PEDIATRICS 53 to 57 and 45

11) Which child should the nurse refer for further assessment due to a probable diagnosis for autism spectrum disorder (ASD)? 1. A 4-year-old girl who doesn't make eye contact with mother and resists the mother's touch 2. A 3-year-old boy who joins one group of children, then moves to another group of children without joining their activities 3. An 18-month-old child who walks around the area using the furniture to provide balance 4. A 6-year-old boy who chatters constantly to anyone who will listen

Answer: 1 Explanation: 1. Although boys are affected more often than girls, lack of eye contact and resistance to physical touch are common symptoms of autism. 2. Although this child is not interacting with other children, it is obvious that the child is aware of other children and interested in their activities, actions that are not indicative of autism. 3. This child may be developmentally delayed, as this behavior is typical of a 10- to 12-month-old child. 4. Children with autism often have language delays and impairment. This child does not have any obvious language issues.

7) Which is the priority nursing diagnosis when planning care for a pediatric client who is diagnosed with bacterial meningitis? 1. Impaired Gas Exchange 2. Risk for Infection 3. Anxiety (parental) 4. Acute Pain

Answer: 1 Explanation: 1. Impaired gas exchange would be the priority to ensure patent airway and adequate gas exchange. 2. The child already has an infection. 3. The parents will be anxious about the outcome for their child, but this is not the priority diagnosis. 4. Pain management is important but is not the priority.

14) Which clinical manifestation should the nurse monitor for when assessing a pediatric client who is diagnosed with a basilar skull fracture? 1. Periorbital ecchymosis 2. Subdural hematoma 3. Protruding bone 4. Epidural hematoma

Answer: 1 Explanation: 1. Periorbital ecchymosis, also called raccoon eyes, is seen with a basilar fracture. 2. Subdural hematoma might be seen with a linear fracture. 3. Protruding bone might be seen with a compound fracture. 4. Epidural hematoma is seen with linear fracture. Page Ref: 1476

16) The nurse is providing care to a child who was treated with aspirin during a viral infection. Which clinical manifestations should cause the nurse concern? 1. Nausea, vomiting, and confusion 2. Headache, vomiting, and seizures 3. Sore throat, moist respirations, and cough 4. Fever, rash, and photophobia

Answer: 1 Explanation: 1. These are the early symptoms of Reye syndrome. 2. These symptoms are associated with a malfunctioning shunt and not the early symptoms of Reye syndrome. 3. These symptoms are more likely to indicate pneumonia, not Reye syndrome. 4. These are not the early symptoms of Reye syndrome.

22) Which clinical manifestations support the diagnosis of viral meningitis? Select all that apply. 1. Abrupt onset of fever 2. Headache 3. Myalgia 4. Hemorrhagic rash 5. Purpura

Answer: 1, 2, 3 Explanation: 1. Abrupt onset of fever is a clinical manifestation associated with viral meningitis. 2. Headache is a clinical manifestation associated with viral meningitis. 3. Myalgia is a clinical manifestation associated with viral meningitis. 4. Hemorrhagic rash is a clinical manifestation associated with bacterial, not viral, meningitis. 5. Purpura is a clinical manifestation associated with bacterial, not viral, meningitis.

21) Which pediatric client diagnoses would cause the nurse to include information related to short stature? Select all that apply. 1. Hypothyroidism 2. Turner syndrome 3. Chronic renal failure 4. Cushing syndrome 5. Diabetes mellitus

Answer: 1, 2, 3, 4 Explanation: 1. Hypothyroidism is a pediatric client diagnosis that would cause the nurse to include information related to short stature. 2. Turner syndrome is a pediatric client diagnosis that would cause the nurse to include information related to short stature. 3. Chronic renal failure is a pediatric client diagnosis that would cause the nurse to include information related to short stature. 4. Cushing syndrome is a pediatric client diagnosis that would cause the nurse to include information related to short stature. 5. Diabetes mellitus is not a pediatric client diagnosis that would cause the nurse to include information related to short stature.

24) Which diagnostic tests should the nurse include in the plan of care for a pediatric client who is at risk for short stature? Select all that apply. 1. Thyroid function studies 2. Adrenocorticotropic hormone (ACTH) and cortisol levels 3. Complete blood count 4. Blood culture 5. Urine creatinine

Answer: 1, 2, 3, 5 Explanation: 1. Thyroid function tests are often included in the plan of care for a pediatric client at risk for short stature. 2. ACTH and cortisol levels are often included in the plan of care for a pediatric client at risk for short stature. 3. A complete blood count often included in the plan of care for a pediatric client at risk for short stature. 4. A blood culture is not included in the plan of care for a pediatric client at risk for short stature. 5. A urine creatinine is often included in the plan of care for a pediatric client at risk for short stature.

14) Which interventions should the nurse include in the plan of care for an adolescent client who is on complete bed rest after spinal fusion surgery secondary to scoliosis to prevent complications associated with immobility? Select all that apply. 1. Encouraging use of the spirometer every 2 hours while the child is awake 2. Log-rolling the client every 2 hours while awake 3. Increasing intake of milk to maintain bone calcium 4. Increasing fruit and grains in the diet 5. Limiting fluid intake to reduce the need to void

Answer: 1, 2, 4 Explanation: 1. Respiratory complications are a common complication of immobility. 2. Turning the client frequently will reduce pressure on bony prominences. 3. Calcium will be pulled from the bones due to immobility. Adding additional calcium in the form of milk will increase the risk of kidney stones. 4. Fruit and grains will provide extra fiber to reduce the risk of complication. 5. Fluid intake should be increased to "flush" the kidneys.

4) A child had an appendectomy and was discharged home at 48 hours postoperative. A week later, the child is readmitted for delayed wound healing. Which causes of delayed wound healing will the nurse review prior to assessing the child? Select all that apply. 1. Infection 2. Predisposing chronic condition, such as diabetes 3. Hypervolemia 4. Inadequate nutrition 5. Hypoxemia

Answer: 1, 2, 4, 5 Explanation: 1. Infection can affect healing and cause excessive scarring. 2. Conditions such as diabetes affect circulating blood volume and are known to affect healing. 3. Hypovolemia, not hypervolemia, would inhibit inflammation due to low circulating blood volume. 4. Poor nutrition without proper protein and calorie intake will affect healing. 5. Hypoxemia makes tissues susceptible to infection due to insufficient oxygenation.

4) Which statement from the parent of a child diagnosed with attention deficit/hyperactivity disorder (ADHD) indicates the need for further education by the nurse? 1. "I will develop a reward system for desired behaviors." 2. "I will take my child to the physician every 3 months for a weight and height check." 3. "I will let him do his homework while he is watching his favorite television show." 4. "I will stick to the same routine each day after school."

Answer: 3 Explanation: 1. A reward system is a part of behavior modification and is appropriate to help the child behave appropriately. 2. Children with ADHD should be screened regularly for height and weight to monitor growth, which can be affected by medication. 3. This child should do homework in a quiet environment, away from distractions. 4. Maintaining the same daily routine helps the child know expectations, and a nighttime routine helps counteract insomnia.

13) Which food should the nurse remove from the food tray for a toddler-age client who is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)? 1. Oatmeal 2. Yogurt 3. Biscuit 4. Watermelon

Answer: 4 Explanation: 1. A child with SIADH may have carbohydrates and fiber, such as in oatmeal. 2. A child with SIADH may have dairy products, such as yogurt. 3. A child with SIADH may have carbohydrates, such as in a biscuit. 4. A child with SIADH is on a fluid restriction. Watermelon contains significant fluid volume, so it would not be a good food for this child to consume.

15) A school nurse suspects that a child who fell at recess has a fractured arm. Which should the nurse consider when applying a splint to transport the child to the hospital? 1. The splint is applied firmly enough to prevent swelling. 2. The arm is fully extended in the splint. 3. The splint is fully padded to prevent skin damage. 4. The joints above and below the suspected fracture are immobilized by the splint.

Answer: 4 Explanation: 1. The purpose of the splint is not to prevent swelling. 2. The nurse will not want to manipulate the arm, so the nurse will splint the arm in the position it is found. 3. The splint does not need to be padded. 4. This is the important concept in splinting—immobilizing the joint above and below the fracture to prevent movement of the bones.

10) Which teaching point should the nurse include when providing education to an adolescent client, who participates in soccer, regarding the plan of care for diabetes mellitus? 1. Decreased food intake 2. Increased doses of insulin 3. Increased food intake 4. Decreased doses of insulin

Explanation: 1. Decreased food intake would increase the chance of hypoglycemia. 2. Increased dose of insulin would cause hypoglycemia. Exercise causes insulin to be used more efficiently by the body, so an increase in insulin would not be needed. 3. An increase in physical activity requires an increase in caloric intake to prevent hypoglycemia. 4. A decreased dose of insulin would not allow the sugar to enter the cells where it is needed during exercise. Page Ref: 1421

6) Which is the priority nursing diagnosis when planning care for an infant who is diagnosed with a severe case of oral thrush (Candida albicans)? 1. Ineffective Infant Feeding Pattern related to discomfort 2. Ineffective Breathing Pattern related to oral thrush 3. Activity Intolerance related to oral thrush 4. Ineffective Airway Clearance related to mucus

Answer: 1 Explanation: 1. An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt treatment is necessary so the infant can resume a normal feeding pattern. 2. Ineffective breathing pattern is not usually associated with oral thrush. An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt recognition and treatment are necessary so that a normal feeding pattern can be resumed. 3. Activity intolerance is not usually associated with oral thrush. An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt recognition and treatment are necessary so that a normal feeding pattern can be resumed. 4. Ineffective airway clearance is not usually associated with oral thrush. An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt recognition and treatment are necessary so that a normal feeding pattern can be resumed.

1) Which is the most likely cause for a bright red perianal inflammation with scaly plaques and small papules noted by the nurse during the assessment of a 12-month-old infant? 1. Candida albicans (yeast) 2. Impetigo (staphylococcus) 3. Infrequent diapering 4. Urine and feces

Answer: 1 Explanation: 1. Candida albicans is frequently the underlying cause of severe diaper rash. When a primary or secondary infection with C. albicans occurs, the rash has bright red, scaly plaques with sharp margins. Small papules and pustules might be seen, along with satellite lesions. 2. Even though diaper dermatitis can be caused by impetigo, urine, feces, and infrequent diapering, the lesions and persistent characteristics are common for Candida infection. 3. Infrequent diapering, along with urine and feces, can cause diaper dermatitis, but the persistence and characteristics of the lesions are common for Candida infection. 4. Urine and feces can cause diaper dermatitis, but the persistence and characteristics of the lesions are common for Candida infection.

10) Which is the priority nursing diagnosis during the acute phase of a third-degree circumferential burn of the right arm for a pediatric client? 1. Altered Tissue Perfusion, Risk for 2. Infection, Risk for 3. Impaired Physical Mobility 4. Altered Nutrition: Less than body Body requirementsRequirements, Risk for

Answer: 1 Explanation: 1. Circumferential burns can restrict blood flow due to edema, resulting in tissue hypoxia. Altered Tissue Perfusion to the extremity is the greatest risk and therefore the priority diagnosis. 2. When the burn is circumferential, blood flow can become restricted due to edema and can result in tissue hypoxia; therefore, the priority diagnosis is Altered Tissue Perfusion, Risk for, to the extremity. Risk of infection would be a secondary priority in this case. 3. Impaired physical mobility is a secondary priority for the child with a circumferential burn. Edema to the area can result in restricted blood flow and tissue hypoxia, making the priority diagnosis Altered Tissue Perfusion, Risk for. 4. Infection, nutrition, and mobility would have secondary priority in this case.

4) A 5-year-old child with a history of hypopituitarism presents with complaints of right hip and leg pain. Which prescribed medication for the diagnosis should the nurse identify as the cause for the current symptoms? 1. Daily growth hormone 2. Insulin before meals and bedtime 3. DDAVP (desmopressin) at bedtime 4. Cortisone injections

Answer: 1 Explanation: 1. Growth hormone injections and hypopituitarism have been associated with slipped capital femoral epiphysis, which manifests with complaints of hip or knee pain. 2. Insulin is not used to treat hypopituitarism. 3. DDAVP reduces urinary output. It does not cause slipped capital femoral epiphysis. 4. Cortisone is not used for hypopituitarism.

12) A 9-month-old infant who is not sitting independently has been diagnosed with ataxic cerebral palsy (CP). Which clinical manifestations would the nurse expect to see in the baby? 1. Hypotonia and muscle instability 2. Hypertonia and persistence primitive reflexes 3. Tremors and exaggerated posturing 4. Hemiplegia and hypertonia

Answer: 1 Explanation: 1. Hypotonia in infancy and muscle instability are seen in ataxic CP. 2. Hypertonia and persistent primitive reflexes are seen in spastic CP. 3. Tremors and exaggerated posturing are seen in dyskinetic CP. 4. Hemiplegia and hypertonia are seen in spastic CP. Page Ref: 1467

11) Which action related to insulin administration should the nurse include in the teaching plan for an adolescent client who has been newly diagnosed with diabetes mellitus to avoid the development of lipoatrophy? 1. Rotating injection sites 2. Checking blood sugars at mealtime and bedtime 3. Using a sliding scale for additional coverage 4. Administration of insulin via insulin pump

Answer: 1 Explanation: 1. Lipoatrophy is caused by using the same insulin injection site. 2. Checking blood sugars does not influence lipoatrophy. 3. A sliding scale does not influence lipoatrophy. 4. Insulin administration via pump does not influence lipoatrophy.

7) Which parental statement indicates to the nurse accurate understanding regarding the care of their child with tinea capitis (ringworm of the scalp)? 1. "We will give the griseofulvin with milk or peanut butter." 2. "We're glad ringworm isn't transmitted from person to person." 3. "Once the lesion is gone, we can stop the griseofulvin." 4. "Well, at least we don't have to worry about the family cat getting the ringworm."

Answer: 1 Explanation: 1. Parents are advised to give oral griseofulvin with fatty foods such as milk or peanut butter to enhance absorption. 2. All members of the family and household pets should be assessed for fungal lesions because person-to-person transmission is common. 3. The medication must be used for the entire prescribed period, even if the lesions are gone. 4. Dogs and cats can develop the fungal lesions and be sources of spread of the organism.

9) Which should the nurse include in the plan of care for a child with a minor burn to enhance nutrition and healing? 1. Protein 2. Minerals 3. Carbohydrates 4. Fats

Answer: 1 Explanation: 1. Parents should be taught that management of a minor burn requires a high-calorie, high-protein diet. This is necessary to meet the increased nutritional requirements of healing. 2. A high-calorie, high-protein diet is required to meet the increased nutritional requirements for healing. 3. The family should be taught that a high-calorie, high-protein diet is best to meet the increased nutritional requirements for healing. 4. A high-calorie, high-protein diet is best to meet the increased nutritional requirements for healing.

2) The nurse is providing care for a pediatric client in the emergency department (ED) with a diagnosis of decreased level of consciousness (LOC) secondary to increased intracranial pressure (ICP). Which healthcare provider order should the nurse question? 1. Passive range-of-motion exercises to promote hip flexion 2. Oxygen at 2 L nasal cannula to keep saturation above 95% 3. Hourly vital signs and neurologic checks 4. Elevate head of bed 30 degrees

Answer: 1 Explanation: 1. Range-of-motion exercises, especially hip flexion, would not be done. It is imperative to keep the child with increased intracranial pressure quiet, with as little stimulation as possible. 2. Oxygen should be ordered to keep the child's O2 saturation above 95%. 3. Hourly vital signs and neurologic checks are appropriate to watch for changes in this child's condition. 4. The head is elevated 30 degrees to help decrease increased intracranial pressure.

6) A hospitalized child has been diagnosed with SIADH (syndrome of inappropriate antidiuretic hormone), a complication of his meningitis. Which laboratory data should the nurse anticipate for this child? 1. Hyponatremia 2. Hypocalcemia 3. Hyperglycemia 4. Hypernatremia

Answer: 1 Explanation: 1. SIADH is associated with increased permeability in distal renal tubes, leading to water intoxication and low sodium. 2. Hypocalcemia is not seen with SIADH. 3. Hyperglycemia is not related to SIADH. 4. Hypernatremia is seen with diabetes insipidus, not SIADH.

16) Which assessment finding would cause the nurse to question whether a preschool-age boy, diagnosed with phenylketonuria shortly after birth, is following the prescribed dietary restrictions? 1. The child's body has a musty odor. 2. This child is a blue-eyed blond. 3. The child appears sleepy and uninterested in the surroundings. 4. The child has a sunburn over his entire body.

Answer: 1 Explanation: 1. The odor is caused by the excretion of phenylketone by-products through the skin and would indicate noncompliance with the dietary restrictions. 2. While this is a characteristic of most children with PKU, it is not related to dietary intake or restrictions. 3. This is not a symptom of untreated phenylketonuria. 4. Photophobia is not associated with PKU. The child with untreated PKU has an eczematous rash. Page Ref: 1428

1) Which assessment finding for a 4-month-old infant would require further action by the nurse? 1. The posterior fontanel is open. 2. The infant has good head control when held upright. 3. The infant is able to roll only from abdomen to back. 4. The anterior fontanel is open and soft.

Answer: 1 Explanation: 1. The posterior fontanel closes between 2 and 3 months of age. 2. Good head control is expected at 4 months of age. 3. Rolling from abdomen to back is a skill the 4-month-old infant should be learning. 4. An open anterior fontanel, which is soft, is a normal finding at 4 months.

6) The nurse is providing care to a child who is diagnosed with Legg-Calvé-Perthes disease. Which parental statement regarding the child's care required further teaching from the nurse? 1. "We're glad this will only take about 6 weeks to correct." 2. "We understand abduction of the affected leg is important." 3. "We know to watch for areas on the skin that the brace might rub." 4. "We understand swimming is a good sport for Legg-Calvé-Perthes."

Answer: 1 Explanation: 1. The treatment for Legg-Calvé-Perthes disease takes approximately 2 years. 2. The leg should be kept in the abducted position to prevent damage to the head of the femur due to Legg-Calvé-Perthes disease. 3. A brace is a component of the treatment of Legg-Calvé-Perthes disease and is worn to prevent damage to the head of the femur, so skin irritation should be monitored. 4. Swimming is a good activity to increase mobility in a child with Legg-Calvé-Perthes disease.

10) Which information should the nurse include in the teaching plan for the parents of a child who is diagnosed with autism spectrum disorder (ASD) as methods to increase the child's socialization? 1. Create a reward system when the child interacts with a person. 2. Punish the child when the child's social behaviors are inappropriate. 3. Use dolls to demonstrate appropriate social interactions to the child. 4. Enroll the child in a day care facility to encourage interaction with other children.

Answer: 1 Explanation: 1. This is appropriate treatment involving behavior modification. 2. Behavior modification uses positive, not negative, reinforcement to encourage the desired behavior. 3. This activity would be a component of play therapy. 4. Enrolling the child in a day care facility may help with interactions, but this is not a description of behavior modification.

18) When the home health nurse visits the home of a 10-month-old child, she observes the environment for risks for injury to the child. Which observation will the nurse discuss with the mother? 1. The mother leaves the filled mop bucket on the floor while in another room. 2. The mother turns all pan handles to the back of the stove. 3. The mother fills the bath tub before bringing the baby into the bathroom. 4. When riding in a car, the child is in a car seat in the middle of the back seat.

Answer: 1 Explanation: 1. Toddlers can drown in a minimum amount of water. The child may look in the bucket and fall in head first. Because of mobility limitations, the child may not be able to get out of the bucket without help. 2. This is appropriate to reduce the risk of injury. 3. This allows the mother to adjust the temperature of the bath water and reduces the risk of burns. 4. This is the safest place for the child.

8) Which nursing action is accurate when applying a 5% permethrin lotion to a toddler with scabies? 1. Applying the lotion to the scalp, forehead, and everywhere below the chin 2. Applying the lotion only on the areas with evidence of activity 3. Applying the lotion only to the hands 4. Applying the lotion only to the scalp only

Answer: 1 Explanation: 1. Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down. The scabicide is also applied to the scalp and forehead of younger children, avoiding the rest of the face. 2. Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down, as well as the scalp and forehead. 3. Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down, including the scalp and forehead. 4. Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down, as well as the scalp and forehead. Page Ref: 1574

17) Which clinical manifestations should the nurse expect when conducting an assessment for a child who is diagnosed with autism spectrum disorder (ASD)? Select all that apply. 1. Arm flapping 2. Language delays 3. Ritualistic behavior 4. Impulsive behavior 5. Sleep disturbances

Answer: 1, 2, 3 Explanation: 1. Arm flapping is a clinical manifestation associated with ASD. 2. Language delay is a clinical manifestation associated with ASD. 3. Ritualistic behavior is a clinical manifestation associated with ASD. 4. Impulsive behavior is a clinical manifestation associated with attention deficit hyperactivity disorder, not ASD. 5. Sleep disturbance is a clinical manifestation associated with attention deficit hyperactivity disorder, not ASD.

22) Which injury prevention strategies should the nurse include in the plan of care for a pediatric client who is diagnosed with muscular dystrophy? 1. Develop a home fire evacuation plan. 2. Provide information regarding oxygen safety. 3. Recommend the use of portable generator. 4. Teach safe transfer methods. 5. Perform neurovascular checks every 2 hours.

Answer: 1, 2, 3, 4 Explanation: 1. Helping the family to develop a home fire evacuation plan is an injury prevention strategy the nurse should include in the plan of care. 2. Providing information regarding oxygen safety is an injury prevention strategy the nurse should include in the plan of care. 3. Recommending the use of a portable generator is an injury prevention strategy the nurse should include in the plan of care. 4. Teaching safe transfer methods is an injury prevention strategy the nurse should include in the plan of care. 5. Performing neurovascular checks is appropriate to include in the plan of care for a client who is receiving traction or casting, not for a client diagnosed with muscular dystrophy. Page Ref: 1542

23) The nurse is planning a teaching session for the parents of a child who is diagnosed with simple partial seizures. Which causes should the nurse include when teaching the parents? Select all that apply. 1. Lesions 2. Cysts 3. Tumor 4. Brain abscesses 5. Brain trauma

Answer: 1, 2, 3, 4 Explanation: 1. Lesions are a cause of simple partial seizures. 2. Cysts are a cause of simple partial seizures. 3. Tumors are a cause of simple partial seizures. 4. Brain abscesses are a cause of simple partial seizures. 5. Brain trauma a cause of complex partial seizures.

21) Which nursing diagnoses should the nurse include in the plan of care for a pediatric client diagnosed with hydrocephalus? Select all that apply. 1. Risk for Infection 2. Impaired Physical Mobility 3. Risk for Caregiver Role Strain 4. Risk for Injury 5. Risk for Constipation

Answer: 1, 2, 3, 4 Explanation: 1. This is an appropriate nursing diagnosis for a pediatric client diagnosed with hydrocephalus. 2. This is an appropriate nursing diagnosis for a pediatric client diagnosed with hydrocephalus. 3. This is an appropriate nursing diagnosis for a pediatric client diagnosed with hydrocephalus. 4. This is an appropriate nursing diagnosis for a pediatric client diagnosed with hydrocephalus. 5. Risk for constipation is not an appropriate nursing diagnosis for a pediatric client diagnosed with hydrocephalus.

19) Which nursing diagnoses should the nurse include in the plan of care for a pediatric client who experiences a traumatic brain injury (TBI)? Select all that apply. 1. Risk for Ineffective Tissue Perfusion: Cerebral 2. Risk for Aspiration 3. Risk for Imbalanced Fluid Volume 4. Compromised Family Coping 5. Chronic Pain

Answer: 1, 2, 3, 4 Explanation: 1. This is an appropriate nursing diagnosis for the nurse to include in the plan of care for the client. 2. This is an appropriate nursing diagnosis for the nurse to include in the plan of care for the client. 3. This is an appropriate nursing diagnosis for the nurse to include in the plan of care for the client. 4. This is an appropriate nursing diagnosis for the nurse to include in the plan of care for the client. 5. This nursing diagnosis is more appropriate for a client diagnosed with cerebral palsy, not a TBI. Page Ref: 1474

1) The nurse is assessing a 4-year-old child with a possible alteration in mental health. Which findings indicate a need for further investigation? Select all that apply. 1. Fails to make eye contact 2. Flinches when touched on the arm 3. History of limited prenatal care and precipitate delivery 4. Head circumference has not changed in over 1 year 5. Flat facial expressions

Answer: 1, 2, 3, 5 Explanation: 1. Making eye contact with the nurse and caregiver is part of the child's overall affect and social skills. A child who fails to make eye contact may have an alteration in mental health. 2. Flinching may indicate a desire to avoid contact; this can indicate a mental health issue and should be further evaluated. 3. History of prenatal care and delivery can help determine potential alterations in mental health in a child. 4. Head circumference is not measured in a 4-year-old. 5. Affect can be determined by facial expression and response to the nurse, helping to determine mental health. Page Ref: 1487

10) Which should the nurse include in the plan of care for a hospitalized school-age child with myelodysplasia? Select all that apply. 1. Implementing interventions for a client of normal intelligence 2. Using latex precautions when providing client care 3. Allowing the client to self-catheterize 4. Ensuring that the client has a low-fiber diet 5. Encouraging the client to shift positions hourly when in the wheelchair

Answer: 1, 2, 3, 5 Explanation: 1. Many children with myelodysplasia have normal intellect. They should be treated according to their intellectual level rather than their motor development. 2. Children with myelodysplasia are at great risk for latex allergy. It is important to use latex-free products. 3. Self-catheterization fosters independence in this child. It is important to maintain the same schedule as much as possible when this child is hospitalized. 4. Children with myelodysplasia need a high-fiber diet to maintain adequate stool and bowel function. 5. Due to decreased sensation in the buttocks and lower extremities, it is very important for the child to shift positions while in the wheelchair, to prevent pressure sores.

20) Which nursing diagnoses should the nurse include in the plan of care for a pediatric client diagnosed with cerebral palsy? Select all that apply. 1. Risk for Constipation 2. Impaired Tissue Integrity 3. Impaired Verbal Communication 4. Acute Pain 5. Risk for Delayed Development

Answer: 1, 2, 3, 5 Explanation: 1. This is an appropriate nursing diagnosis for a pediatric client diagnosed with cerebral palsy. 2. This is an appropriate nursing diagnosis for a pediatric client diagnosed with cerebral palsy. 3. This is an appropriate nursing diagnosis for a pediatric client diagnosed with cerebral palsy. 4. Chronic, not acute, pain is an acute nursing diagnosis for a pediatric client diagnosed with cerebral palsy. 5. This is an appropriate nursing diagnosis for a pediatric client diagnosed with cerebral palsy. Page Ref: 1468

19) Which interventions should the nurse include in the plan of care for a child who is diagnosed with an intellectual disability? Select all that apply. 1. Providing emotional support to the family 2. Maintaining a safe environment for the client 3. Educating the family that maintenance of activities of daily living (ADL) is impossible to achieve 4. Participating in the individualized education program (IEP) process 5. Recommending permanent institutionalization

Answer: 1, 2, 4 Explanation: 1. The nurse should include interventions in the plan of care for a child diagnosed with an intellectual disability that support the family. 2. The nurse should include interventions in the plan of care for a child diagnosed with an intellectual disability that maintain a safe environment. 3. Maintenance of ADL will be determined by the severity of the intellectual disability. 4. The nurse should participate in the IEP process for a child who is diagnosed with an intellectual disability. 5. Permanent institutionalization is no longer recommended for children diagnosed with an intellectual disability.

17) Which should the nurse include in the neurovascular assessment for an infant following casting of the leg for talipes equinovarus? 1. Warmth 2. Capillary refill 3. Pedal pulse 4. Sensation 5. Movement of the toes

Answer: 1, 2, 4, 5 Explanation: 1. The temperature of the foot of the casted leg should be compared to the temperature of the other foot. 2. This indicates blood return to the tissues and is an important finding. 3. The pedal pulse cannot be reached in the casted foot. 4. Nerve function is evaluated by touching the toes and noting the child's response. 5. The child is encouraged to wiggle the toes. If the client is an infant, tickling will cause the child to respond with movement.

20) Which are appropriate interventions for the nurse to include in the plan of care for a child who is receiving traction? Select all that apply. 1. Monitoring breath sounds 2. Assessing neurovascular status every 2 hours 3. Repositioning every 2 to 3 hours 4. Using moleskin to protect the skin from rough edges 5. Encouraging the parents cuddle with their child

Answer: 1, 2, 5 Explanation: 1. Children who are receiving traction are at risk for atelectasis and pneumonia; therefore, the nurse should monitor breath sounds frequently. 2. Child who are receiving traction are at risk for circulatory compromise; therefore, the nurse should perform neurovascular checks every 2 hours. 3. Repositioning every 2 to 3 hours is more appropriate for a child who is casted. 4. Using moleskin to protect the skin from rough edges is more appropriate for a child who is casted. 5. Children who are receiving traction should be allowed up to 1 hour per day without the traction device, at which time the child can eat and cuddle with parents. Page Ref: 1523

15) Which changes should the school nurse implement to decrease the risk for the development of type 2 diabetes mellitus for a population who is identified as being at risk? Select all that apply. 1. Increase the amount of daily physical activity. 2. Meet with all parents and explain the risk that is associated with obesity. 3. Test each child's urine monthly. 4. Teach the parents to avoid administering aspirin to their children. 5. Work with the cafeteria to decrease the amount of fat in the foods served.

Answer: 1, 2, 5 Explanation: 1. Increased physical activity will decrease a child's risk of developing type 2 diabetes. 2. Obese children have an increased risk of type 2 diabetes. Working with the parents, the nurse can reduce the obesity in the school. 3. Testing urine will not decrease the risk of developing type 2 diabetes, although it may lead to earlier diagnosis of the disease. 4. Aspirin administration is not related to type 2 diabetes. 5. A diet high in fat is associated with type 2 diabetes.

12) The nurse is teaching the caregiver of a child who is newly diagnosed with type 1 diabetes mellitus how to minimize pain with insulin injections. Which interventions should the nurse include in the teaching session? Select all that apply. 1. Do not reuse needles. 2. Remove all bubbles from the syringe before injecting. 3. Have the child flex the muscle during injection. 4. Inject insulin when it is cold. 5. Do not change the direction of the needle during insertion or withdrawal.

Answer: 1, 2, 5 Explanation: 1. Reusing needles leads to more pain on injection. 2. Removing bubbles from the syringe minimizes pain. 3. Flexing or tensing muscles during injection causes more discomfort. 4. Insulin should be injected when it is at room temperature to minimize pain. 5. Keeping the direction of the syringe constant will minimize pain.

9) The nurse is planning care for a school-age child diagnosed with separation anxiety disorder. Which aspects of cognitive-behavior therapy (CBT) should the nurse include in the teaching plan for the child's family? Select all that apply. 1. Self-talking 2. Relaxation 3. Hypnosis 4. Antidepressant medications 5. Recognition of feelings

Answer: 1, 2, 5 Explanation: 1. Self-talking helps a child to focus the inner thoughts on the desired behavior. 2. Teaching self-relaxation skills can help the child to reduce anxiety. 3. Hypnosis is not a component of cognitive-behavioral therapy. 4. Although medications may be a part of the treatment plan, it is not a component of cognitive-behavioral therapy. 5. Recognition and acceptance of feelings helps the child to move forward toward a desired behavior.

20) Which items noted in a pediatric client's medical record indicate the child may be experiencing a learning disability? Select all that apply. 1. Dyslexia 2. Dysphagia 3. Dyspraxia 4. Scoliosis 5. Hypotonia

Answer: 1, 3 Explanation: 1. Dyslexia is the medical term indicating problems with reading, writing, and spelling. This indicates the child may be experiencing a learning disability. 2. Dysphagia is a medical term indicating problems with swallowing. This would not indicate the child is experiencing a learning disability. 3. Dyspraxia is the medical term indicating problems with manual dexterity and coordination. This indicates the child may be experiencing a learning disability. 4. Scoliosis is curvature of the spine. This does not indicate the child may be experiencing a learning disability; however, this is often associated with Down syndrome. 5. Hypotonia is decreased muscle tone. This does not indicate the child may be experiencing a learning disability; however, this is often associated with Fragile X syndrome.

23) Which functions of the adrenal androgens should the nurse include in a teaching session for a pediatric client diagnosed with alterations in adrenal function? Select all that apply. 1. Stimulates bone development 2. Increases sodium ion reabsorption 3. Stimulates secondary sexual characteristics 4. Increases potassium excretion by the kidneys 5. Activates the sympathetic nervous system

Answer: 1, 3 Explanation: 1. This is a function of androgens. 2. This is a function of aldosterone, not androgens. 3. This is a function of androgens. 4. This is a function of aldosterone, not androgens. 5. This is a function of epinephrine, not aldosterone.

21) Which are appropriate interventions for the nurse to include in the plan of care for a child who is casted? Select all that apply. 1. Monitoring breath sounds 2. Assessing neurovascular status every 4 hours 3. Repositioning every 2 to 3 hours 4. Using moleskin to protect the skin from rough edges 5. Encouraging the parents cuddle with their child

Answer: 1, 3, 4, 5 Explanation: 1. Children who are casted are at risk for atelectasis and pneumonia; therefore, the nurse should monitor breath sounds frequently. 2. Child who are casted are at risk for circulatory compromise; therefore, the nurse should perform neurovascular checks every 2, not 4, hours. 3. Repositioning every 2 to 3 hours is appropriate for a child who is casted. 4. Using moleskin to protect the skin from rough edges is appropriate for a child who is casted. 5. Children who are casted should be allowed to cuddle with parents to promote developmentally appropriate care.

2) The nurse is providing information to an adolescent newly diagnosed with diabetes. Which clinical manifestations of diabetic ketoacidosis (DKA) should the nurse include in the teaching session? Select all that apply. 1. Change in mental status 2. Tachycardia 3. Fruity breath odor 4. Rapid, shallow respirations 5. Abdominal pain

Answer: 1, 3, 5 Explanation: 1. A change in mental state can be associated with DKA. 2. Tachycardia is not a typical symptom of DKA. 3. A fruity breath odor is common when the client is in a state of ketoacidosis. 4. Respirations are rapid, but deep (Kussmaul breathing) in DKA. 5. Abdominal pain is commonly seen with DKA.

17) Which preventative strategies should the nurse include in a teaching session for a mother whose infant is at risk for febrile seizures? Select all that apply. 1. Increasing oral intake of fluids 2. Administering dose-appropriate aspirin 3. Providing a sponge bath with cold water 4. Decreasing oral fluid intake 5. Patting the child dry after a tepid bath

Answer: 1, 5 Explanation: 1. Fluid intake will help heat loss. 2. Aspirin should be avoided due to the risk for Reye syndrome. 3. Cold water may cause shivering, which will increase the body temperature. 4. Decreasing fluid intake would increase the retention of heat. 5. A tepid bath will bring down the temperature; patting, instead of rubbing, will help keep the child's temperature down. Page Ref: 1444

5) The nurse is teaching a mother of a young child with a newly diagnosed seizure disorder. The child is prescribed valproic acid (Depakote) for control of seizures. Which parental statement indicates the need for further education? 1. "I will not use carbonated beverages to dilute his medication." 2. "I will give his medicine on an empty stomach so he will absorb it better." 3. "I will not let him chew his tablet." 4. "I will bring him to the physician's office for regular blood work to check bleeding times."

Answer: 2 Explanation: 1. Carbonated beverages should never be used to dilute valproic acid. 2. Valproic acid (Depakote) should be given with foods to decrease gastrointestinal irritation. 3. This child should not be allowed to chew a valproic acid tablet. 4. It is appropriate to have periodic blood studies to check bleeding times and platelet count.

17) The nurse is providing care to a newborn who is suspected of having Turner syndrome. Which should the nurse assess the newborn for based on the current diagnosis? 1. Club foot (talipes equinovarus) 2. Congenital heart anomalies 3. Hyperbilirubinemia due to liver abnormalities 4. Diaphragmatic hernia

Answer: 2 Explanation: 1. Club foot is not associated with Turner syndrome. 2. Congenital heart anomalies, including coarctation of the aorta, frequently are associated with Turner syndrome. 3. The newborn with Turner syndrome has the normal risk for hyperbilirubinemia. 4. Diaphragmatic hernias are not associated with Turner syndrome.

13) A pediatric client is admitted to the emergency department with a traumatic brain injury (TBI) that caused a loss of consciousness. The last set of vital signs showed heart rate 48, blood pressure (BP) 148/74 mmHg, respiratory rate 28 and irregular. Which does the nurse suspect based on these data? 1. Spinal cord injury 2. Increased intracranial pressure. 3. Typical for sleep 4. Improvement

Answer: 2 Explanation: 1. If the child suffered a spinal cord injury, and neurogenic shock were suspected, the child would be hypotensive. 2. These vital signs show increased BP, with a wide pulse pressure, slow heart rate, and respirations that are irregular, all indicating possible significant increased intracranial pressure. 3. Normal sleeping pulse at this age is 60 to 90 bpm. 4. Without previous vital signs, there is no way to determine if the current changes in the vital signs indicate improvement.

14) Which sequela should the nurse include in the teaching session for a parent who does not believe in medication for the treatment of the newborn's hypothyroidism? 1. Heart disease 2. Mental retardation 3. Renal failure 4. Thyroid storm

Answer: 2 Explanation: 1. If the hypothyroidism is left untreated, the child will experience bradycardia but will not develop heart disease. 2. Untreated hypothyroidism will lead to mental retardation. 3. Untreated hypothyroidism does not lead to renal failure. 4. Thyroid storm is a complication of hyperthyroidism, not hypothyroidism.

9) Which should the nurse include in a teaching session for the parents of an infant who will be placed in a Pavlik harness for the treatment of congenital developmental dysplasia? 1. Apply lotion or powder to minimize skin irritation. 2. Check at least 2 or 3 times a day for red areas under the straps. 3. Put clothing over the harness for maximum effectiveness of the device. 4. Place a diaper over the harness, preferably using a thin, superabsorbent, disposable diaper.

Answer: 2 Explanation: 1. Lotion or powder can contribute to skin breakdown and should not be used. 2. The skin underneath the straps of the brace should be checked 2 or 3 times a day for red areas, which might indicate skin breakdown. 3. A light layer of clothing should be worn under the brace to assist in preventing skin breakdown, not over the brace. 4. The diaper should be placed under the brace, along with a light layer of clothing.

16) Which assessment data obtained by the nurse during the health history portion of the assessment process support the current diagnosis of Duchenne muscular dystrophy (MD) for an 18-month-old child? 1. Infant was postmature by almost 2 weeks. 2. The child seems very muscular. 3. The child walked early and without support at 10 months. 4. The child's older sister developed scoliosis in the fourth grade.

Answer: 2 Explanation: 1. Postmaturity is not related to Duchenne MD. 2. Duchenne MD is also called pseudohypertrophic due to the enlarged appearance of the muscle. The pathophysiology is infiltration of the muscle fibers with fatty tissue. 3. This finding is not indicative of Duchenne MD. 4. The older sister's scoliosis is not related to MD. Duchenne MD is sex-linked recessive and affects only boys.

1) The home health nurse is visiting a 3-month-old infant who is diagnosed with congenital hypothyroidism and is prescribed daily levothyroxine. Which should the nurse include in the infant's continued plan of care? 1. Stopping the medication as long as the child continues to grow 2. Preventing hypothermia with appropriate clothing 3. Changing formula because it is contraindicated with prescribed medication 4. Monitoring growth and development without any other prescribed interventions

Answer: 2 Explanation: 1. The medication must be continued for life. 2. The parents should be cautioned to dress the child appropriately to prevent hypothermia. 3. The infant formula is not contraindicated with the prescribed medication. 4. The child will continue to need monitoring and intervention even if growth and development are not affected.

5) Which assessment finding would require an immediate nursing action when providing care to an adolescent who is postoperative for spinal fusion surgery? 1. Sleeps when not bothered but arouses easily with stimuli 2. Impaired color, sensitivity, and movement to lower extremities 3. Nausea relieved by antiemetics 4. Pain relieved by analgesics

Answer: 2 Explanation: 1. This is a normal response postanesthesia. 2. When the spinal column is manipulated, there is a risk for impaired color, sensitivity, and movement to lower extremities. 3. Nausea in the postoperative period is not uncommon, but it is not the priority at this time. 4. Pain is a common finding in the postoperative period and should be addressed, but impaired color, sensitivity, and movement of the lower extremities constitute the priority at this time.

20) The nurse is providing care to a newborn female who is born with ambiguous genitalia. The follow-up investigation discovers adrenogenital syndrome (also called congenital adrenal hyperplasia [CAH]). The parents question why the baby's genitalia looks more male than female. Which response by the nurse is accurate? 1. "The disorder caused your baby to be a hermaphrodite with both male and female sex organs." 2. "The changes in the genitalia are due to increased androgens secondary to deficient cortisol." 3. "The excessive cortisol caused the enlargement of the female tissue, creating a male appearance." 4. "Your baby has only one sex chromosome resulting in an XO configuration.

Answer: 2 Explanation: 1. This statement is incorrect. The child's internal organs will be ovaries only. 2. Deficient cortisol causes the amount of adrenocorticotropic hormone (ACTH) to be high, overstimulating the adrenal production of androgens, which causes the pseudomasculinization. 3. The cortisol level is decreased, not increased. 4. XO sex chromosomes describe Turner syndrome, not CAH.

7) Which teaching topic is the priority for the nurse who is teaching the family of an infant diagnosed with osteogenesis imperfecta? 1. Cast care 2. Trunk and extremity support during everyday care 3. Postoperative spinal surgery care 4. Traction care

Answer: 2 Explanation: 1. Traction, casts, and spinal surgery are not routinely done for osteogenesis imperfecta. 2. With osteogenesis imperfecta, nursing care focuses on preventing fractures. Because the bones are fragile, the entire body must be supported when the child is moved. 3. Traction, casts, and spinal surgery are not routinely done for osteogenesis imperfecta. 4. Traction, casts, and spinal surgery are not routinely done for osteogenesis imperfecta.

8) An infant returns to the unit following surgical correction of bilateral congenital clubfeet. The infant has bilateral long-leg casts. The nurse notes that the toes on both feet are edematous, but there is color, sensitivity, and movement to them. Which action by the nurse is the priority? 1. Apply a warm, moist pack to the feet. 2. Elevate the legs on pillows. 3. Encourage movement of the toes. 4. Call the surgical provider to report the edema.

Answer: 2 Explanation: 1. Warm, moist heat will increase swelling and the moisture may cause the cast to disintegrate. 2. The infant's legs should be elevated on a pillow for 24 hours to promote healing and help with venous return. This is the priority action. 3. An infant would not be able to follow directions to move the toes, and in this case it would not be as effective as would elevating the legs on pillows. 4. Some amount of swelling can be expected, so it would not be appropriate to notify the physician, especially if the color, sensitivity, and movement to the toes remained normal.

3) The 10-year-old child is admitted to the hospital following an accident at school that resulted in a puncture wound of the abdomen. Two days after the injury, the child continues in the inflammation phase of healing. What would the nurse expect to see while changing the child's dressing and assessing the wound? 1. The wound is contracting, and the edges are growing together. 2. A blood clot has formed, sealing the wound. 3. Epithelial cells are growing into the wound. 4. The wound is pale and weepy.

Answer: 2 Explanation: 1. Wound contraction and inward movement of the wound edge occur during the reconstruction phase of wound healing. 2. Clot formation to seal the wound with fibrin and trapped cells and platelets occurs during the inflammation phase of wound healing, in the first 3 to 5 days. 3. Epithelial cells growing into the wound occurs in the reconstruction phase of wound healing. 4. During the initial phase of healing, there is increased blood flow, giving the area an "inflamed" appearance.

12) The father of a school-age child who requires hospital admission for intravenous antibiotics to treat osteomyelitis states, "I don't understand why normal antibiotics can't be used." Which should the nurse include in the response to the father? 1. The antibiotic of choice is not available in oral form. 2. Blood flow to bones is limited, and parenteral administration is necessary to get appropriate blood levels. 3. Because the child is older now, it is harder to get the child to cooperate with oral antibiotics. 4. Because 2 weeks of therapy is necessary, the intravenous route will produce fewer side effects.

Answer: 2 Explanation: 1. Most antibiotics are available in multiple forms. 2. This is accurate information. 3. The older child can understand the reason for antibiotics and cooperate. 4. Both oral and intravenous antibiotics may have side effects.

18) Which clinical manifestations should the nurse expect when assessing a pediatric client who is diagnosed with congenital hip dysplasia (CHD)? Select all that apply. 1. Limited adduction of the affected hip 2. Asymmetry of thigh fat folds 3. Telescoping of the thigh 4. Muscle weakness 5. Atrophy of the muscles

Answer: 2, 3 Explanation: 1. The nurse would anticipate limited abduction, not adduction, of the affected hip for a child diagnosed with CHD. 2. Asymmetry of the thigh fat folds is a clinical manifestation associated with CHD. 3. Telescoping of the thigh is a clinical manifestation associated with CHD. 4. Muscle weakness is not an expected clinical manifestation associated with CHD. 5. Atrophy of the muscles is not an expected clinical manifestation associated with CHD.

16) Which statements should the nurse include in the definition of mental health during a health maintenance fair for pediatric clients? Select all that apply. 1. Mental health is the change in thought that occurs during childhood. 2. Mental health is foundational to a sense of personal well-being. 3. Mental health does not impact physical health. 4. Mental health involves successful engagement in activities. 5. Mental health changes over time.

Answer: 2, 4 Explanation: 1. Cognition, not mental health, is the change in thought that occurs during childhood; therefore, the nurse should not include this information. 2. Mental health is foundational to a sense of personal well-being; therefore, the nurse should include this information in the presentation. 3. Mental health does impact physical health; therefore, the nurse should not include this information. 4. Mental health does involve successful engagement in activities; therefore, the nurse should include this information in the presentation. 5. Cognition, not mental health, changes over time; therefore, the nurse should not include this information.

22) Which functions of the adrenal hormone aldosterone should the nurse include in a teaching session for a pediatric client diagnosed with alterations in adrenal function? Select all that apply. 1. Stimulates bone development 2. Increases sodium ion reabsorption 3. Stimulates secondary sexual characteristics 4. Increases potassium excretion by the kidneys 5. Activates the sympathetic nervous system

Answer: 2, 4 Explanation: 1. This is a function of androgens, not aldosterone. 2. This is a function of aldosterone. 3. This is a function of androgens, not aldosterone. 4. This is a function of aldosterone. 5. This is a function of epinephrine, not aldosterone. Page Ref: 1399

2) Which clinical manifestations should the nurse monitor for when conducting a scoliosis screening for a school-age child? Select all that apply. 1. Lordosis 2. Prominent scapula 3. Pain 4. A one-sided rib hump 5. Uneven shoulders and hips

Answer: 2, 4, 5 Explanation: 1. Lordosis is not present with scoliosis. 2. The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula. 3. Pain generally is not present with scoliosis unless it is severe. 4. The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula. 5. The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula.

5) A child diagnosed with autism spectrum disorder (ASD) is admitted to the hospital with dehydration. Which should the nurse include in the plan of care for this child? 1. Discourage the parents from bringing favorite toys from home that might be lost. 2. Take the child on a tour of the pediatric unit. 3. Assign the child to a single-bed hospital room. 4. Take the child to the playroom for arts and crafts.

Answer: 3 Explanation: 1. Children with autism often carry a special toy. This should be kept with the child. 2. Taking a child with autism on a tour of the pediatric unit would be too much stimulation for this child. A quiet, controlled environment is best for a child with autism. 3. A single room is the best place for an autistic child if the child must be hospitalized. 4. Arts and crafts might be appropriate for an autistic child if they are done in the child's room. Going to the playroom would be too much stimulation for this child.

6) A school-age child is diagnosed with a learning disorder that is characterized by problems with manual dexterity and coordination. Which term should the nurse use when documenting this child's disorder in the medical record? 1. Dysgraphia 2. Dyscalculia 3. Dyspraxia 4. Dyslexia

Answer: 3 Explanation: 1. Children with dysgraphia have difficulty with writing, spelling, and composition. 2. Children with dyscalculia have problems with mathematics and computation problems. 3. Children with dyspraxia have problems with manual dexterity and coordination. 4. Children with dyslexia have difficulty with writing, reading, and spelling.

11) Which side effect should the nurse include in the parent teaching for a child who is prescribed a baclofen pump for cerebral palsy? 1. Diarrhea 2. Hypertonia 3. Hypotonia 4. Restlessness

Answer: 3 Explanation: 1. Continuous baclofen infusion does not cause diarrhea. 2. Hypertonia is not seen as a side effect of baclofen infusion. 3. Hypotonia is possible if the child is getting too much baclofen. 4. Restlessness is not seen with baclofen; rather, these children can be drowsy and sleepy. Page Ref: 1466

8) The nurse is caring for a 9-month-old infant who just returned from the postanesthesia care unit (PACU) after a shunt placement for hydrocephalus. Which healthcare provider prescription should the nurse question? 1. Vital signs and neurologic checks hourly 2. Small, frequent formula feedings 3. Elevate head of bed 4. Daily head circumference

Answer: 3 Explanation: 1. Frequent vital signs and neurologic checks are needed postoperatively. 2. Small, frequent feedings are appropriate to decrease the chance of vomiting. 3. The 9-month-old should be placed in a flat position so that cerebrospinal fluid drainage is not too rapid. 4. Daily head circumferences are needed to help evaluate shunt functioning.

7) The nurse is assessing a child with Down syndrome. Which illness should the nurse monitor for due to the increased risk for children with Down syndrome? 1. Rheumatic heart disease 2. Glomerulonephritis 3. Leukemia 4. Hepatitis

Answer: 3 Explanation: 1. Heart defects might be seen with Down syndrome, but not rheumatic heart disease, which is associated with group A beta-hemolytic streptococcus infection. 2. Glomerulonephritis is not seen in association with Down syndrome. 3. Children with Down syndrome have a significantly higher than average risk of developing leukemia. 4. Hepatitis is not associated with Down syndrome.

8) The nurse is caring for a child just admitted with diabetic ketoacidosis (DKA). Which healthcare provider prescription should the nurse question? 1. Neurologic checks hourly 2. Insert urinary catheter and measure output hourly 3. NPH insulin IV at 0.1 unit/kg per hour 4. Stat serum electrolytes

Answer: 3 Explanation: 1. Hourly neurologic checks are an appropriate order. 2. Urinary catheter and hourly outputs are appropriate. 3. NPH insulin is never administered IV. A short-acting insulin needs to be ordered. 4. Stat electrolytes are an appropriate order. Page Ref: 1423

5) Which clinical manifestations should the nurse anticipate when providing care to an adolescent client who presents with untreated Graves disease? 1. Hyperglycemia, ketonuria, and glucosuria 2. Weight gain, hirsutism, and muscle weakness 3. Tachycardia, fatigue, and heat intolerance 4. Dehydration, metabolic acidosis, and hypertension

Answer: 3 Explanation: 1. Hyperglycemia, ketonuria, and glucosuria are signs of diabetes. 2. Weight gain, hirsutism, and muscle weakness are seen in clients with Cushing disease. 3. Clinical manifestations of Graves disease are tachycardia, fatigue, and heat intolerance, seen with hyperthyroidism. 4. Dehydration, metabolic acidosis, and hypertension are signs of congenital adrenal hyperplasia.

1) Which finding, noted during the newborn admission assessment, would lead the nurse to suspect unilateral congenital hip dysplasia? 1. Lordosis 2. Trendelenburg sign 3. Asymmetry of the gluteal and thigh fat folds 4. Telescoping of the affected limb

Answer: 3 Explanation: 1. Lordosis does not occur with hip dysplasia. 2. Trendelenburg sign and telescoping of the affected limb are signs that present in an older child with congenital hip dysplasia. 3. A sign of congenital hip dysplasia in the infant would be asymmetry of the gluteal and thigh fat folds. 4. Trendelenburg sign and telescoping of the affected limb are signs that present in an older child with congenital hip dysplasia.

2) Which factor, noted by the nurse during the pediatric health history portion of the assessment process, would indicate the child is at risk for attention deficit/hyperactivity disorder (ADHD)? 1. Measles, mumps, and rubella vaccine 2. Advanced parental age 3. Prenatal exposure to smoke 4. Immune response

Answer: 3 Explanation: 1. Measles, mumps, and rubella vaccine has been thought to be associated with autism spectrum disorder, though a relationship has never been established through research. 2. Advanced parental age has been associated with autism spectrum disorders. 3. Research shows that a mother's use of cigarettes during pregnancy can increase the risk for ADHD. 4. Immune response can be associated with autism spectrum disorders.

14) Which nursing action assists in the diagnosis of mental health and cognitive disorders that occur during childhood? 1. Monitoring vital signs 2. Administering prescribed medications 3. Conducting a developmental assessment 4. Documenting an accurate history and physical

Answer: 3 Explanation: 1. Monitoring vital signs is not a nursing action that assists in the diagnosis of mental health and cognitive disorders in pediatric clients. 2. Administering prescribed medications is not a nursing action that assists in the diagnosis of mental health and cognitive disorders in pediatric clients. 3. Conducting a developmental assessment is a nursing action that assists in the diagnosis of mental health and cognitive disorders in pediatric clients. 4. Documenting an accurate history and physical is not a nursing action that assists in the diagnosis of mental health and cognitive disorders in pediatric clients

7) The nurse is giving discharge instructions to the parents of a child whose adrenal glands have been removed due to a tumor. Which parental statement indicates the need for further education? 1. "I will call the doctor if my child has restlessness and confusion." 2. "If my child has any gastric irritation, I will give him antacids." 3. "If my child has vomiting and diarrhea, I will hold his hydrocortisone." 4. "I will give my child his hydrocortisone in the morning."

Answer: 3 Explanation: 1. Restlessness and confusion can be signs of adrenal insufficiency, and the healthcare provider would need to know these symptoms. No further instruction is needed. 2. Hydrocortisone can cause gastric irritation, and antacids are given between meals. No further instruction is needed. 3. If the child is ill and cannot take hydrocortisone by mouth, the child would need to have an injection. Failure to give hydrocortisone could lead to severe illness and cardiovascular collapse. The mother needs additional instruction. 4. The child should have hydrocortisone in the morning, which mimics the normal diurnal pattern of cortisol secretion. No further instruction is needed.

4) Which is the priority nursing diagnosis for nurse to use when planning care for a school-age child who must wear a brace for correction of scoliosis? 1. Impaired Gas Exchange, Risk for 2. Altered Growth and Development, Risk for 3. Impaired Skin Integrity, Risk for 4. Impaired Mobility, Risk for

Answer: 3 Explanation: 1. Risk for impaired gas exchange is a late effect of scoliosis and would not be the priority. If the client is compliant with wearing the brace, the risk should be minimized. 2. The diagnosis of Altered Growth and Development would not be the priority and should be corrected by the wearing of the brace. 3. The skin should be monitored for breakdown in any area where the brace might rub against the skin; therefore, Risk for Impaired Skin Integrity is the priority nursing diagnosis. 4. The diagnosis of Impaired Mobility would not be the priority and should be corrected if the client is compliant with wearing the brace.

13) A school-age client presents to the pediatric clinic with a history of abdominal pain 3 to 4 mornings per week over the last 2 months. The mother states the child usually complains on school days and always seems to be better by afternoon. Which mental health disorder does the nurse suspect? 1. Separation anxiety 2. Depression 3. School phobia 4. Bipolar disorder

Answer: 3 Explanation: 1. Separation anxiety is most common in girls between the ages of 7 and 9 and may be accompanied by depression when separated. The child was able to successfully separate for a nonschool activity. 2. Depression is often manifested by sleep issues, avoidance of social interactions, and low energy. 3. The child is using somatic complaints to avoid attending school. 4. Bipolar disorder involves periods of hyperactivity alternating with periods of lethargy.

9) An adolescent presents in the emergency department (ED) with confusion. The healthcare provider suspects diabetic ketoacidosis (DKA). A stat serum glucose is done, and the result is 7l5 mg/dL. Which clinical manifestations does the nurse anticipate upon assessment for this client? 1. Tachycardia, dehydration, and abdominal pain 2. Sweating, photophobia, and tremors 3. Dry mucous membranes, blurred vision, and weakness 4. Dry skin, shallow rapid breathing, and dehydration

Answer: 3 Explanation: 1. Tachycardia is seen in hypoglycemia. 2. Sweating, photophobia, and tremors are indicative of hypoglycemia. 3. Dry mucous membranes, blurred vision, and weakness are seen with hyperglycemia. 4. Dry skin and dehydration are signs of hyperglycemia, but shallow breathing is a sign of hypoglycemia. Page Ref: 1422

15) The mother of a 22-month-old child states, "My child does not seem to be developing like my sister's daughter, who is the same age." Which screening test should the nurse plan to conduct based on the current data? 1. Magnetic resonance imaging (MRI) of the head 2. An electroencephalogram (EEG) 3. A Denver II 4. Chromosomal study

Answer: 3 Explanation: 1. The MRI is a diagnostic test, not a screening test, and it is not performed by the nurse. 2. An electroencephalogram evaluates brains wave activity of the brain. It does not evaluate the child's behavior. 3. The Denver Developmental Screening Test II is a tool used by the nurse that evaluates language and development. 4. A chromosomal test is not a screening test but a diagnostic test. It is not performed to determine developmental delay.

13) Which assessment finding for a toddler-age child in balanced Bryant traction for a fractured right femur would require immediate action by the nurse? 1. The child keeps trying to turn and lie on his belly. 2. The ropes are unequal in length. 3. The child's buttocks are resting on the bed. 4. The Ace bandage wrapping the legs is wrinkled.

Answer: 3 Explanation: 1. This child needs a jacket restraint to maintain appropriate positioning if someone cannot stay with him. It does not require notifying the surgeon. 2. In balanced traction, the ropes and pulleys determine the traction and the length of the rope is unimportant. 3. In order to provide adequate counter-traction, the buttocks should be slightly elevated off the bed. The surgeon should be notified. 4. This is not a significant finding.

3) Which data, noted by the nurse during the physical assessment, would indicate the need to refer an adolescent client for further treatment due to possible depression? Select all that apply. 1. Agoraphobia 2. Somatic complaints 3. Focus on violence 4. Poor self-care 5. Poor school performance

Answer: 3, 4, 5 Explanation: 1. Agoraphobia, which is a fear of being in places or situations from which escape might be difficult or embarrassing, is seen in children with a panic disorder, not with depression. 2. Somatic complaints are more commonly associated with depression in the younger school-age child. 3. Focus on violence can be associated with depression in the adolescent. 4. Poor self-care can be associated with depression in an adolescent. 5. Poor school performance is associated with depression in the adolescent with depression.

12) Which activities should the nurse include in the plan of care for a child diagnosed with attention deficit/hyperactivity disorder (ADHD) to improve behavior and learning? Select all that apply. 1. Asking the mother to seek a prescription for methylphenidate (Ritalin) for the child 2. Placing the child's desk at the back of the room to reduce distractions 3. Developing a consistent routine for the classroom 4. Limiting the decorations in the classroom 5. Determining areas where the child performs well and using these areas to promote self-esteem

Answer: 3, 4, 5 Explanation: 1. It is not the nurse's or teacher's place to suggest medications for this child. 2. The child's desk should be placed at the front of the room to promote attention. 3. Consistency is important for the child with ADD/ADHD and reduces impulsive behavior. 4. Decorations are distracting and should be limited. 5. This is appropriate and will help reduce "acting out" behaviors.

11) Which clinical data noted by the nurse during the shift assessment indicate the pediatric client may be experiencing compartment syndrome? Select all that apply. 1. Pink, warm extremity 2. Dorsalis pedis pulse present 3. Prolonged capillary refill time 4. Pain not relieved by pain medication 5. Paresthesia of the leg

Answer: 3, 4, 5 Explanation: 1. Pink, warm extremity is a normal finding post fracture reduction. 2. A present dorsalis pedis pulse would be a normal finding post fracture reduction. 3. A prolonged capillary refill time is a sign of compartment syndrome. 4. A prolonged capillary refill time with loss of paresthesia and pain not relieved by medication are signs of compartment syndrome. 5. Paresthesia is tingling and numbness of the affected extremity and is a sign of compartment syndrome.

25) Which assessment data for a pediatric client supports the diagnosis of familial or idiopathic central diabetes insipidus (DI)? Select all that apply. 1. Polyuria 2. Polydipsia 3. Nocturia 4. Enuresis 5. Constipation

Answer: 3, 4, 5 Explanation: 1. Polyuria is not a clinical manifestation associated with familial or idiopathic central DI. 2. Polydipsia is not a clinical manifestation associated with familial or idiopathic central DI. 3. Nocturia is a clinical manifestation associated with familial or idiopathic central DI. 4. Enuresis a clinical manifestation associated with familial or idiopathic central DI. 5. Constipation a clinical manifestation associated with familial or idiopathic central DI.

9) A neonate with a meningomyelocele is to have surgery in the morning. Which nursing action is appropriate for this neonate? 1. Applying a diaper to prevent contamination of sac 2. Positioning the newborn in a side-lying position 3. Encouraging the mother to hold the newborn because she will not be able to pick him up after surgery 4. Positioning the newborn in a prone position

Answer: 4 Explanation: 1. A diaper is not used because it also puts pressure on the sac. 2. A side-lying position would be contraindicated because it would place pressure on the sac. 3. The mother should not hold the baby because that would put too much pressure on the sac. 4. The newborn should be placed in a prone position to keep pressure off the sac.

3) Which parental statement would cause the nurse to include further education related to the care required for a child who is diagnosed with congenital clubfoot? 1. "We're getting a special car seat to accommodate the casts." 2. "We'll watch for any swelling of the feet while the casts are on." 3. "We'll keep the casts dry." 4. "We're happy this is the only cast our baby will need."

Answer: 4 Explanation: 1. Using a car seat is the law. Special car seats to accommodate the casts are available and should be utilized. 2. Parents should be watching for swelling while the casts are on. 3. Keeping the casts dry is important to prevent complications. 4. Serial casting is the treatment of choice for congenital clubfoot. The cast is changed every 1 to 2 weeks until the corrected foot position is achieved.

5) Which is the priority intervention when planning care for an infant who is diagnosed with eczema? 1. Applying antibiotics to lesions 2. Keeping the baby content 3. Maintaining adequate nutrition 4. Preventing infection of lesions

Answer: 4 Explanation: 1. Antibiotics are not routinely applied to the lesions, since the lesions are not related to infection. However, impaired skin barrier function and cutaneous immunity place the infant at greater risk for the development of skin infection. 2. Keeping the infant content is not as high a priority as is prevention of infection. An infant with eczema is at a greater risk for the development of skin infection. 3. Maintaining adequate nutrition is important, but it is not as high a priority. Due to impaired skin barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infection. 4. Nursing care should focus on preventing infection of lesions. Due to impaired skin barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infections by organisms.

3) A 4-year-old client with intractable seizures has been on a ketogenic diet for the last 6 months, with a decrease in seizure activity. This child is now admitted to the pediatric unit with left-sided pain. Which possible complication to this diet does the nurse suspect? 1. Appendicitis 2. Bowel obstruction 3. Urinary tract infection 4. Kidney stones

Answer: 4 Explanation: 1. Appendicitis does not occur as a result of the ketogenic diet. 2. The ketogenic diet does not cause a bowel obstruction. 3. Urinary tract infections are not a result of a ketogenic diet. 4. Kidney stones are seen in 5% of children on a ketogenic diet.

6) A young child admitted to the pediatric unit has fever, irritability, and vomiting with suspected bacterial meningitis. Which cerebrospinal fluid (CSF) result should the nurse anticipate based on these data? 1. Decreased protein count 2. Clear, straw-colored fluid 3. Positive for red blood cells (RBCs) 4. Decreased glucose level

Answer: 4 Explanation: 1. Bacterial meningitis causes CSF protein levels to be elevated due to swelling and obstruction of CSF flow. 2. In bacterial meningitis, the fluid is often cloudy with white blood cells (WBCs). 3. The nurse would expect WBCs to be elevated due to the infection. The RBCs may indicate a bloody tap. 4. Glucose levels are low in CSF when a child has bacterial meningitis.

10) Which action by the nurse is appropriate for a child who presents in the emergency department with an ankle injury? 1. Avoid compressing the area to allow tissue swelling as necessary. 2. Perform passive range-of-motion to the extremity. 3. Lower the extremity below the level of the heart. 4. Apply ice to the extremity.

Answer: 4 Explanation: 1. For the first 24 hours for a sprain, rest, ice, compression, and elevation (RICE) should be followed. Therefore, the nurse should apply a compression bandage to the extremity. 2. For the first 24 hours for a sprain, rest, ice, compression, and elevation (RICE) should be followed. Therefore, the nurse should rest the extremity rather than perform range-of-motion. 3. For the first 24 hours for a sprain, rest, ice, compression, and elevation (RICE) should be followed. Therefore, the nurse should elevate the extremity. 4. For the first 24 hours for a sprain, rest, ice, compression, and elevation (RICE) should be followed. Therefore, the nurse should apply ice to the extremity.

19) Which type of nutrition should the nurse include when planning care for a newborn who is diagnosed with galactosemia? 1. Goat's milk formula 2. Breast milk 3. Cow's milk-based formula 4. Lactose-free formula

Answer: 4 Explanation: 1. Goat's milk formula contains galactose and is excluded from the newborn's diet. 2. Breast milk contains galactose and is excluded from the newborn's diet. 3. Cow's milk-based formula contains galactose and is excluded from the newborn's diet. 4. A lactose-free formula is the type of nutrition the nurse should include in the teaching plan for this newborn.

2) Which finding noted by the school nurse while conducting pediculosis capitis (head lice) checks would indicate the need for treatment? 1. White, flaky particles throughout the entire scalp region 2. Lesions on the scalp that extend to the hairline or neck 3. Maculopapular lesions behind the ears 4. Silver/white sacs attached to the hair shafts in the occipital area

Answer: 4 Explanation: 1. Lice and nits must be distinguished from dandruff, which appears as white, flaky particles. 2. Lesions might be present from itching, but the positive sign of head lice is evidence of nits. 3. Lesions might be present from itching, but the positive sign of head lice is evidence of nits. 4. Evidence of pediculosis capitis includes silver/white sacs (nits) that are attached to the hair shafts, frequently in the occiput area.

3) A child weighing 18.2 kg with a history of diabetes insipidus (DI) has been admitted to the hospital. Which healthcare provider prescription should the nurse question? 1. Stat electrolytes 2. Urine specific gravity with each void 3. DDAVP (desmopressin) PO 4. Restrict oral fluids to 500 mL every 24 hours

Answer: 4 Explanation: 1. Stat electrolytes would be an appropriate order to check for hypernatremia. 2. Urine specific gravity is checked because it is often low. 3. DDAVP is the drug of choice for a child with DI. 4. Fluid replacement, not fluid restriction, is necessary for child with DI.

4) A child with a history of seizures arrives in the emergency department (ED) in status epilepticus. Which is the priority nursing action? 1. Take vital signs. 2. Establish an intravenous line. 3. Perform rapid neurologic assessment. 4. Maintain patent airway.

Answer: 4 Explanation: 1. Taking vital signs is important, but airway always comes first. 2. Once the airway is secure, securing an IV is vital. 3. A rapid neurologic assessment is appropriate once the airway is secure. 4. Airway is always the priority of care.

15) A teacher states to the school nurse, "I have a student who will often just stare at me for 15 seconds after asking a question; then the student blinks and asks me to repeat the question. Should I be concerned?" Which should the nurse include in the response to the teacher? 1. The child has a crush on the teacher. 2. The child has increased intracranial pressure. 3. The child may have had a head injury. 4. The child is experiencing absence seizures.

Answer: 4 Explanation: 1. There are no data to suspect a childhood crush is creating the situation. 2. There is no indication of increased intracranial pressure. 3. There is no indication of a head injury. 4. Absence seizures may cause staring and blinking; they are more common in girls in this age group and often are first noticed by the classroom teacher.

8) Which children should the nurse identify as exhibiting a delay in meeting developmental milestones? Select all that apply. 1. An 18-month-old toddler who is unable to speak in sentences 2. A 2-year-old child who is unable to cut with scissors 3. A 2-year-old child who cannot recite her phone number 4. A 6-year-old child who is unable to sit still for a short story 5. A 5-year-old child who is unable to button his shirt

Answer: 4, 5 Explanation: 1. An 18-month-old toddler is not usually able to speak in sentences. This is a skill to be accomplished by the age of 2.5 years. 2. A child who cannot cut with scissors by kindergarten age is considered abnormal. 3. A 2-year-old child is not expected to be able to recite a phone number. 4. A 6-year-old child should be able to sit still for a short story. A 3- to 5-year-old child should be able to sit still through a short story. 5. A 5-year-old child should be able to button his shirt.

18) Which clinical manifestations should the nurse expect when conducting an assessment for a child who is diagnosed with attention deficit/ hyperactivity disorder (ADHD)? Select all that apply. 1. Arm flapping 2. Language delays 3. Ritualistic behavior 4. Impulsive behavior 5. Sleep disturbances

Answer: 4, 5 Explanation: 1. Arm flapping is a clinical manifestation associated with autism spectrum disorder, not ADHD. 2. Language delay is a clinical manifestation associated with autism spectrum disorder, not ADHD. 3. Ritualistic behavior is a clinical manifestation associated with autism spectrum disorder, not ADHD. 4. Impulsive behavior is a clinical manifestation associated with ADHD. 5. Sleep disturbance is a clinical manifestation associated with ADHD.

19) Which clinical manifestations should the nurse expect when assessing a pediatric client who is diagnosed with Legg-Calvé-Perthes disease? Select all that apply. 1. Limited abduction of the affected hip 2. Asymmetry of thigh fat folds 3. Telescoping of the thigh 4. Muscle weakness 5. Atrophy of the muscles

Answer: 4, 5 Explanation: 1. Limited abduction of the affected hip is a clinical manifestation associated with clinical hip dysplasia, not Legg-Calvé-Perthes disease. 2. Asymmetry of the thigh fat folds is a clinical manifestation associated with clinical hip dysplasia, not Legg-Calvé-Perthes disease. 3. Telescoping of the thigh is a clinical manifestation associated with clinical hip dysplasia, not Legg-Calvé-Perthes disease. 4. Muscle weakness is an expected clinical manifestation associated with Legg-Calvé-Perthes disease. 5. Atrophy of the muscles is not an expected clinical manifestation associated with Legg-Calvé-Perthes disease.

18) Which prescription regarding an oral hydrocortisone for a toddler-age client diagnosed with congenital adrenal insufficiency should the nurse anticipate when the client is admitted to the hospital with pneumonia? 1. It will be discontinued. 2. It will be reduced. 3. It will be continued as previously prescribed. 4. It will be increased.

Explanation: 1. Hydrocortisone is the glucocorticoid that helps the body deal with stress. It would be inappropriate to stop the medication. 2. The drug dosage would not be decreased. 3. During periods of stress, the child will need additional corticosteroids. 4. During periods of stress including illness and surgery, the dose of steroids needs to be increased. Page Ref: 1409