerned about his mild cough, poor appetite, low-grade fever, weight loss, and fussiness over the last 2 weeks. Which nursing intervention would be the nurse's highest priority? 1. Weigh the baby to have an accurate weight using standard precautions. 2. Reassure the mother that the baby may only have a cold, which can last a few weeks. 3. Immediately initiate droplet face-mask precautions, and isolate the client. 4. Take a rectal temperature while completing the assessment using standard precautions.

3. Immediately initiate droplet face-mask precautions, and isolate the client.

Which would be the priority nursing intervention for a newly admitted child with Kawasaki disease? 1. Continuous cardiovascular and oxygen-saturation monitoring. 2. Vital signs every 4 hours until stable. 3. Strict intake and output monitoring hourly. 4. Begin aspirin therapy after fever has resolved.

1. Continuous cardiovascular and oxygen-saturation monitoring. Rationale: Cardiovascular manifestation of Kawasaki disease are the major complications in pediatric patients. Continuous cardiac monitoring is required to alert the nurse of any cardiovascular complications. Decreased oxygen saturation and respiratory changes have been shown to be early indicators of potential complications.

A 2-year-old admitted to the hospital 2 days ago has been crying and is inconsolable much of the time. The nurse's best response to the child's parents who are concerned about this behavior is that the child is in the: 1. Detachment phase of separation anxiety, which is normal for children during hospitalization. 2. Despair stage of separation anxiety, which is normal for children during hospitalization. 3. Bargaining stage of separation anxiety, which is normal for children during hospitalization. 4. Protest stage of separation anxiety, which is normal for children during hospitalization.

4. Protest stage of separation anxiety, which is normal for children during hospitalization. Rationale: During the protest stage of separation anxiety, children are often inconsolable, and often cry more than they do when they are at home. These children also frequently ask to go home. During the despair stage of separation, children usually have a loss of appetite, altered sleep patterns, and a lack of much interest in play. The bargaining stage is not a stage of separation anxiety, it's a stage of grief. During the detachment phase, children are usually fairly cheerful, and they often lack a preference for their parents (usually this occur after discharge).

Which clinical assessment of a neonate with bacterial meningitis would warrant immediate intervention? 1. Irritability. 2. Rectal temperature of 100.6℉ (38.1℃). 3. Quieter than usual. 4. Respiratory rate of 25 breaths per minute.

4. Respiratory rate of 25 breaths per minute. Rationale: A normal neonate's respiratory rate is 30-60 breaths per minute. Neonates respiratory systems are immature, and the rate may initially double in response to illness. If no immediate interventions are begun when there is respiratory distress, a neonate's respiratory rate will slow down, develop worsening respiratory distress and, eventually, respiratory arrest. Neonates with slower or faster respiratory rates are true emergency cases; they require identification of the cause of distress.

Which approach should the nurse use to gather information from a child brought to the ED for suspected child abuse? 1. Promise the child that her parents will not know what she tells the nurse. 2. Promise the child that she will not have to see the suspected abuser again. 3. Use correct anatomical terms to discuss body parts. 4. Tell the child that the abuse is not her fault and that she is a good person.

4. Tell the child that the abuse is not her fault and that she is a good person. Rationale: Many young children believe abuse or illness us their fault, and they should be reminded they are not to blame. Many children this age believe they have acquired a disease or have been abused because they are bad people.

According to developmental theories, which important event does the nurse understand is essential to the development of the toddler? 1. The child learns to feed self. 2. The child develops friendships. 3. The child learns to walk. 4. The child participates in being potty-trained.

4. The child participates in being potty-trained. Rationale: Developmental theorists like Erickson and Freud believe that toilet training is the essential event that must be mastered by the toddler.

Which signs and symptoms would the nurse expect to assess in a child with rheumatic fever? 1. Ankle and knee joint pain. 2. Negative group A beta streptococcal culture. 3. Large red "bulls eye"-appearing rash 4. Stiff neck with photophobia.

1. Ankle and knee joint pain.

Which response about safety measures is the most appropriate advice for the 2-year-old's mother who had her older home remodeled to reduce the lead level? 1. "Wash and dry the child's hands and face before he eats." 2. "Remodeling the home to remove the lead is all you need to do." 3. "It is best to use hot water to prepare the child's food to decrease the lead." 4. "Diet does not matter in reducing lead levels in the child."

1. "Wash and dry the child's hands and face before he eats." Rationale: Washing and drying hands and face, especially before eating, decreases lead ingestion.

Which would be the nurse's best response if a mother asks if her baby still needs the Hib vaccine because he already had Hib? 1. "Yes it is recommended that the baby still get the Hib vaccine." 2. "No, if he has had Hib, he will not need to receive the vaccine." 3. "Let me take a nasal swab first; if it is negative, he will receive the Hib vaccine." 4. "The physician will order a blood rest, and depending on results, your child may need the vaccine."

1. "Yes it is recommended that the baby still get the Hib vaccine." Rationale: The infant needs the Hib vaccine to ensure protection against many serious infections caused by Hib, such as bacterial meningitis, bacterial pneumonia, epiglottis, septic arthritis, and sepsis.

The parents of a 12-month-old with HIV are concerned about his receiving routine immunizations. What will the nurse tell them about immunizations? 1. "Your child will not receive routine immunizations today." 2. "You child will receive the recommended vaccines today." 3. "Your child is not severely immunocompromised, but I would still be concerned about his receiving them." 4. "You child may develop infections if he gets his routine immunizations. Your child will not be immunized today."

1. "Your child will not receive routine immunizations today." Rationale: The nurse acknowledges a client's fears and then discusses the concerns to clarify any misconceptions. Immunizations and influenza vaccine are recommended to prevent infection. Immunocompromised HIV-infected children should not receive the varicella and MMR live vaccines.

A 3-year-old is hospitalized for an ASD repair. The parents have decided to go home for a few hours to spend with her siblings. The child asks when her mommy and daddy will be back. The nurse's best response is: 1. "Your mommy and daddy will be back after your nap." 2. Your mommy and daddy will be back at 6:00 pm." 3. "Your mommy and daddy will be back later this evening." 4. "Your mommy and daddy will be back in 3 hours."

1. "Your mommy and daddy will be back after your nap." Rationale: Preschoolers understand time in relation to events.

A 10-month-old is carried into the emergency department by her parent after she fell down 15 stairs in her walker. Which would be your highest priority nursing intervention? 1. Assess airway while simultaneously maintaining cervical spine precautions. 2. Assess airway, breathing, and circulation simultaneously. 3. Prepare for diagnostic radiological testing to check for any injuries. 4. Obtain venous access and draw blood for testing.

1. Assess airway while simultaneously maintaining cervical spine precautions.

Which would be the most appropriate injury prevention/safety teaching for an adolescent? 1. Inquire which are the favorite sports, discuss the teen's knowledge and application of appropriate safety principles. 2. Tell the teen to be careful performing sports activities because every sport has the potential for injury. 3. Tell the teen not to let friends encourage drinking, smoking, or taking drugs. 4. Ask the mother what sports the teen plays and if a helmet is worn with contact sports.

1. Inquire which are the favorite sports, discuss the teen's knowledge and application of appropriate safety principles.

A 4-year-old hospitalized with FTT has orders for daily weights, strict intake and output, and calorie counts. Which action by the nurse would be a concern? 1. The nurse weighs the child every morning after breakfast. 2. The nurse weighs the child with no clothing except fo undergarments. 3. The nurse sits with the child while the child eats her meals. 4. The nurse weighs the child using the same scale every morning.

1. The nurse weighs the child every morning after breakfast. Rationale: The child should be weighed every day on the same scale before eating. Her weight will not be an accurate reflection if she is fed prior to being weighed.

Which finding would the nurse consider abnormal when performing a physical assessment on a 6-month-old? 1. The posterior fontanel is open. 2. The anterior fontanel is open. 3. Beginning signs of tooth eruption. 4. Able to track and follow objects.

1. The posterior fontanel is open. Rationale: The posterior fontanel should close between 6 and 8 weeks of age. The anterior fontanel should close between 12 and 18 months of age. The other two options are normal.

A 13-year-old boy is hospitalized for a femur fracture. He was hit by a car while he and his friends were racing bikes near a major intersection. The child's parents are concerned about his judgement. The nurse should tell the parents that the behavior is: 1. Typical of young teens. 2. Related to hormonal surges during adolescence. 3. An isolated incident and will not likely happen again. 4. Related to teen rebellion.

1. Typical of young teens. Rationale: The brains of young teens are not completely developed, which often leads to poor judgement and impulse control.

Which method is the most effective way to present an educational program on abstinence to adolescents? 1. Use peer-led groups that emphasize the consequences of unprotected sexual contact. 2. Teach students methods to resist peer pressure. 3. Offer students the opportunity to care for a simulator infant for 1 week. 4, Offer statistics, pamphlets, and films discussing the consequences of unprotected sexual contact.

1. Use peer-led groups that emphasize the consequences of unprotected sexual contact.

Which would be the priority intervention for a child diagnosed with chickenpox (varicella) who was prescribed diphenhydramine (Benadryl) for itching? 1. Give a warm bath with mild soap before lotion application. 2. Avoid Caladryl lotion while taking diphenhydramine (Benadryl). 3. Apply Caladryl lotion generously to decrease itching. 4. Give a cool shower with mild soap to decrease itching.

2. Avoid Caladryl lotion while taking diphenhydramine (Benadryl). Rationale: Caladryl lotion contains diphenhydramine (Benadryl), and the child would be at risk for toxicity if the Caladryl is applied to open lesions.

A 3-year-old is attending her grandfather's funeral. Her parents told her that her grandfather is in heaven with God. Which statement describes a 3-year-old child's understanding of spirituality? 1. "The body is here with us on Earth, and the spirit is in heaven." 2. "He is in heaven. Is this heaven?" 3. "The spirit is no longer in his body." 4. "He won't need his body in heaven."

2. "He is in heaven. Is this heaven?" Rationale: Three-year-old children are literal thinkers. The child's parents told her that Grandpa was in heaven. She sees his body, so she thinks they are all in heaven.

Which statement from parents of a newborn diagnosed with Tay-Sachs disease indicates successful understanding of the long-term prognosis? 1. "If we give our baby a proper diet, early intervention, and physical therapy, he can live to adulthood." 2. "He will have normal development for about 6 months before progressive developmental delays occur." 3. "With intense physical therapy and early intervention, we can prevent developmental delays." 4. "If we give our baby a lactose-free diet for life, we can minimize developmental delays and learning disabilities."

2. "He will have normal development for about 6 months before progressive developmental delays occur." Rationale: Tay-Sachs disease is a genetic disorder in which the infant has normal development for the first 6 months. After 6 months, developmental delays and neurological worsening occur. Dietary restriction or providing physical therapy does not change the outcome.

What would be the most appropriate advice to give to the parent of a child with slight visual blurring after being hit in the face with a basketball? 1. "Apply ice, observe for any further eye complaints, and bring him back if he has increased pain." 2. "Take him to the emergency department to ensure that he does not have any internal eye damage." 3. "Call your pediatrician if he starts vomiting, is hard to wake up, or has worsening of eye blurring." 4. "Observe for any further eye complaints, headaches, dizziness, or vomiting, and if worsening occurs, take him to your pediatrician."

2. "Take him to the emergency department to ensure that he does not have any internal eye damage."

An 18-year-old with a rash and itching in the groin area is concerned that he has contracted a sexually transmitted disease and does not want his parents to find out. The nurse's best response is: 1. "We will need to contact your parents to let them know." 2. "We will not contact your parents regarding your visit." 3. "Who would your like us to contact about your visit here today?" 4. "We cannot promise that the hospital will not contact your parents."

2. "We will not contact your parents regarding your visit." Rationale: An adolescent has every right to privacy as long as the situation is not life-threatening. Also, this is legally an adult.

A 16-year-old is having a discussion with the nurse about the teen's recent diagnosis of lupus. In explaining the child's prognosis, the nurse uses the knowledge that adolescents are: 1. Preoccupied with thoughts to the here and now. 2. Able to understand and imagine possibilities for the future. 3. Capable of thinking only in concrete terms. 4. Overly concerned with past events and relationships.

2. Able to understand and imagine possibilities for the future. Rationale: Adolescents are becoming abstract thinkers and are able to imagine possibilities for the future.

Which would be the priority intervention for a child suspected of having varicella (chickenpox)? 1. Contact precautions. 2. Contact and droplet respiratory precautions. 3. Droplet respiratory precautions. 4. Universal precautions and standard precautions.

2. Contact and droplet respiratory precautions. Rationale: Varicella is highly contagious. Contact and droplet respiratory precautions should be started immediately because the primary source of transmission is secretions of the respiratory tract (droplet) and also by contaminated surfaces.

The nurse is going to give a 6-month-old a dose of Rocephin IM. What must the nurse do when the 1.5 mL dose arrives from the pharmacy? 1. Administer the injection into the deltoid muscle. 2. Divide the dose into two injections. 3. Administer the injection into the dorsogluteal muscle. 4. Give dose as a single injection into the vastus lateralis muscle.

2. Divide the dose into two injections. Rationale: A nurse should not deliver more than 1 mL per IM injection to a 6-month old.

What would be the priority nursing action on finding the varicella vaccine at room temperature on the shelf in the medication room? 1. Ensure the varicella vaccine's integrity is intact; if intact, follow the five eights of medication administration. 2. Do not administer this batch of vaccine. 3. Ensure the varicella vaccine's integrity is intact; if intact, give the vaccine after verifying proper physician orders. 4. Ask the mother if the child has had any proper reactions to varicella.

2. Do not administer this batch of vaccine. Rationale: The varicella vaccine integrity cannot be assured if the vaccine is at room temperature, so do not administer.

Which is the most appropriate nursing intervention when caring for a child newly admitted with a mild head concussion and no cervical spine injury? 1. Keep head of bed flat, side rails up, and safety measures in place. 2. Elevate head of bed, side rails up, and safety measures in place. 3. Observe for drainage from any orifice and notify physician immediately. 4. Continually stimulate the child to keep awake to check neurological status.

2. Elevate head of bed, side rails up, and safety measures in place.

A 16-year-old male is hospitalized for cystic fibrosis. He will be an inpatient for 2 weeks while he receives IV antibiotics. Which action taken by the nurse will most enhance his psychosocial development? 1. Fax the teen's teacher, and have her send his homework. 2. Encourage the teen's friends to visit him while in the hospital. 3. Encourage the teen's grandparents to visit him frequently. 4. Tell the teen he is free to use his phone to call or text his friends.

2. Encourage the teen's friends to visit him while in the hospital. Rationale: Teens are most concerned about being like their peers. Having the teen's friends visit will help him feel he is still part of the school and social environment.

To obtain an adolescent's health information, the nurse should: 1. Interview the adolescent using direct questions. 2. Gather information during a casual conversation. 3. Interview the adolescent only in the presence of the parents. 4. Gather information only from the parents.

2. Gather information during a casual conversation. Rationale: Frequently adolescents will share more information when it is gathered during a casual conversation.

What would be the best plan of care for a newborn whose mother's hepatitis B antigen status is unknown? 1. Give the infant the hepatitis B vaccine within 12 hours of birth. 2. Give the infant the hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth. 3. Give the infant the hepatitis B vaccine within 24 hours of birth. 4. Give the infant the hepatitis B vaccine and hepatitis B immune globulin within 24 hours of birth.

2. Give the infant the hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth.

A 9-year-old girl builds a clubhouse in her backyard. She hangs a sign outside her clubhouse that says, "No boys allowed" printed on it. The child's parents are concerned that she is excluding their neighbor's son, and they are upset. What would the school nurse tell the child's parents? 1. Her behavior is cause for concern and should be addressed. 2. Her behavior is common among school-age children. 3. Her feelings about boys will subside within the next year. 4. They should have their daughter speak with the school counselor.

2. Her behavior is common among school-age children.

Which foods would the nurse recommend to the mother of a 2-year old with anemia? 1. 32-oz of while cow's milk per day. 2. Meats, eggs, and green vegetables. 3. Fruits, whole grains, and rice. 4. 8-oz of juice, three times per day.

2. Meats, eggs, and green vegetables. Rationale: This is the most iron-rich option.

Which toy is the best choice for a 12-month-old? 1. Baby doll 2. Musical rattle 3. Board book 4. Colorful beads

2. Musical rattle Rationale: A musical rattle is the perfect toy for this child. Infants have short attention spans and enjoy auditory and visual stimulation. ** 1 and 3 are good options, but they will likely just put them in their mouth, so they're not the best option. 4 is a choking hazard.

A child with a newly applied left leg cast initially feels one, then starts to cry and tells his mother his leg hurts. Which assessment would be the nurse's first priority? 1. Cast integrity. 2. Neurovascular integrity. 3. Musculoskeletal integrity. 4. Soft-tissue integrity.

2. Neurovascular integrity.

Which activity can the nurse provide for a 9-year-old to encourage a sense of industry? 1. Allow the child to choose what time to take his medication. 2. Provide the child with the homework his teacher has sent. 3. Allow the child to assist with his bath. 4. Allow the child to help with his dressing change.

2. Provide the child with the homework his teacher has sent. Rationale: The school-age child is focused on academic performance; therefore, the child can achieve a sense of industry by completing his homework and staying on track with his classmates.

Which nursing intervention should take place prior to all vaccine administrations? 1. Document the vaccination to be administered on the immunization record and medical record. 2. Provide the vaccine information statement handout, and answer all questions. 3. Administer the most painful vaccination first, and then alternate injection sites. 4. Refer to the vaccination as "baby shots" so the parents understands the baby will be receiving an injection.

2. Provide the vaccine information statement handout, and answer all questions.

Which instruction would be of highest priority for the mother of an infant receiving his first oral rotavirus vaccine? 1. "Call the physician if he develops fever or cough." 2. "Call the physician if he develops fever, redness, or swelling at the injection site." 3. "Call the physician if he develops bloody stool or diarrhea." 4. "Call the physician if he develops constipation and irritability."

3. "Call the physician if he develops bloody stool or diarrhea."

The nurse is instructing a new breastfeeding mother in the need to provide her premature infant with an adequate source of iron in her diet. Which statement reflects a need for further education of the new mother? 1. "I will use only breast milk or an iron-fortified formula as a source of milk for my baby until she is at least 12 months old." 2. "My baby will need to have iron supplements introduce when she is 4 months old." 3. "I will need to add iron supplements to my baby's diet when she is 2 months old." 4. :When my baby begins to eat solid foods, I should introduce iron-fortified cereals to her diet."

3. "I will need to add iron supplements to my baby's diet when she is 2 months old." Rationale: Premature infants have iron stores from the mother that last approximately 2 months, so it is important to introduce iron supplement by 2 months of age. Full-term infants have iron stores that last approximately 4-6 months.

The nurse is using the FLACC scale to rate the pain level in a 9-month-old. Which is the nurse's best response to the father's question of what the FLACC scale is? 1. "It estimates a child's level of pain utilizing vital signs information." 2. "It estimates a child's level of pain based on parents' perception." 3. "It estimates a child's level of pain utilizing behavioral and physical responses." 4. "It estimates a child's level of pain utilizing a numeric scale from 0 to 5."

3. "It estimates a child's level of pain utilizing behavioral and physical responses."

The mother of 11-year-old fraternal twins tells the nurse at their well-child checkup that she is concerned because her daughter has gained more weight and height than her twin brother. The mother is concerned that there is something wrong with her son. The nurse's best response is: 1. "I understand your concern. I will take with the physician, and we can draw some lab work." 2. "Let me ask you whether your son has been ill lately." 3. "It is normal for girls to grow a little taller and gain more weight than boys at this age." 4. "It is normal for you to be concerned, but I am sure your son will catch up with your daughter eventually."

3. "It is normal for girls to grow a little taller and gain more weight than boys at this age."

The nurse realizes that a 5-year-old's mother needs further education about the Denver Developmental Screening Test when she states: 1. "It screens for gross motor skills." 2. "It screens for fine motor skills." 3. "It screens for intelligence level." 4. "It screens for language development."

3. "It screens for intelligence level." Rationale: The Denver Developmental Screening test does not test a child's level of intelligence.

When discharging a newborn, which injury prevention instruction would be of highest priority to tell the parents? 1. "Place safety locks on all medicine cabinets and household cleaning supplies." 2. "Transport the infant in the front seat when driving alone so you can see the baby." 3. "Never leave the baby unattended on a raised, unguarded area." 4. "Place safety guards in front of any heating appliance, stove, fireplace, or radiator."

3. "Never leave the baby unattended on a raised, unguarded area."

The mother of a 15-year-old is frustrated because he spends much of his weekend time sleeping. Which is the nurse's best response to the mother's frustration? 1. "Your son may be trying to catch up on the sleep missed during the week." 2. "Developmental theorists believe that teens require more sleep as they begin to integrate new roles into their lives." 3. "Teens require more sleep due to the rapid physical growth that is occurring." 4. "Teens require more sleep due to the increase in their social obligations."

3. "Teens require more sleep due to the rapid physical growth that is occurring."

A 13-year-old tells the nurse that he is worried because his breasts are growing. They hurt, and he is embarrassed to take his shirt off during gym class. What should the nurse tell him? 1. "The pediatrician will draw some blood to find out why your breasts are growing." 2. "It is just a slight hormonal imbalance that can be easily corrected with medication." 3. "This is a normal condition of puberty that will resolve within a year or two." 4. "This is a rare finding that occurs in about 5% of boys during puberty."

3. "This is a normal condition of puberty that will resolve within a year or two." Rationale: Gynecomastia and breast tenderness are common for about a third of boys during middle puberty. Gynecomastia usually resolves in 2 years.

Which would be the most appropriate discharge instructions for a child with a right wrist sprain 3 hours ago? 1. "You should rest, elevate the wrist above the heart, apply heat wrapped in a towel, and use the sling when walking." 2. "You can use the wrist, but stop if it hurts; elevate the wrist when not in use, and use the sling when walking." 3. "You should rest, apply ice wrapped in a towel, elevate the wrist above the heart, and use the sling when walking." 4. "You do not have to take any special precautions; do not use any movements that cause pain, and apply alternate heat and ice, each wrapped in a towel."

3. "You should rest, apply ice wrapped in a towel, elevate the wrist above the heart, and use the sling when walking."

A 3-year-old admitted to the hospital with croup has the following vital signs: heart rate 90, respiratory rate 44, blood pressure 100/52, and temperature 98.8℉ (37.1℃). The nurse's best response is: 1. "Your son's blood pressure is elevated, but the other vital signs are within the normal range." 2. "Your son's temperature is elevated, but the other vital signs are within the normal range." 3. "Your son's respiratory rate is elevated, but the other vital signs are within the normal range." 4. "Your son's heart rate is elevated, but the other vital signs are within the normal range."

3. "Your son's respiratory rate is elevated, but the other vital signs are within the normal range."

A 12-month-old boy weighed 8 lb 2 oz at birth. Understanding developmental milestones, what should the nurse caring for the child expect the current weight to be? 1. 16 lb 4 oz 2. 20 lb 5 oz 3. 24 lb 6 oz 4. 32 lb 8 oz

3. 24 lb 6 oz

Which nursing action would help foster a hospitalized 3-year-old's sense of autonomy? 1. Let the child choose what time to take the oral antibiotics. 2. Allow the child to have a doll for medical play. 3. Allow the child to administer her own dose of Keflex (cephalexin) via oral syringe. 4. Let the child watch age-appropriate videos.

3. Allow the child to administer her own dose of Keflex (cephalexin) via oral syringe. Rationale: Allowing preschoolers to participate in actions of which they are capable is an excellent way to enhance their autonomy.

Which action is a developmentally appropriate method for eliciting a 4-year-old's operation in obtaining the blood pressure? 1. Have the child's parents help put on the blood pressure cuff. 2. Tell the child that if he sits still, the blood pressure machine will go quickly. 3. Ask the child if he feels a squeezing of his arm. 4. Tell the child that measuring the blood pressure will not hurt.

3. Ask the child if he feels a squeezing of his arm. Rationale: Preschool children enjoy games, and it is a good way to elicit their assistance and cooperation during a procedure. A nurse should not promise that the procedure will not hurt because every child's perception of pain is different.

The parents of a newborn are asking the nurse how to use the infant car seat and where it should be placed in their vehicle. Which is the next most appropriate action by the nurse? 1. Give the parents a pamphlet explaining how to install the car seat. 2. Accompany the parents to the car, and show them how to install the car seat. 3. Contact the hospital's car seat safety officer, and ask the officer to accompany the parents to the car for car seat installations. 4. Show the parents a video on car seat installation and safety, and ask if they are comfortable with the information.

3. Contact the hospital's car seat safety officer, and ask the officer to accompany the parents to the car for car seat installations. Rationale: The car seat safety officer is the best choice, as that individual would have the needed information and certification to help the family.

The mother of a 13-year old girl tells the nurse that she is concerned because her daughter has gained 10 lb since she began puberty. The child's mother asks the nurse for advice about what to do about her daughter's weight gain. Which should the nurse do? 1. Provide the child's mother with some pamphlets on nutrition and healthy eating. 2. Provide the child's mother with information about a new exercise program for teens. 3. Inform the child's mother that it is common for teen girls to gain weight during puberty. 4. Inform the child's mother that her daughter will likely gain another 5 to 10 lb in the next year.

3. Inform the child's mother that it is common for teen girls to gain weight during puberty.

An adolescent has a diagnosis of new-onset diabetes. What would most influence a teenager's food choices as he begins to make changes in his diet? 1. Parents and their dietary choices. 2. Cultural background. 3. Peers and their dietary choices. 4. Television and other forms of media influence.

3. Peers and their dietary choices.

After airway, breathing, and circulation have been assessed and stabilized, which intervention should the nurse implement for a child diagnosed with encephalitis? 1. Assist with a lumbar puncture, and give reassurance. 2. Obtain a throat culture, then begin antibiotics. 3. Perform initial and serial neurological assessments. 4. Administer antibiotics and antipyretics.

3. Perform initial and serial neurological assessments.

Which is the best method of distraction for an 8-year-old who is having surgery later today and is NPO? 1. Use the telephone to call friends. 2. Watch television. 3. Play a board game. 4. Read the central line pamphlet he was given.

3. Play a board game. Rationale: A board game is the optimal choice because school-age children enjoy being engaged in an activity with others that will require some skill and challenge.

The mother of a child 2 years 6 months has arranged a play date with the neighbor and her child 2 years 9 months. During the play date the two mothers should expect that the children will do which of the following? 1. Share and trade toys while playing. 2. Play with one another with little or no conflict. 3. Play alongside one another but not actively with one another. 4. Only play with one or two items, ignoring most of the other toys.

3. Play alongside one another but not actively with one another.

Which nursing action is most appropriate to gain information about how a child is feeling? 1. Actively attempt to make friends with the child before asking about her feelings. 2. Ask the child's parents what feelings she has expressed in regard to her diagnosis. 3. Provide the child with some paper to draw a picture of how she is feeling. 4. Ask the child direct questions about how she is feeling.

3. Provide the child with some paper to draw a picture of how she is feeling. Rationale: Often children will include much more detail about their feelings in drawings. They will often express things in pictures they are unable to verbalize. School-age children often do not share all of their feelings verbally, especially to people with whom they are not familiar.

Which technique should the nurse suggest to the mother of an 8-year-old who does not want to complete her chores? 1. Grounding. 2. Time-out. 3. Reward system. 4. Spanking.

3. Reward system.

Which statement would indicate to the nurse that a school-age child is not developmentally on track for age? 1. The child is able to follow a four- to five-step command. 2. The child started wetting the bed on admission to the hospital. 3. The child has an imaginary friend named Kelly. 4. The child enjoys playing board games with her sister.

3. The child has an imaginary friend named Kelly. Rationale: Most school-aged children do not have imaginary friends. This is much more common for children of 3 and 4 years of age.

The mother of a child diagnosed with erythema infectiosum (fifth disease) is crying, and says, "I'm afraid. Will my unborn baby die? I have a planned cesarean section next week." Which statement would be the most therapeutic response? 1. "Let me get the physician to come and talk with you." 2. "I understand. I would be afraid too." 3. Would you like me to call your obstetrician to have you seen as soon as possible?" 4. "I understand you are afraid. Can we talk about your concerns?"

4. "I understand you are afraid. Can we talk about your concerns?"

Which would be the most therapeutic response for the mother of a 6-month-old who tells the nurse she does not want her infant to have the DTaP vaccine because the infant had localized redness the last time she received the vaccine? 1. "I will let the physician know, and we will not administer the DTaP vaccination today." 2. "Every child has that allergic reaction, and your child will still get the DTaP today." 3. "I will let the physician know that you refuse further immunizations for your daughter." 4. "Would you mind if we discussed your concerns?"

4. "Would you mind if we discussed your concerns?"

Which is the nurse's best response to the mother of a 2-month-old who is going to get the IPV immunization when the mother tells the nurse the older brother is immunocompromised? 1. "Your baby should not be immunized because your immunocompromised son could develop polio." 2. "Your baby should receive the oral poliovirus vaccine instead so your immunocompromised son does not get sick." 3. "You should separate your 2-month-old child from the immunocompromised son for 7 to 14 days after the IPV."

4. "Your baby can be immunized with the IPV; he will not be contagious."

What would be the nurse's best response if the foster mother of a 15-month-old with an unknown immunization history comes to the clinic requesting immunizations? 1. "Your foster child will not receive any immunizations today." 2. "You foster child will receive the MMR, Hib, IPV, and hepatitis B vaccines." 3. "Your foster child could have harmful effects if we revaccinate with prior vaccines." 4. "Your foster child will receive only the Hib and DTaP vaccines today."

4. "Your foster child will receive only the Hib and DTaP vaccines today." Rationale: Vaccines routinely due at 15 months include Hib and DTaP. To catch up missed immunizations the nurse would need the child's immunization record to verify what he has received.

The mother of an adolescent complains that he has had some recent behavioral changes. He comes home from school every day, closes his door, and refrains from interaction with his family. The nurse's best response to the mother is: 1. "You should speak with your son and ask him directly what is wrong with him." 2. "You should set limits with your son and tell him that this is unacceptable behavior." 3. "Your son's behavior is abnormal, and he is going to need a psychiatric referral." 4. "Your son's behavior is normal. You should listen to him without being judgmental."

4. "Your son's behavior is normal. You should listen to him without being judgmental."

What information should a school nurse include in a discussion on nutrition with a fourth-grade class? 1. The number of calories that a fourth-grade child should consume in a day. 2. A list of high-calorie foods that all fourth-graders should avoid. 3. How to read food labels so children know which foods are good for them. 4. A list of nutritious foods with basic scientific information about how they affect the body organs and systems.

4. A list of nutritious foods with basic scientific information about how they affect the body organs and systems.

Which families would be appropriate to refer for genetic counseling? 1. Parents with a macrososmic infant. 2. Parents with a neonatal abstinence syndrome infant. 3. Couple with a history of planned abortions. 4. Couple with a history of multiple miscarriages.

4. Couple with a history of multiple miscarriages.

Which teaching is most important for a child with PKU? 1. The child is able to eat a quarter-pound hamburger and drink a milkshake daily. 2. If the child wants soda, diet soda is preferred over milk or dairy products. 3. The child may have ice cream in an unlimited quantity once a week. 4. Diet soda or anything with the sweetener aspartame should be avoided.

4. Diet soda or anything with the sweetener aspartame should be avoided. Rationale: The artificial aspartame should be avoided because it is converted to phenylalanine in the body.

Which statement accurately describes how the nurse should approach an 11-year-old to do a physical assessment? 1. Ask the child's parents to remain in the room during the physical exam. 2. Auscultate the heart, lungs, and abdomen first. 3. Explain that the physical exam will not hurt. 4. Explain what the nurse will be doing in basic understandable terms.

4. Explain what the nurse will be doing in basic understandable terms.

Which statement accurately describes the best method for assessing a 12-month old? 1. The nurse should assess the child on the examining table. 2. The nurse should assess the child in a head-to-toe sequence. 3. The nurse should have the child's mother assist in holding her down. 4. The nurse should assess the child while she is in her mother's lap.

4. The nurse should assess the child while she is in her mother's lap.