Peds Exam III

12) A school-age child diagnosed with congenital heart block codes in the emergency department. The parents witness this and stare at the resuscitation scene unfolding before them. Which is the best nursing intervention in this situation? 1. Asking the parents to help bag the child 2. Asking the parents to sit near the child's face and touch their child 3. Asking the parents to stand at the foot of the cart to watch 4. Asking the parents to leave the room

Answer: 2 Explanation: 1. Parents never should be asked to take part in emergency efforts unless absolutely necessary. 2. Parents should be helped to support their child through emergency procedures, if they are able. 3. Merely watching the resuscitation serves no purpose for the child. 4. If the parents interfere with resuscitation efforts, or are unable to tolerate the situation, they can be asked to leave later.

19) A child is admitted to the emergency department (ED) for scald burns to the buttocks and thighs. According to the mother, she was preparing the child's bath and before she could test the water, the child fell in and was scalded. Which would cause the nurse to suspect abuse? 1. The burns are uneven, with some burns deeper than others. 2. The child's hands and feet are free of burns. 3. In addition to the main burn site, there are splash burns surrounding the area. 4. The mother was home alone with the child.

Answer: 2 Explanation: 1. This might occur in an accidental scald burn. 2. Someone who falls in hot water would immediately try to get out by using the hands and feet. 3. This would be a logical finding. 4. It is not unusual for a mother to be home alone with a child.

2) Which is a common fear, in addition to separation anxiety, for the hospitalized pediatric client between the ages of 6 and 18 months? 1. Disfigurement 2. Death 3. Stranger anxiety 4. Bodily injury

Answer: 3 Explanation: 1. Infants do not fear disfigurement. 2. Infants and toddlers do not fear death. 3. In addition to separation anxiety, infants between 6 and 18 months of age might display stranger anxiety when confronted with strangers such as healthcare providers. 4. Infants and toddlers do not fear bodily injury.

2) At which age will the nurse begin to calculate body mass index (BMI) as a part of the nursing assessment process? 1. 12 months 2. 18 months 3. 2 years 4. 4 years

Answer: 3 Explanation: 1. While the nurse will plot a child's growth at 12 months of age a BMI is not included in the physical assessment at this time. 2. While the nurse will plot the child's growth at 18 months of age, a BMI is not included in the physical assessment at this time. 3. BMI is first calculated at 2 years of age, and gives information about the relationship between the height and weight of the child. With this information, the nurse would be able to develop strategies that can reduce the incidence of obesity. 4. The nurse will not initiate BMI calculation for a 4 year old; this action should be implemented into the nursing assessment prior to 4 years of age.

4) The nurse is completing a physical examination of a 4-year-old girl. Which is the best position to place the child in to assess the genitalia? 1. Supine, with legs at a 50-degree angle 2. Right side-lying 3. In prone position, with knees drawn up under the body 4. Frog-legged position

Answer: 4 Explanation: 1. The child will not tolerate the legs at a 50-degree angle for long. 2. There is no reason for a side-lying position, and the child will not tolerate holding the top leg up for long. 3. Prone with knees drawn up will allow assessment of the anus, but it will not allow for visualization of the vaginal area. 4. Having the child lie supine, flexing her knees and pulling them up to a frog-legged position, allows for accurate assessment of the genitalia and is well tolerated by the majority of children.

2) The nurse is taking a health history from the family of a 3-year-old child. Which statement or question by the nurse would be most likely to establish rapport and elicit an accurate response from the family? 1. "Tell me about the concerns that brought you to the clinic today." 2. "Does any member of your family have a history of asthma, heart disease, or diabetes?" 3. "Hello, I would like to talk with you and get some information about you and your child." 4. "You will need to fill out these forms; make sure that the information is as complete as possible."

Answer: 1 Explanation: 1. Asking the parents to talk about their concerns is an open-ended question and one that is more likely to establish rapport and an understanding of the parents' perceptions. 2. Asking about a number of items at once might be confusing to the family. 3. Giving an introduction before asking the parents for information is likely to establish rapport, but giving an explanation of why the information would be needed will be even more effective at establishing rapport and also getting more accurate, pertinent information. 4. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified by the nurse directing the interview.

3) A mother of two children, an 8-year-old and a 10-year-old, tells you that her husband has recently been deployed to the Middle East. The mother is concerned about the children's constant interest in watching TV news coverage of activities in the Middle East. Which suggestion by the nurse to the mother is most appropriate? 1. "Spend time with your children, and take cues from them about how much they want to discuss." 2. "Allow the children to watch as much television as they want. This is how they are coping with their father's absence." 3. "The less that you discuss this, the quicker the children will adjust to their father's absence. Try to keep them busy and use distractions to keep their mind off of it." 4. "It will just take some time to adjust to their father's absence and then everything will return to normal."

Answer: 1 Explanation: 1. Children need to be able to discuss their feelings and concerns with an adult; otherwise, their emotional distress could increase. 2. Constant viewing of the TV coverage of the war might increase the children's anxiety and fear for their father's safety. 3. Children need to be able to discuss their feelings and concerns with an adult; otherwise, their emotional distress could increase. 4. The mother should be aware that even though the children might appear to have adjusted, there could be delayed reactions or regressions in behavior.

17) Prior to discharging the child from the hospital, what routine discharge instructions should the nurse discuss with the family? 1. Monitoring signs and symptoms specific to condition 2. Instruction on performing a medical examination on the child 3. No instructions are needed; the family is familiar with the child. 4. A list of all diagnostic tests obtained during the hospitalization and their results

Answer: 1 Explanation: 1. Families need support and education as they continue to be anxious or stressed over their child's hospitalization. Standard discharge plans for routine hospital discharge include monitoring signs and symptoms specific to the condition and care at home. 2. The family does not need to know how to complete a medical examination on the child. 3. The family knows the child but needs teaching regarding the signs and symptoms to watch for in case of recurrence or complications arise. 4. This information was shared with the family as the tests were performed and results received.

1) Which is the priority nursing action when performing a physical assessment on a toddler? 1. Leaving intrusive procedures such as eye and ear examinations until the end 2. Explaining each part of the examination to the child before performing it 3. Performing the assessment from head to toe 4. Asking the mother to tell the child not to be afraid

Answer: 1 Explanation: 1. Intrusive procedures such as examinations of the eyes, ears, throat, and genitals should be done last to decrease the anxiety of the child during the initial phases of the examination, which include heart and lungs. 2. A toddler is too young to understand the medical terminology. 3. Intrusive procedures such as examinations of the eyes, ears, throat, and genitals should be done last to decrease the anxiety of the child during the initial phases of the examination, which include heart and lungs. 4. Asking the mother to tell the child not to be afraid is an inappropriate response.

2) The emergency department (ED) nurse is talking with a preschooler about the death of the child's parents in a motor vehicle crash. Which should the nurse take into consideration when formulating the client's plan of care? 1. Preschool-age children often believe that death is their fault. 2. Preschool-age children believe death is permanent. 3. Preschool-age children engage in reality-based thinking. 4. Preschool-age children may believe the parents will not come back home.

Answer: 1 Explanation: 1. Preschoolers engage in magical thinking, and might believe they wished or caused the death of their parents. 2. Preschoolers do not have a concept of death as permanent; therefore, they might expect their parents to return home. 3. Preschoolers engage in magical thinking, and might believe they wished or caused the death of their parents. 4. Preschoolers do not have a concept of death as permanent; therefore, they might expect their parents to return home.

5) A school nurse is performing annual height and weight screening. The nurse notes that three adolescent girls who are close friends each lost 15 pounds over the past year. Which is the priority nursing action? 1. Obtaining a nutritional history for each of these adolescents 2. Referring these adolescents to the school psychologist 3. Calling the respective parents to discuss the eating patterns of each adolescent 4. Speaking with the adolescents in a group to discuss the problems associated with anorexia nervosa

Answer: 1 Explanation: 1. The school nurse must evaluate why these three friends have all lost 15 pounds in 1 year. The best way to begin this assessment is to obtain a nutritional history for each client. 2. Referring the adolescents to a school psychologist without performing a complete nursing assessment is not appropriate. 3. Speaking with the parents would not be appropriate at this time. 4. Discussing anorexia nervosa at this point is too extreme.

14) While assessing a 10-month-old infant, the nurse notices that the sclerae have a yellowish tint. Which organ system would require more in-depth assessment based on this finding? 1. Hepatic 2. Cardiac 3. Genitourinary 4. Respiratory

Answer: 1 Explanation: 1. This infant's sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver or hepatic system. 2. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system. 3. Tenting of the skin and dry mucous membranes could be signs of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system. 4. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system.

1) The nurse develops and implements a health promotion plan for an adolescent client. What should the nurse include in the evaluation of the plan? 1. Methods to expand and sustain successful approaches 2. Instruction to the client on what is considered healthy behavior 3. Advice for promoting health behaviors that will maintain a healthy lifestyle 4. Information on the client's attitude toward health

Answer: 1 Explanation: 1. When establishing youth programs, whether with individual adolescents or with groups, the nurse includes methods to expand and sustain successful approaches. 2. Instruction on healthy behaviors would be included in the implementation phase of the plan. 3. Advising why promoting healthy behaviors is important is part of the implementation phase of the plan. 4. Including the adolescent's attitude toward health has little to do with evaluating the success of the plan.

18) Which nursing actions are developmentally appropriate when caring for a hospitalized school-age child? Select all that apply. 1. Knocking on the school-age child's hospital room door prior to entering 2. Giving clear instructions about details of treatment 3. Providing brochures regarding sexuality 4. Offering medical equipment to play with prior to a procedure 5. Using toys for distraction during a painful procedure

Answer: 1, 2 Explanation: 1. It is developmentally appropriate for the nurse to knock on the school-age child's door prior to entering the hospital room to provide care. 2. It is developmentally appropriate for the nurse to give clear instructions to the school-age child regarding details of the treatment. 3. Information regarding sexuality is more appropriate for the adolescent versus the school-age child. 4. Offering medical equipment to play with prior to a procedure is more appropriate for the preschool, not the school-age, child. 5. Using toys for distraction during a painful procedure is more appropriate for the preschool, not the school-age, child.

19) The nurse is preparing for a health maintenance visit for a 9-month-old infant. Which teaching topics are appropriate for the nurse to include during the scheduled visit? Select all that apply. 1. Using iron-fortified formula 2. Encouraging self-feeding of finger foods 3. Increasing the number of daily milk feedings 4. Encouraging cups for all feedings 5. Introducing burping techniques

Answer: 1, 2 Explanation: 1. The nurse should teach the parents the importance of continuing to use an iron-fortified formula until the infant reaches 12 months of age. 2. The nurse should encourage the parents to allow for self-feeding opportunities with finger foods. 3. The number of daily milk feedings should be decreased, not increased, at this stage of development. 4. While the cup should be introduced by 9 months of age, it is not appropriate for the nurse to encourage the use of a cup for all feedings until 12 months of age. 5. While it may be appropriate for the nurse to reinforce burping techniques through the first year of life, the nurse would not introduce this teaching at 9 months of age.

20) The nurse is assessing a 6-month-old infant during a scheduled well-baby check-up. Which are expected findings for this infant? Select all that apply. 1. No head lag when pulled for sitting 2. Ability to turn from back to abdomen 3. Manipulates objects 4. Transfers objects from one hand to the other 5. A pincer grasp is noted.

Answer: 1, 2, 3 Explanation: 1. A 6-month-old infant should not have head lag when pulled for sitting. This is an expected finding. 2. A 6-month-old infant should be able to turn from back to abdomen. This is an expected finding. 3. A 6-month-old infant is able to manipulate objects. This is an expected finding. 4. The nurse would not anticipate that the 6-month-old infant would be able to transfer objects from one hand to the other. This is an unexpected finding. 5. The nurse would not anticipate that the 6-month-old infant would use a pincer grasp. This is an unexpected finding.

26) The nurse is assessing a child and suspects the child's mother is abusing an opiate. Which clinical manifestations exhibited by the child's mother lead the nurse to this conclusion? 1. Constricted pupils 2. Mood swings 3. Impaired memory 4. Tremors 5. Psychosis

Answer: 1, 2, 3 Explanation: 1. Constricted pupils are a clinical manifestation associated with opiate abuse. 2. Mood swings are a clinical manifestation associated with opiate abuse. 3. Impaired memory is a clinical manifestation associated with opiate abuse. 4. Tremors are a clinical manifestation associated with alcohol, not opiate, abuse. 5. Psychosis is a clinical manifestation associated with hallucinogen, not opiate, abuse.

15) Which screenings are appropriate for an adolescent client who admits to being sexually active during a scheduled health maintenance visit? Select all that apply. 1. Herpes simplex virus 2. Gonorrhea 3. Chlamydia 4. Impetigo 5. Mononucleosis

Answer: 1, 2, 3 Explanation: 1. Herpes simplex 1 and 2 can be sexually transmitted and should be included in the screening. 2. Some individuals with gonorrhea may display no symptoms. Because it is a sexually transmitted infection, screening for it would be appropriate. 3. Chlamydia is the most common sexually transmitted infection in the United States. Screening is appropriate. 4. Impetigo is a skin infection caused by staphylococcus or streptococcus; it is not a sexually transmitted infection. 5. Although mononucleosis is sometimes called "the kissing disease," it is not considered a sexually transmitted infection. Sexual intercourse is not required for transmission.

22) Which clinical manifestations should the nurse anticipate when providing care to a pediatric client who huffing glue? Select all that apply. 1. Impaired coordination 2. Elevated liver enzymes 3. Delirium 4. Dementia 5. Giddiness

Answer: 1, 2, 3 Explanation: 1. Impaired coordination is a clinical manifestation that the nurse anticipates for a client who abuses volatile inhalants, such as glue. 2. Elevated liver enzymes are a clinical manifestation that the nurse anticipates for a client who abuses volatile inhalants, such as glue. 3. Delirium is a clinical manifestation that the nurse anticipates for a client who abuses volatile inhalants, such as glue. 4. Dementia is not a clinical manifestation that the nurse anticipates for a client who abuses volatile inhalants, such as glue. 5. Giddiness is not a clinical manifestation that the nurse anticipates for a client who abuses volatile inhalants, such as glue.

16) Which topics are appropriate for the nurse to include when teaching preventive disease strategies during infancy? Select all that apply. 1. Metabolic screenings 2. Hearing screenings 3. Risks of environmental smoke exposure 4. Stranger danger strategies

Answer: 1, 2, 3 Explanation: 1. It is appropriate for the nurse to include information regarding metabolic screening when teaching preventative disease strategies to the parents of an infant. 2. It is appropriate for the nurse to include information regarding hearing screening when teaching preventative disease strategies to the parents of an infant. 3. It is appropriate for the nurse to include information on the risks of environmental smoke exposure when teaching preventative disease strategies to the parents of an infant. 4. Stranger danger strategies are more appropriate for the parents of a preschool-age child. 5. Bike safety is more appropriate for the parents of preschool-age and school-age children.

15) Which nursing actions are appropriate for the 2-month-old infant during a scheduled health maintenance visit? Select all that apply. 1. Reviewing infant fluid needs with the parents 2. Reinforcing the importance of heating bottles with water versus the microwave 3. Demonstrating proper gum care to the parents 4. Educating the parents to begin introducing solid foods, such as rice cereal 5. Recommending that juice be introduced in a sippy cup

Answer: 1, 2, 3 Explanation: 1. It is appropriate for the nurse to review infant fluid needs with the parents during the 2-month health maintenance visit. 2. It is appropriate for the nurse to reinforce the importance of heating bottles with water versus the microwave with the parents during the 2-month health maintenance visit. 3. It is appropriate for the nurse to demonstrate proper gum care to the parents during the 2-month health maintenance visit. 4. The nurse would not educate the parents to begin introducing solid foods during the 2-month visit. Solid foods are not introduced until 6 months of age. 5. While juice should only be offered in a sippy cup, the nurse would not recommend this during the 2-month health maintenance visit. This subject is appropriate during the 6-month health maintenance visit.

17) Which assessment strategies are appropriate when assessing a family of Asian descent, who speak fluent English, during a scheduled health maintenance appointment for a toddler-age child? Select all that apply. 1. Using open-ended questions 2. Phrasing questions in a neutral manner 3. Avoiding prolonged eye contact 4. Asking all questions directly to the interpreter 5. Asking several questions for time management purposes

Answer: 1, 2, 3 Explanation: 1. Open-ended questions should be used during all health history interviews, if possible. It is especially important with families of Asian descent who tend to answer with "yes" or anticipate the answer the nurse wants to hear. 2. The nurse phrases questions in a neutral manner in order to decrease the risk of the family anticipating the answer that the nurse wants to hear, which often occurs with families of Asian descent. 3. Direct or prolonged eye contact is often seen as a sign of disrespect when assessing a family of Asian descent. 4. While the family is of Asian descent, the family speaks fluent English; therefore, there is no need for an interpreter unless the family requests this service. If an interpreter is used, the nurse would direct the questions to the family, not the interpreter. 5. The nurse will ask questions one at a time and avoid asking several questions at once.

14) Which strategies would be helpful for nurses who work with terminally ill children to avoid burnout? Select all that apply. 1. Participating in a mentoring relationship with experienced hospice nurses 2. Participating in support groups with mental health professionals 3. Participating in team decisions regarding the dying child's plan of care 4. Declining the family's invitation to attend the child's funeral 5. Planning the child and family's care alone as the primary nurse

Answer: 1, 2, 3 Explanation: 1. Team decisions, mentorship, and support groups all alleviate the responsibility of providing nursing care and coping with the death of a child alone. 2. Team decisions, mentorship, and support groups all alleviate the responsibility of providing nursing care and coping with the death of a child alone. 3. Team decisions, mentorship, and support groups all alleviate the responsibility of providing nursing care and coping with the death of a child alone. 4. Distancing oneself from the family can result in unresolved grief. 5. Planning the child's care alone might result in an excessive burden of guilt.

17) Which assessment questions are appropriate when the nurse is assessing the mental health of a preschool-age client? Select all that apply. 1. "Is your child experiencing nightmares?" 2. "Does your child ask questions about the genitalia?" 3. "How do you implement punishment for your child when a rule is broken?" 4. "Is your child up-to-date on recommended immunizations?" 5. "Does your child wear safety equipment when riding a bicycle?"

Answer: 1, 2, 3 Explanation: 1. The nurse inquires about nightmares when assessing the mental health of a preschool-age client. 2. The nurse inquires about sexual exploration when assessing the mental health of a preschool-age client. 3. The nurse inquires about implementing punishment for broken rules when assessing the mental health of the preschool-age client. 4. Assessing immunization status is not included in a mental health assessment for a preschool-age client. 5. Assessing the use of safety equipment is not included in a mental health assessment for a preschool-age client.

29) Which nursing actions are appropriate for teaching the family of a pediatric client requiring skilled care prior to discharge? 1. Teaching how to use home equipment 2. Educating on symptoms that indicate distress 3. Encouraging participation in a cardiopulmonary resuscitation course 4. Recommending that one parent take a leave of absence from work 5. Discouraging participation in case coordination activities

Answer: 1, 2, 3 Explanation: 1. The nurse will educate the family regarding equipment that will be used after discharge. It is essential that the family perform a successful return demonstration. 2. The nurse will teach the family symptoms that indicate the client is experiencing distress and include information on who to contact if these symptoms should occur. 3. The nurse will encourage the family to participate in a cardiopulmonary resuscitation course prior to discharge. 4. While it is appropriate for the nurse to educate the family on the Family Medical Leave Act (FMLA), it is not appropriate for the nurse to recommend that one parent take a leave of absence from work. 5. The nurse should encourage the family to participate in care coordination for their child if they indicate they would like to learn about this portion of the child's healthcare management.

assessment process for an infant? Select all that apply. 1. Asking the family how they are adjusting to having the infant in the home 2. Monitoring the parents for clinical manifestations associated with fatigue 3. Assessing for behaviors that indicate appropriate bonding 4. Placing the infant on the scale for a weight and length assessment 5. Auscultating heart and lung sounds while the infant is asleep

Answer: 1, 2, 3 Explanation: 1. When performing general observations during the assessment of an infant the nurse will ask the parents how they are adjusting to having an infant in the home. 2. When performing general observations during the assessment of an infant the nurse will monitor the parents for clinical manifestations associated with fatigue. 3. When performing general observations during the assessment of an infant the nurse will assess for behaviors that indicate appropriate bonding. 4. Placing the infant on the scale to measure height and weight is not an appropriate action when performing general observations during the assessment process. 5. Auscultating heart and lung sounds is not an appropriate action when performing general observations during the assessment process.

19) Which interventions will the nurse recommend for a toddler-age client who is biting other children at daycare? Select all that apply. 1. Using a time-out as a form of discipline for the child's behavior 2. Separating the child from the situation 3. Telling the child it is not okay to hurt another person 4. Inquiring whether the child is getting enough sleep 5. Implementing distraction to avert the behavior

Answer: 1, 2, 3, 4 Explanation: 1. A time-out is an appropriate intervention for the nurse to suggest when a toddler-age child is exhibiting behaviors that include other people, such as biting. 2. Separation of the child from the situation is an appropriate intervention for the nurse to suggest when a toddler-age child is exhibiting behaviors that include other people, such as biting. 3. It is appropriate to encourage the parents to tell the child that the behavior is unacceptable when the child is exhibiting behaviors that include other people, such as biting. 4. When a child is exhibiting behaviors that include other people, such as biting, it is appropriate to assess the amount of sleep the child is getting each night. Lack of sleep is a common cause for behaviors such as biting. 5. Distraction is appropriate for undesirable behaviors exhibited by the child; however this is not an appropriate when the child is exhibiting behaviors that include other people, such as biting.

28) Which are barriers to successful discharge planning that the nurse may need to plan for when providing care to a pediatric client who is approaching discharge? Select all that apply. 1. Financial concerns 2. Parental unavailability for teaching 3. Lack of equipment 4. Poor teamwork 5. Insurance payment for services

Answer: 1, 2, 3, 4 Explanation: 1. Financial concerns related to the cost associated with care that is needed after discharge is one barrier to successful discharge planning when providing care to the pediatric client who is approaching discharge. 2. Parents who are not available for discharge instruction is one barrier to successful discharge planning when providing care to the pediatric client who is approaching discharge. 3. Not having the equipment the family will use after discharge is one barrier to successful discharge planning when providing care to the pediatric client who is approaching discharge. 4. Poor teamwork is one barrier to successful discharge planning when providing care to the pediatric client who is approaching discharge. 5. Insurance payment for services is not a known barrier to successful discharge planning when providing care to the pediatric client who is approaching discharge.

18) Which nursing actions are appropriate when conducting a mental health assessment for a toddler-age child? Select all that apply. 1. Observing the child's interaction with family members 2. Asking the caregiver to describe the child's typical day 3. Giving the child a crayon to assess ability to use 4. Determining the number of hours the child sleeps each night 5. Inquiring about recent exposure to communicable diseases

Answer: 1, 2, 3, 4 Explanation: 1. When conducing a mental health assessment for a toddler-age child it is appropriate for the nurse to observe the child's interaction with family members. 2. When conducting a mental health assessment for a toddler-age child it is appropriate for the nurse to ask the caregiver to describe the child's typical day. 3. When conducting a mental health assessment for a toddler-age child it is appropriate to determine whether the child is mastering age-appropriate skills, such as the use of a crayon for a toddler-age child. 4. When conducting a mental health assessment for a toddler-age child it is appropriate to inquire about the number of hours of sleep the child gets each night. 5. The nurse assesses exposure to communicable diseases during a typical health maintenance visit; however, this action is not appropriate when assessing the toddler's mental health.

23) Which nursing interventions should the nurse implement for a school-age child who is the victim of physical abuse by a parent? Select all that apply. 1. Referring members of the family for appropriate counseling 2. Protecting the child from further injury 3. Allowing the child to wear clothing during the examination process 4. Discouraging parental participation in the plan of care 5. Documenting the child's response to parental interaction

Answer: 1, 2, 3, 5 Explanation: 1. It is appropriate for the nurse to refer members of the family for appropriate counseling. 2. It is appropriate for the nurse to protect the child from further injury. 3. It is appropriate for the nurse to allow the child to wear clothing during the examination process. 4. The nurse should encourage the parents to participate in the child's plan of care; however, the nurse should closely monitor interactions between the child and parent. 5. It is appropriate for the nurse to document the child's response to parental interaction.

19) The nurse is providing care to a child who is nearing death. Which nursing actions may offer the family support? 1. Using active listening techniques 2. Looking the parents in the eye when talking 3. Refusing to cry while in the child's room 4. Offering to call and notify family 5. Avoiding being in the room to allow the family to grief

Answer: 1, 2, 4 Explanation: 1. Active listening encourages the parents to talk if they feel the need. 2. This behavior indicates willingness to listen. 3. This is no longer considered inappropriate and allows the parents to know that the nurse feels sadness at the loss. 4. This would be appropriate and helpful to the parents. 5. The nurse should provide support to the parents. Often just sitting in the room quietly is an appropriate intervention.

16) Which will the nurse assess in the family of a 3-year-old child during a pediatric clinic visit scheduled due to regressive behavior? Select all that apply. 1. Change in parental marital status 2. Level of education for each parent 3. Health of child's siblings 4. Maternal depression 5. Child's exposure to communicable diseases

Answer: 1, 3, 4 Explanation: 1. Changes that occur with the family members of a 3-year-old child could be the source of the regressive behavior being exhibited. It is appropriate for the nurse to assess for a change in parental marital status. 2. The nurse would not need to assess the level of education for each parent for a 3-year-old child exhibiting regressive behavior. This information will already be compiled in the child's medical record. 3. A change in the health of the child's siblings could cause regressive behavior. This is appropriate for the nurse to include in the family assessment. 4. Maternal depression can be associated with poor self-concept and could be a reason for regressive behavior. This is appropriate for the nurse to include in the family assessment. 5. While it is appropriate for the nurse to assess the child's exposure to communicable disease, this is not included in the family assessment for regressive behavior.

19) Which statements are true in regard to the physical assessment the nurse conducts for an infant and a toddler? Select all that apply. 1. An infant client will have all clothing removed during the weight assessment. 2. A toddler client's assessment will include a length assessment instead of a height assessment. 3. An infant client will have a blood pressure assessment at each visit. 4. It is inappropriate to ask the toddler-age client if he or she can perform certain tasks. 5. It is appropriate to allow the toddler-age client to play with equipment prior to use.

Answer: 1, 4 Explanation: 1. An infant client will have all clothing removed during the weight assessment. 2. The toddler-age client will be assessed for weight and height. Length is used when assessing an infant client. 3. Infant clients do not routinely have their blood pressure assessed. This will become a part of the assessment process at the age of 3 years. 4. The nurse would not ask the toddler-age client if they can perform certain tasks, as the answer will typically be "no." 5. Toddlers should not be allowed to play with equipment during the assessment process. It is appropriate to demonstrate the use of the instruments on the parent when assessing a toddler-age client.

8) The school nurse is planning a smoking prevention program for middle school students. Which is most likely to be effective in preventing this population from smoking? 1. A demonstration of the pathophysiology of the effects of smoking tobacco on the body given by the school's biology teacher 2. A talk on the importance of not smoking given by a local high school basketball star 3. Colorful posters with catchy slogans displayed throughout the school 4. A pledge campaign during which students sign contracts saying that they will not use tobacco products

Answer: 2 Explanation: 1. A physical demonstration may help the children recognize the long-term effects of smoking, but information from adults is not likely to influence children of this age more than the pressure of their peers will. 2. While all of the strategies are good, the most effective would be to have a local high school basketball star come to talk to the students about the importance of not smoking because students at this age are more likely to listen to and attempt to emulate someone of their own peer group. 3. Information from posters is not likely to influence children of this age more than the pressure of their peers will. 4. Information from signed contracts is not likely to influence children of this age more than the pressure of their peers will.

2) A nurse is teaching an African American mother of a 3-month-old infant, born in the late fall, who is being exclusively breastfed. Which is the priority nutrient for the nurse to include in the teaching session? 1. Iron 2. Vitamin D 3. Calcium 4. Fluoride

Answer: 2 Explanation: 1. An infant's iron stores are usually adequate until about 4 to 6 months of age. 2. This infant will have limited exposure to sunlight due to decreased sun exposure in the fall and winter months. The limited sun exposure combined with the infant's dark skin means the infant may need additional vitamin D. 3. The infant should be receiving sufficient amounts of calcium from breast milk. 4. Fluoride supplementation, if needed, does not begin until the child is approximately 6 months old.

13) An adolescent experiencing status asthmaticus is rushed to the emergency department by ambulance. The parents arrive and ask to see their child. The triage nurse at the reception desk knows that the adolescent was pronounced dead on arrival. Which is the best action by the triage nurse at this time? 1. Ask the parents to please take a seat in the waiting room. 2. Immediately escort the parents to a quiet, private room. 3. Tell the parents that they must wait because only the healthcare provider can talk with them. 4. Immediately tell the parents, "I'm sorry, but your child didn't make it."

Answer: 2 Explanation: 1. Asking parents to wait is uncaring and insensitive. 2. The best nursing intervention is to give the parents an appropriate environment before they are told the news, so that they can begin grieving privately. 3. Nurses as well as other healthcare providers are capable of breaking bad news to families with caring and empathy. 4. Telling the parents the news in public is uncaring and insensitive.

5) A preschool-age boy presents to the outpatient clinic for a sore throat. In the child's mind, which is the most likely causative agent of the sore throat? 1. Being exposed to a classmate with strep throat 2. Yelling at sibling for being annoying 3. Not eating the right foods 4. Not taking daily vitamins

Answer: 2 Explanation: 1. At this age, the child does not yet understand that he can become sick from exposure to someone else who is sick. 2. Preschoolers understand some aspects of being sick, but not the cause of illness. They are likely to think that they are sick as a result of something that they have done. They frequently will view illness as punishment. 3. Not eating the right foods can be a factor in some illnesses, but this thinking is beyond the level of a 4-year-old boy. 4. While not taking his vitamins can be a factor in some illnesses, this thinking is beyond the capabilities of a 4-year-old boy.

20) The nurse is having difficulty coping with the impending death of a child. Who is the best resource for the nurse to consult during this difficult situation? 1. Other staff nurses 2. Hospice nurses 3. Unit nurse manager 4. Nurse's spouse

Answer: 2 Explanation: 1. Coworkers will also have a difficult time with the death. 2. Mentorship with experienced hospice nurses as well as additional educational experiences could help promote professional nursing care. 3. The unit manager also might have a difficult time with the impending death. 4. The spouse might not fully understand why this is affecting the nurse.

13) The home health nurse is conducting a home visit for a family. The toddler-age child, who is potty training, has an "accident." The mother becomes angry with the child and calls him a baby for messing himself. Which is the nurse concerned with regarding the toddler's development, based on the mother's reaction? 1. The child's cognitive development 2. The child's sense of independence 3. The child's conscience 4. The child's superego

Answer: 2 Explanation: 1. Erikson's theory is related to psychosocial development. The mother's criticism will not affect the child's ability to think. 2. Erikson's toddler stage is autonomy (independence) versus shame and doubt. The mother's criticism may hinder the child's sense of independence. 3. Conscience is what controls our knowledge of right and wrong and is a component of Kohlberg's theory. The mother's criticism will not affect the child's conscience, according to Kohlberg. 4. In Freudian theory, the superego is the moral and ethical system of the personality. The mother's criticism will not affect the child's superego.

14) Which action should the nurse include when providing education regarding methods to enhance health promotion during a scheduled health maintenance visit for a 4-year-old child? 1. Recognizing that food jags are common 2. Involving the child in snack selection and preparation 3. Encouraging the use of a highchair with a safety strap 4. Recommending the child consumes high-fat foods

Answer: 2 Explanation: 1. Food jags are not common for a 4-year-old child. This is more common for the 2-year-old child. 2. A 4-year-old child should be involved in snack selection and preparation. 3. The use of a highchair with a safety strap is not information that should be included for a 4-year-old child during a health maintenance visit. This is more appropriate for a toddler-age child. 4. Low-fat, not high-fat, foods should be encouraged during the health maintenance visit.

8) A child is being prepared for surgery. The parents request to be present during anesthesia induction. Which response by the nurse is most appropriate? 1. Telling the parents the names of all the medications that will be administered 2. Explaining what the parents will see and hear during induction 3. Telling the parents they will be upset to see the child under anesthesia 4. Ignoring the request and focusing on the child

Answer: 2 Explanation: 1. Parents do not need to know the names of the medications the child will receive. 2. The nurse explains visual and auditory experiences, such as a surgical gown, cap, shoe covers, and the parents' role during induction. The nurse offers the parents an opportunity to ask questions and voice concerns. 3. The nurse should tell the parents what to expect but not how they will feel while they watch their child. 4. The nurse should never ignore a request made by parents.

6) The nurse is working with first-time parents. Which activity will the nurse suggest to encourage the development of good muscle tone in their infant? 1. Placing the infant in an infant seat rather than lying down in a crib 2. Surrounding the infant with toys and other stimulating items to encourage motor movement 3. Swaddling the infant 4. Putting the infant to bed each night at 8 p.m., even if the infant protests with crying

Answer: 2 Explanation: 1. Placing the infant in an infant seat is more restrictive than lying in a crib, which allows free moment. 2. Encouraging movement best assists the infant to obtain good muscle tone. 3. Swaddling the infant, while calming for a young infant, restricts movement. 4. The bedtime has nothing to do with development of infant muscle tone.

9) The mother of a child admitted to the intensive care unit (ICU) appears very angry and tells the nurse no one is providing information about the child. Which response by the nurse is most appropriate? 1. Asking the mother to leave if the behavior continues 2. Apologizing for the mother's perception and assure the mother that the staff will keep her informed. 3. Offering to ask the healthcare provider to come and talk with her 4. Telling the mother her behavior will upset the child

Answer: 2 Explanation: 1. Telling the mother she will be asked to leave will only worsen the situation. 2. Nursing techniques include informing the family of potential problems that could occur. If the child's condition changes, make every effort to inform the family immediately. 3. The mother is already angry because of the lack of information sharing. The nurse should not "pass the buck" to the healthcare provider. 4. The mother is already angry, and informing her that her behavior will upset the child will only anger her more.

4) The pediatric group is providing care to a group of hospitalized clients. Which client is at the greatest risk for developing separation anxiety if the parents are unable to stay with the child at all times? 1. 6 month old 2. 18 month old 3. 4 year old 4. 6 year old

Answer: 2 Explanation: 1. The 6-month-old child does not experience separation anxiety, which usually begins at around 1 year of age. 2. The young toddler is at greatest risk. Toddlers are the group most at risk for a stressful experience when hospitalized. Separation from parents increases this risk greatly. 3. The 4-year-old child is past the age when separation anxiety would be most prevalent. 4. The 6-year-old child is attending school and is used to short periods of separation from parents.

11) Parents are in the pediatric clinic with their infant for a 1-month checkup. Which assessment question regarding immunizations should the nurse ask the infant's parents? 1. "Did your baby receive the influenza vaccine prior to hospital discharge?" 2. "Did your baby receive the hepatitis B vaccine prior to hospital discharge?" 3. "Did your baby receive the rubella vaccine prior to hospital discharge?" 4. "Did your baby receive the rotavirus vaccine prior to hospital discharge?"

Answer: 2 Explanation: 1. The influenza vaccine is not administered at birth. 2. Hepatitis B is given routinely at birth. 3. The rubella vaccine is not administered at birth. 4. The rotavirus vaccine is not administered at birth.

6) The following information is collected during the nursing assessment: the adolescent's menses began when she was 12 years old; a current body mass index (BMI) of 27.5; inconsistent school performance over the last several years. Which is the priority area of teaching for this adolescent? 1. Menstrual cycle 2. Nutritional intake 3. School performance 4. Mental health status

Answer: 2 Explanation: 1. The menstrual cycle appears to have started at a normal time, and so it is not the priority. 2. The BMI for this client is too high, placing the adolescent at risk for cardiovascular disease, hypertension, and diabetes mellitus in later life. Therefore, nutritional intake is the most important topic to focus on with this client at this time. 3. School performance is important; however, this is not the priority. 4. Mental health status is important; however, this is not the priority.

17) The mother of a dying 3-year-old child posts on Facebook: "Family and friends. Michael's heart is giving out. Looks like it will be tonight. He is surrounded by family and not in pain. I treasure every minute of being his mother. Pray for us." Which stage of grieving, according to Kubler-Ross, is the mother experiencing? 1. Denial 2. Acceptance 3. Bargaining 4. Depression

Answer: 2 Explanation: 1. The mother recognizes that death is near and is accepting of it. 2. The mother has come to terms with her loss. 3. The request for prayer is not an example of bargaining. In her acceptance of her child's impending death, she is including her religious beliefs as a support. 4. There is sadness in her message, but the overall message is one of acceptance.

11) A female client arrived by life flight to the hospital after experiencing multiple traumas in a .motor vehicle crash involving a suspected drunk driver. Which statement is most important for the nurse to make to the parents before they see their child? 1. "You should press charges against the drunk driver." 2. "Your child's condition is very critical; her face is swollen, and she might not look like herself." 3. "Your child's leg was crushed, and might have to be amputated." 4. "Don't worry, everything will be okay. We will take excellent care of your child."

Answer: 2 Explanation: 1. The nurse supports the family, but remains nonjudgmental about accident details. 2. The priority is to prepare the parents for the child's changed appearance. 3. The priority is to prepare the parents for the child's changed appearance. Truthful statements about the child's condition can be introduced after the parents have seen the child and grasped the situation. 4. The priority is to prepare the parents for the child's changed appearance. The nurse must not offer false reassurance or project future stressful events.

3) The parents of a child who is critically injured wish to stay in the room while the child is receiving emergency care. Which nursing action is most appropriate in this situation? 1. Asking the healthcare provider if the parents can stay with the child 2. Allowing the parents to stay with the child 3. Escorting the parents to the waiting room and assuring them that they can see their child soon 4. Telling the parents that they do not need to stay with the child

Answer: 2 Explanation: 1. The physician does not make the decision whether the parents stay with the child; the parents make the decision. 2. Parents should be allowed to stay with their child if they wish to do so. This position is supported by the Emergency Nurses Association and is a key aspect of family-centered care. 3. Parents should be allowed to stay with their child if they wish instead of going to the waiting room where they lack privacy. 4. The parents need to make the decision about staying with their child without input from the nurse.

10) An infant presents to the emergency department (ED) with physical injuries. The nurse is taking the child's history. Which parental statement would cause the nurse to be suspicious of abuse? 1. "I was walking up the steps and slipped on the ice and fell while carrying my baby." 2. "The baby's 18-month-old brother was trying to pull the baby out of the crib and dropped the baby on the floor." 3. "I placed the baby in the infant swing. His 6-year-old brother was running through the house and tripped over the swing, causing it to fall." 4. "I did not realize that my baby was able to roll over yet, and I was just gone a minute to check on dinner when the baby rolled off of the couch and onto our tile floor."

Answer: 2 Explanation: 1. This statement is plausible from a developmental perspective; therefore, the nurse would not be suspicious of abuse. 2. Developmentally, it would be very difficult for an 18-month-old child to pull an infant out of a crib. 3. This statement is plausible from a developmental prospective; therefore, the nurse would not be suspicious of abuse. 4. This statement is plausible from a developmental prospective; therefore, the nurse would not be suspicious of abuse.

4) During a scheduled health maintenance visit for a 6-month-old infant the nurse asks, "Does the baby sit without assistance, and is the baby crawling?" Which process is the nurse using in this interaction? 1. Health promotion 2. Developmental surveillance 3. Health maintenance 4. Disease surveillance

Answer: 2 Explanation: 1. While health promotion activities are related to developmental surveillance, this question is looking specifically at the milestones. 2. The question asked by the nurse is seeking information about developmental milestones; therefore, the nurse is involved in developmental surveillance. 3. While health maintenance activities are related to developmental surveillance, this question is looking specifically at the milestones. 4. These questions are not classified as disease surveillance questions.

19) Which nursing actions are developmentally appropriate when providing care to a hospitalized toddler-age child? Select all that apply. 1. Using a crib mobile for distraction during a procedure 2. Having a potty-chair available 3. Allowing self-feeding opportunities 4. Showing equipment that will be used during the scheduled surgery 5. Assessing drawings to determine concerns

Answer: 2, 3 Explanation: 1. A crib mobile would be more developmentally appropriate for the infant, not the toddler-age, child. 2. Many toddlers are potty training; therefore, it is appropriate for the nurse to have a potty-chair available for the child. 3. It is appropriate for the nurse to allow for self-feeding opportunities as this is developmentally appropriate for a toddler-age child. 4. Showing equipment that will be used during a scheduled surgery is not a developmentally appropriate intervention for a toddler-age child. This is more appropriate for the preschool-age child. 5. Assessing drawing to determine concerns is developmentally appropriate for the preschool, not the toddler-age, child.

21) The nurse notes dental issues during the assessment of an adolescent client. Which topics will the nurse explore further to determine the cause of the issues? Select all that apply. 1. Use of fluoridated water 2. Use of a mouth guard when playing physical sports 3. Anorexia nervosa 4. Bulimia nervosa 5. Use of daily vitamins

Answer: 2, 3, 4, 5 Explanation: 1. Fluoride is not needed in the adolescent once all teeth have emerged; this does not constitute a risk factor. 2. Sports injuries can be the cause of dental issues without proper safety equipment, such as a mouth guard. 3. Dental injuries can be related to eating disorders. 4. Repeated vomiting can destroy enamel due to contact with acidic stomach juices. 5. A lack of certain vitamins can cause dental issues.

19) Which teaching topics are appropriate for the nurse to include for an adolescent who admits to the use of chewing tobacco? Select all that apply. 1. Lung cancer 2. Nicotine addiction 3. Mouth cancers 4. Emphysema 5. Mouth ulcers

Answer: 2, 3, 5 Explanation: 1. Smokeless tobacco does not increase the risk of lung cancer. 2. Nicotine addiction occurs with chewing tobacco just as it does with smoking cigarettes. 3. Cancer of the mouth is associated with chewing tobacco. 4. Respiratory illnesses are not a common risk factor for smokeless tobacco. 5. Mouth ulcers occur in individuals who chew tobacco.

20) Which characteristics of abusers should the nurse include in the teaching session for elementary school teachers regarding child abuse? Select all that apply. 1. Physical illness 2. Alcoholism 3. Many friends and families nearby 4. Unrealistic expectations for their child 5. The abuser has no relationship to the child.

Answer: 2, 4 Explanation: 1. This is not a common finding in abusers. 2. Drug addiction and alcoholism are common findings in the abuser. 3. The child abuser is often socially isolated. 4. Abusive parents often feel the child is misbehaving for activities, such as soiling their diapers. 5. Most abusers are parents or people who have contact with the child on a regular basis.

8) The parents of a 2.5-year-old boy are concerned about their child's finicky eating habits. While counseling the parents, which statements by the nurse would be accurate? Select all that apply. 1. "Nutritious foods should be made available at all times of the day so that the child is able to 'graze' whenever he is hungry." 2. "The child is experiencing physiologic anorexia, which is normal for this age group." 3. "A general guideline for food quantity at a meal is one quarter cup of each food per year of age." 4. "It is more appropriate to assess a toddler's nutritional demands over a 1-week period rather than a 24-hour one." 5. "The toddler should drink 16 to 24 ounces of milk daily."

Answer: 2, 4, 5 Explanation: 1. Food should be offered only at meal and snack times. 2. Physiologic anorexia is caused when the extremely high metabolic demands of infancy slow to keep pace with the slower growth of toddlerhood, and it is a very normal finding at this age. 3. The correct general guideline for food quantity is 1 tablespoon of each food per year of age. 4. It is not unusual for toddlers to have food jags where they only want one or two food items for that day. So it is more helpful to look at what their intake has been over a week instead of a day. 5. Two to three cups of milk per day are sufficient for a toddler; more than that can decrease his desire for other foods and lead to dietary deficiencies. Children should sit at the table while eating to encourage socialization skills.

6) The parents of a 2-year-old girl inquire about information to help their child transition to bed each night. Which response by the nurse is appropriate? 1. Let the child cry self to sleep a few nights to adjust to the transition. 2. Play a favorite video at bedtime on a television in the child's room to enhance relaxation. 3. Read a book to the child just before bedtime each night. 4. Let the child fall asleep while playing and then put the child in bed.

Answer: 3 Explanation: 1. A child of this age will not just learn to fall asleep on her own if left alone. Letting the child cry for an extended period of time can affect attachment issues. 2. Having a television in a 2-year-old child's room is not a healthy practice. This can lead to decreased physical activity. 3. Developing a quiet routine just before bedtime can help calm the child and give an expectation to what will happen next: going to bed. 4. Letting the child fall asleep while playing is not healthy, as it allows the child to get to the point of exhaustion without any limits set.

5) The nurse is working with children in hospice care. The mother of a young child with cancer talks with the nurse about the future holiday celebrations she will miss with her child. Which is the mother experiencing based on these data? 1. Actual loss 2. Perceived loss 3. Anticipatory loss 4. Loss

Answer: 3 Explanation: 1. Actual loss is a real loss objectively confirmed by others. 2. A perceived loss is subjectively experienced by a person, but cannot be confirmed by others. 3. Anticipatory loss is experienced before the loss actually transpires. 4. Loss is a general term for something of value being changed, no longer available, or no longer able to be experienced by an individual.

9) An obese adolescent who adamantly denies sexual activity has a positive pregnancy test. Which response by the nurse is most appropriate? 1. "When was your last menstrual period (LMP)?" 2. "Tell me how you feel about your body image." 3. "Let's discuss some activities that you have done within the past few months that could possibly lead to pregnancy." 4. "Why are you denying sexual intercourse?"

Answer: 3 Explanation: 1. Asking about the LMP does not help connect the adolescent's past behavior to her pregnancy. 2. The adolescent's body image does not address the teen's current situation. 3. The nurse must help the adolescent realize that previous behaviors have led to a positive pregnancy test. The only response by the nurse that will accomplish this goal is to ask a direct question in which the nurse and client search for an answer. 4. This option is too confrontational and may alienate the adolescent.

7) Two 3-year-old clients are playing together in a hospital playroom. One is working on a puzzle, while the other is stacking blocks. Which type of play are these children participating in based on this scenario? 1. Cooperative play 2. Solitary play 3. Parallel play 4. Associative play

Answer: 3 Explanation: 1. Cooperative play is when children demonstrate the ability to cooperate with others and to play a part in order to contribute to a unified whole. The school-age child participates in cooperative play. 2. Solitary play is when a child plays alone. Infants' play style is described as solitary. 3. Parallel play is when two or more children play together, each engaging in his or her own activities. 4. Associative play is characterized by children interacting in groups and participating in similar activities. Preschoolers' play style is associative.

13) Which observation in a health supervision visit leads the nurse to have concerns about the infant's mental health? 1. A 1-month-old is swaddled by the parent because of crying after an immunization. 2. A 7-month-old infant grabs her mother and cries when the nurse attempts touch. 3. A 9-month-old avoids eye contact with parents and the nurse. 4. A 10-month-old reportedly sleeps about 12 hours total per night.

Answer: 3 Explanation: 1. Crying after a painful procedure, such as an immunization, is a normal reaction by the 1-month-old infant. Swaddling the infant for comfort is a normal reaction by the parent. 2. Grabbing for her mother and crying when the nurse attempts touch is a normal reaction for a 7-month-old infant. 3. The nurse should expect the 9-month-old to have eye contact with the parents and the nurse. If no eye contact is made, the nurse should implement a more detailed assessment of the infant's mental health. 4. Sleeping 12 total hours per night is considered normal behavior for a 10-month-old infant.

24) A nurse obtains a nutritional health history from a 10-year-old child. Which food increases the risk for dental caries necessitating education regarding oral hygiene? 1. Sorbet and yogurt 2. Fluoridated water 3. Gummy bears and licorice 4. Peanuts and crackers

Answer: 3 Explanation: 1. Foods such as peanut butter, crackers, sorbet, and yogurt do not stick to the teeth, and are not considered foods that increase dental caries. 2. Fluoridated water has been shown to decrease the incidence of dental caries. 3. Food items that stick to the teeth lead to dental caries. Items such as gummy bears and licorice stick to the teeth and lead to dental caries. 4. Foods such as peanut butter, crackers, sorbet, and yogurt do not stick to the teeth, and are not considered foods that increase dental caries.

4) Which action by the nurse is appropriate when teaching the parents of a 2-year-old child during a scheduled health maintenance visit? 1. Encouraging the parents to allow the child to pour liquids using a pitcher 2. Being sure that all major foods group have been introduced to the child 3. Teaching the parents that it is appropriate to switch from whole to 2% milk 4. Educating the child about food groups

Answer: 3 Explanation: 1. It is not appropriate to encourage the parents to allow the child to pour liquids using a pitcher until 3 years of age. 2. The nurse should ensure that all major foods groups have been introduced to the child at 1 year of age. 3. The nurse will teach the parents that it is appropriate to switch from whole to 2% milk during the 2-year-old's health maintenance visit. 4. The nurse would not educate the child about food groups until the age of 4 years.

1) Which adolescent behavior, reported by a parent, would cause the nurse to suspect possible substance abuse? 1. Becoming very involved with friends and in activities related to basketball 2. Becoming moody, crying, and weeping one minute and then cheerful and excited the next 3. Receiving numerous detentions for sleeping in class 4. Wearing baggy, oversized clothing and dyeing hair black

Answer: 3 Explanation: 1. Periodically distancing themselves from their parents and preferring involvement with their peers are normal adolescent behaviors. 2. Mood swings are normal adolescent behaviors. 3. Even though most teens do prefer staying up late, they are not usually so tired that they fall asleep during the day, especially while engaged in classroom activities. This behavior is abnormal and could indicate involvement with substance abuse or an underlying pathology. 4. Experimentation with different clothes and hair is a normal adolescent behavior.

16) The nurse is speaking with a preschool-age child whose sibling recently died. Which feelings should the nurse anticipate from the preschool-age child? 1. The child may feel that his or her bad behavior caused the sibling's death as a punishment. 2. The child may feel that the sibling died as a result of a fight. 3. The child may feel that having bad thoughts about the sibling caused the death. 4. The child may feel that the sibling died because the parents did not like that sibling.

Answer: 3 Explanation: 1. Preschool-age children do not have a fear of being bad and the sibling's subsequently being punished. 2. Fighting is normal, and preschool-age children do not have those thoughts. 3. Preschool-age children might fear that they caused their brother or sister to be injured or become ill, or they may worry that bad thoughts on their part brought on the illness. 4. Preschool-age children are more likely to believe that they somehow were the cause of their sibling's death, not their parents.

9) Which is the priority nursing action when working with a parent who is suspected of Munchausen syndrome by proxy? 1. Try to keep the parent separated from the child as much as possible. 2. Explain to the child that the parent is causing the illness and that the healthcare team will prevent the child from being harmed. 3. Carefully document parent-child interactions. 4. Confront the parent with concerns of possible abuse.

Answer: 3 Explanation: 1. Separating the parent from the child might alienate the parent and cause her to leave with the child. 2. Talking to the child about the healthcare team's suspicions could be confusing and frightening for the child. 3. Munchausen syndrome by proxy is very difficult to prove, and evidence provided by the careful documentation of the nursing staff can be very influential. Care must be taken not to make the parent suspicious and to keep the child in the hospital until enough evidence is collected. 4. Confronting the parent might alienate the parent and cause her to leave with the child.

16) A child is being discharged from the hospital requiring complex, long-term care with medication administration through a central line and maintenance of oxygen administration by nasal cannula. A home health nurse will be visiting each day. What should the nurse teach the family members prior to hospital discharge? 1. How to insert an IV line 2. Nothing, the family is familiar with the care 3. Instruction on oxygen administration 4. How to remove a central line

Answer: 3 Explanation: 1. Starting an IV line is not within the family's responsibilities for home care. 2. The nurse can never assume the family members are familiar with the care required, even if they have been participating during the hospital stay. 3. Prior to discharge, the parents will need to learn about oxygen administration. 4. Removing a central line is not within the realm of what family members need to do at home.

10) The nurse is caring for a child in the pediatric intensive care unit (PICU). The parents have expressed anger over the nursing care their child is receiving. Which nursing action is most appropriate? 1. Explaining to the parents that their anger is affecting their child, and they will not be allowed to visit the child until they calm down 2. Asking the healthcare provider to talk with the family 3. Acknowledging the parents' concerns and collaborating with them regarding the care of their child 4. Calling the hospital chaplain to sit with the family

Answer: 3 Explanation: 1. Telling the parents that they cannot visit their child will only increase their anger. 2. Calling the healthcare provider might be appropriate at some point, but the nurse must assume the role of supporter in this situation to promote a sense of trust. 3. Hospitalization of the child in a PICU is a great stressor for parents. If the parents feel that they are not informed or involved in the care of their child, they might become angry and upset. 4. Calling the chaplain could be appropriate at some point, but the nurse needs to collaborate with the parents about the care the child receives.

6) A school-age client is in the playroom when the respiratory therapist arrives to give a scheduled breathing treatment. Which is the most appropriate nursing action? 1. Escorting the child to his room and asking the child-life specialist to bring toys to the bedside 2. Rescheduling the treatment for a later time 3. Assisting the child back to his room for the treatment but reassuring him that he may return when the procedure is completed 4. Showing the respiratory therapist to the playroom so the treatment can be performed

Answer: 3 Explanation: 1. The child should be allowed to return to the playroom as soon as the procedure is completed; bringing toys to the bedside is unnecessary. 2. Scheduled respiratory treatments should be performed on time. 3. It is important for scheduled treatments to occur on time, so the child should go back to his room. He can return to the playroom as soon as the treatment is completed. 4. Procedures should not be performed in the playroom.

9) Which immunization will the nurse provide parental education during the health maintenance visit for a 4-year-old child? 1. Hepatitis B #3 2. Haemophilus influenzae type B #2 3. Inactive poliovirus #3 4. Measles, mumps, and rubella #1

Answer: 3 Explanation: 1. The third hepatitis B vaccine is administered between 6 and 18 months of age. 2. The second Haemophilus influenzae type B vaccine is administered 6 months after the first vaccine, which is scheduled at 12 months of age. 3. The third inactive poliovirus vaccine is often administered between 4 and 6 years of age. The nurse would provide parental education during the health maintenance visit. 4. The first measles, mumps, and rubella vaccine is administered between 12 and 15 months of age.

18) The nurse is leading a recovery group of parents who have lost a child. As the opening topic for the night's discussion, the nurse reviews information about the grief process to the parents and talks about how different people grieve. Which parental statement indicates the need for more education regarding the grieving process? 1. "I understand that everyone grieves differently." 2. "Looking back, I realize why I became so angry when the doctors didn't cure my daughter." 3. "It's been 6 months since my son died, so why isn't my wife ready to move on with our lives?" 4. "I'm glad you described some common grief reactions. I thought I was going crazy for a while."

Answer: 3 Explanation: 1. This statement is accurate. This father understands this concept correctly. 2. Anger is a part of the grief process. This father has been able to look at his own behavior and recognize it as normal. 3. There is no standard period of grief. It is individual. This father has not heard the nurse's discussion. 4. This father has applied the knowledge of grief behaviors to his own behavior. He understands the discussion.

15) The nurse is conducting a physical assessment for a preschool-age child. When plotting the child's body mass index (BMI) the nurse notes that the child's is at the 90th percentile. Which action by the nurse is appropriate? 1. Referring the child to a nutritionist 2. Conducting a developmental assessment 3. Assessing the child's level of activity 4. Checking a blood glucose level

Answer: 3 Explanation: 1. While the nurse will need to assess a detailed dietary intake for the child it is not appropriate to refer the child to a nutritionist at this time. 2. There is no reason for the nurse to conduct a developmental assessment based on the current assessment data. 3. A child with a BMI that is 85% or greater should have a detailed dietary intake assessment conducted along with assessing the child's level of activity. 4. The current assessment data do not support the need to check the child's blood glucose level.

15) As children grow and develop, their style of play changes. Place the descriptions of play styles in order from infancy to school age. 1. Plays beside but not with other children 2. Plays games with other children and is able to follow the rules of the game 3. Plays alone with play directed by others 4. Plays with others in loose groups

Answer: 3, 1, 4, 2 Explanation: 1. This describes parallel play, seen in toddlers. 2. This describes cooperative play, seen in the school-age child. 3. This describes infant-style play, called solitary play. 4. This describes associative play, which is seen in the preschooler.

21) The nurse provides education to the parents of a 7-month-old infant regarding play. Which parental responses indicate accurate understanding of the information presented? Select all that apply. 1. "I should offer my baby toys that are black and white." 2. "My baby will prefer stuffed animals during this stage of development." 3. "I should offer my baby a teething ring during this stage of development." 4. "My baby will want to interact with other people." 5. "I should offer my baby large blocks to stack while sitting on the floor."

Answer: 3, 4 Explanation: 1. Black and white toys are often preferred by infants from birth to 3 months, not at 7 months. The statement indicates the need for further education. 2. Stuffed animals are often enjoyed by infants between 3 months and 6 months, not at 7 months. The statement indicates the need for further education. 3. Many babies are teething by 7 months of age; therefore, it is appropriate to offer the infant a teething ring. This statement indicates accurate understanding of the information presented. 4. By 6 to 9 months of age, the infant will enjoy interacting with other people. This statement indicates appropriate understanding of the information presented. 5. Stacking blocks is not a skill acquired until 9 to 12 months of age. This statement indicates the need for further education.

4) The parents of a 12-month-old client ask the nurse for suggestions regarding age-appropriate toys for their child. Which toys are appropriate for the nurse to recommend for this client? Select all that apply. 1. Soft toys that can be mouthed 2. Toys with black-and-white patterns 3. Toys that can pop apart and go back together 4. Jack-in-the-box toys 5. Push-and-pull toys

Answer: 3, 4, 5 Explanation: 1. A 12-month-old client is more mobile and shows less interest in soft toys that can be placed in the mouth. 2. A 12-month-old client will tend to enjoy colorful toys, not toys with black-and-white patterns. 3. A 12-month-old client has gross and fine motor skills that are becoming more developed and enjoys toys that can help them refine these skills. 4. A 12-month-old client enjoys toys that can be manipulated and that grabs his or her attention. A jack-in-the-box toy allows both. 5. A 12-month-old client is learning to walk and will enjoy toys that promote mobility.

11) The nurse is conducting an admission assessment for a newborn client. Which physical findings suggest the newborn is preterm? Select all that apply. 1. The ear pinna quickly returns to original position after being bent manually. 2. The infant's resting position is tightly flexed. 3. Labia are widely separated with clitoris prominent. 4. Breast area is barely perceptible with flat areola, no bud. 5. Sole creases do not extend the length of the foot.

Answer: 3, 4, 5 Explanation: 1. This finding is associated with fetal maturity. 2. This finding is associated with fetal maturity. A preterm baby will rest with arms and legs extended. 3. The labia cover the perineal area, including the clitoris for a term newborn. 4. This is an indication of immaturity associated with the prematurity. 5. This is an indication of prematurity.

12) The nurse is conducting a health history for the family of a 3-year-old child. Which statements or questions by the nurse would establish rapport and elicit an accurate response from the family? Select all that apply. 1. "Hello, I would like to talk with you and get some information on you and your child." 2. "Does any member of your family have a history of asthma, heart disease, or diabetes?" 3. "Tell me about the concerns that brought you to the clinic today." 4. "You will need to fill out these forms; make sure that the information is as complete as possible." 5. Asking the child, "What is your doll's name?"

Answer: 3, 5 Explanation: 1. Introducing self before asking the parents for information is likely to establish rapport, but it does not give the nurse an understanding of the parents' perceptions. 2. Beginning with a question about family history of diseases does not establish rapport. 3. Asking the parents to talk about their concerns is an open-ended question, and one that will establish rapport and give the nurse an understanding of the parents' perceptions. 4. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified by the nurse directing the interview. 5. Including the child in the health history process by asking the name of the doll is aquestion from the nurse that establishes rapport.

11) While taking the history of a 10-year-old child, the parents admit to owning firearms. Which should the nurse suggest to enhance the child's safety based on this information? 1. Keeping all the guns put away and out of the child's reach 2. Taking the child to a shooting range for lessons on how to use a gun properly 3. Storing the guns and ammunition in the same place 4. Using a gun lock on all firearms in the house

Answer: 4 Explanation: 1. A 10-year-old child is able to reach any area of the house; more precautions need to be taken. 2. Teaching gun safety is appropriate to a family that has guns; however, it is not sufficient to protect the child. The guns must be secured at all times the adults are not supervising the guns. 3. It is recommended that guns and ammunitions be stored separately. 4. Statistics show that about 75% of unintentional deaths and suicides are committed with firearms found in the home. The safety measures of using a gun lock, keeping the gun and ammunition separate, and putting the guns in a locked cabinet will at least make the guns less accessible.

11) Which screening is appropriate for the school nurse to perform on all adolescent students? 1. Respiratory rate 2. Hepatitis B profile 3. Chest x-ray 4. Scoliosis

Answer: 4 Explanation: 1. A respiratory rate is not a screening examination for all adolescents. It is done throughout childhood at each health supervision visit. 2. The hepatitis B profile is needed only once, prior to administration of the hepatitis B vaccine; however, this is not a required screening for all adolescents. 3. A chest x-ray is not a routine screening test for adolescents. 4. Routine screening for adolescents includes checking for scoliosis, height, weight, and blood pressure measurements.

25) The mother of a 12-year-old child informs the nurse that the child's father died from sudden cardiac death at 44 years old. Which laboratory tests does the nurse anticipate will be prescribed by the healthcare provider? 1. Chest x-ray 2. Complete blood count (CBC) with differential 3. Electroencephalogram (EEG) 4. Lipid profile

Answer: 4 Explanation: 1. A routine chest x-ray might be ordered by the healthcare provider, but will not provide relevant information at this time. 2. The CBC is routine, but will not give information related to cardiac disease. 3. An EEG reveals information about brain activity, not about cardiac status. 4. This child should have a lipid profile completed at 12 years old, and based on the results, further testing might be needed.

7) During a 4-month-old infant's well-child checkup, the nurse discusses introduction of solid foods into the infant's diet. Although the nurse recommends delaying the introduction of many foods into the diet, which food(s) will the nurse discuss delaying because they increase the risk for food allergy? 1. Honey 2. Carrots, beets, and spinach 3. Pork 4. Cow's milk, eggs, and peanuts

Answer: 4 Explanation: 1. Although honey can contain botulism spores that cannot be detoxified by the infant younger than 1 year old, it does not cause an allergic reaction. 2. Carrots, beets, and spinach contain nitrates and should not be given before 4 months of age. 3. The addition of pork is delayed until the infant is 8 to 10 months old because meats are hard to digest. 4. Cow's milk, eggs, and peanuts are foods that have been associated with food allergies. management across

4) A 7-year-old child is seen in the pediatric clinic 3 times in the last 2 months for complaints of abdominal pain. On each occasion, the physical examination and all ordered laboratory work have been normal. Which is the priority nursing assessment at this time? 1. The child's normal eating habits 2. Recent viral illnesses or other infectious symptoms 3. Review of the child's immunization history 4. Changes in school or home life

Answer: 4 Explanation: 1. Because of the abdominal complaints, the child's eating habits would have already been discussed. 2. With normal blood work and tests, the chance of any illness over the last few months is unlikely. 3. The immunization history would have been reviewed on the previous visits. 4. With a normal examination and laboratory work, there is a high probability that this child's abdominal pain is stress related, and it is most important to identify the possible stressors in this child's life to aid in diagnosis and treatment. Asking about changes in home or school life is most likely to get to information about recent stresses in the child's life.

6) A nurse is assessing language development in all the pediatric clients presenting at the healthcare provider's office for well-child visits. At which age would the nurse further assess language development if the client is unable to verbalize the words "dada" and "mama"? 1. 3 months 2. 6 months 3. 8 months 4. 12 months

Answer: 4 Explanation: 1. By 3 months of age, infants vocalize during play and with familiar people. The infant may also begin to laugh. At this time, they do not use these as names for the parents. 2. By 6 months of age, infants will be making the sounds "mamamamam" and "dadadada" because they like to repeat sounds. At this time, they do not use these as names for the parents. 3. By 8 months of age, infants will be making the sounds "mamamamam" and "dadadada" because they like to repeat sounds. At this time, they do not use these as names for the parents. 4. By 12 months of age, children should be able to verbalize "mama" or "dada" to identify their mother or father. This client would require further assessment by the nurse.

12) A child has a planned hospitalization in a few weeks, and the client and family appear very stressed. Which nursing action will minimize the stress for the client and family? 1. Telling the client and family that everything will be fine 2. Explaining to the client and family how the child will benefit from the surgery 3. Telling the client and family that the surgeon is very good 4. Giving a tour of the hospital unit or surgical area to the client and family

Answer: 4 Explanation: 1. The nurse cannot know for certain that everything will be fine. 2. The pros and cons of the surgery would have been explained to the family prior to the decision to have the surgery. Restating the benefits will not reduce the stress of the client and family. 3. Telling them the surgeon is very good is not going to minimize stress for long. They need to be more familiar with what to expect in a familiar environment. 4. A variety of approaches can be used to provide information and allay fears. Tours of the hospital unit or surgical area are helpful. This activity assists the child and family to become familiar with the environment they will encounter.

8) While interviewing the parents of a toddler-age client, the nurse notes that the mother is pregnant. At the end of the visit, the nurse decides to give a new pamphlet to the parents about car seat usage for newborns. Which is the purpose of this action by the nurse? 1. Secondary preventative health maintenance 2. Developmental health screening 3. Tertiary preventative health maintenance 4. Primary preventative health maintenance

Answer: 4 Explanation: 1. The secondary level of prevention is focused on diagnosis of a problem, usually medical in nature, in order to address it and make a plan of care. 2. This is education, and not a developmental screening to elicit data. The focus of the teaching is on an unborn child, so developmental level is not a current issue. 3. The tertiary level of preventative care is related to restoring a level of functioning that is below an expected level, such as in a rehabilitation situation. 4. The teaching regarding proper car seat use is an example of an activity that might decrease the opportunity for injury in a newborn; therefore, this is primary preventive health maintenance.

2) During a well-child examination, the parents of a 4-year-old client inform the nurse that they are thinking of buying a television for their child's bedroom and ask for advice as to whether this is appropriate. Which response by the nurse is most appropriate? 1. "It is okay for children to have a television in their room as long as you limit the amount of time they watch it to less than 2 hours per day." 2. "Research has shown that watching educational television shows improves a child's performance in school." 3. "Don't buy a television for your child's room; he is much too young for that." 4. "Research has shown that children with a television in their bedroom spend significantly less time playing outside than other children."

Answer: 4 Explanation: 1. This information is correct in that limiting television viewing to less than 2 hours per day is appropriate, but the probability of this occurring with a television in the child's room is low; the child will most likely be watching much more than 2 hours per day. 2. This statement might encourage the parents to allow the child to watch more television, and the child's developmental need for physical activity is greater than the benefit that he might obtain by watching educational programs. 3. This statement does not give parents a rationale, and it might seem opinionated to them. 4. Young children need to be physically active at this age. Research has shown that children with a television in their bedroom spend significantly less time playing outside than do other children, and physical inactivity in children has been linked to many chronic diseases, such as obesity and type 2 diabetes. Telling parents this is the best response because it gives the parents an evidence-based reason for not placing a television in the child's room.

10) An adolescent is admitted to the eating disorders unit with a 2-year history of anorexia nervosa. Assessment data indicate that the adolescent has recently sustained additional weight loss and electrolyte imbalances. Which is the priority when planning care for this client? 1. Individual counseling 2. Family therapy 3. Regulation of antidepressant drugs 4. Nutritional support

Answer: 4 Explanation: 1. This will be an important component of inpatient treatment but is not the priority intervention. 2. Family therapy is usually a component of the treatment of anorexia nervosa but is not the priority intervention. 3. Antidepressant drugs may be used as a component of the treatment, but this is not the priority intervention. 4. Hospitalization usually is in response to the weight loss and electrolyte imbalances, so nutritional support becomes the priority intervention. All other activities can be managed as outpatient therapies.

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

Answer: 4 Explanation: 1. Transductive reasoning is when a child connects two events in a cause-effect relationship because the events occurred at the same time. 2. Conservation is when a child knows that matter is not changed when its form is altered. 3. Centration is when a child focuses on only one particular aspect of a situation. 4. A child who has developed object permanence has the ability to understand that even though something is out of sight, it still exists.

13) The nurse is planning health promotion activities for a toddler-age child during a scheduled health maintenance visit. Which action by the nurse is appropriate during this visit? 1. Connecting developmental skills with risks for injury 2. Recognizing that childcare attendance increases the risk for communicable disease 3. Planning education for treatment of common disease processes 4. Illustrating developmental progression on a screening tool

Answer: 4 Explanation: 1. Connecting developmental skills with risks for injury is an action that prevents disease and injury. This is not a health promotion activity. 2. Recognizing that attendance at a daycare center increases the risk for communicable disease is an action that prevents disease and injury. This is not a health promotion activity. 3. Planning treatment for common disease processes is an action that prevents disease and injury. This is not a health promotion activity. 4. Illustrating developmental progression on a screening tool is a health promotion action.

5) Which is the correct order for the nurse to conduct a physical assessment for a toddler-age client? Place in order from first assessment to last assessment. 1. Auscultation of chest 2. Examination of eyes, ears, and throat 3. Palpation of abdomen 4. General appearance

Answer: 4, 1, 3, 2 Explanation: 1. Auscultation usually is less threatening to the toddler than is palpation, especially if the nurse first demonstrates using the stethoscope on a parent or a toy. 2. The most uncomfortable, most invasive examination for the toddler is most likely to be the examination of the eyes, ears, and throat; therefore, this assessment should be performed last. 3. Palpation can be more threatening than is observing or listening, so it should be completed after both. 4. The nurse will begin the assessment by looking at the child. This can be done while the mother is holding the child and the nurse is talking to the mother. This environment will be neutral for the child and will not cause anxiety.

12) A vegetarian adolescent is prescribed iron supplementation secondary to a diagnosis of iron-deficiency anemia. Which food will the nurse encourage the adolescent to increase intake of based on the current diagnosis? 1. Black tea 2. Eggs 3. Fresh fruit 4. Milk

Answer: 2 Explanation: 1. Black tea contains tannins, which decrease the absorption of iron. 2. Eggs are one type of food rich in iron. 3. Dried fruit, not fresh fruit, is rich in iron. 4. Foods containing phosphorus, such as milk, decrease absorption of iron.

13) The nurse is planning to teach a group of adolescents about what can happen when having unprotected sex. Which nursing action will allow effective communication with the group? 1. Offering personal opinions on the topic 2. Allowing for discussion among the participants 3. Lecturing on the topic for the allotted time without any discussion 4. Discussing sex education related to religious belief

13) The nurse is planning to teach a group of adolescents about what can happen when having unprotected sex. Which nursing action will allow effective communication with the group? 1. Offering personal opinions on the topic 2. Allowing for discussion among the participants 3. Lecturing on the topic for the allotted time without any discussion 4. Discussing sex education related to religious belief

5) A vegetarian adolescent is placed on iron supplementation secondary to a diagnosis of iron-deficiency anemia. Which will the nurse encourage the adolescent to drink when taking the daily iron supplement? 1. Orange juice 2. Black or green tea 3. Milk 4. Tomato juice

Answer: 1 Explanation: 1. Acidity increases absorption of iron. 2. Foods containing phosphorus, such as in milk; oxalates, such as in tomatoes; and tannins, such as in teas, all decrease absorption of iron. 3. Foods containing phosphorus, such as in milk; oxalates, such as in tomatoes; and tannins, such as in teas, all decrease absorption of iron. 4. Foods containing phosphorus, such as in milk; oxalates, such as in tomatoes; and tannins, such as in teas, all decrease absorption of iron.

5) A parent says to a nurse, "How do you know when my baby needs these screening tests the doctor just mentioned?" Which response by the nurse is most appropriate? 1. "Screening tests are done in the newborn nursery, and from these results, additional screening tests are ordered throughout the first 2 years of life." 2. "Screening tests are done at each office visit." 3. "Screening tests are most often done when the doctor suspects something is wrong with the child." 4. "Screening tests are administered at the ages when a child is most likely to develop a condition."

Answer: 4 Explanation: 1. This provides incorrect information to the parent. Abnormal newborn screening tests require immediate follow-up. 2. This provides incorrect information to the parent. Screening tests are not done at each office visit. 3. This provides incorrect information to the parent. Screening tests are done to detect the possibility of problems, and are not done when a problem is suspected. 4. "Screening tests are administered at ages when a child is most likely to develop a condition" provides a definition for screening tests.

19) The nurse is providing care to a toddler-age client who is diagnosed with celiac disease. Which interventions will the nurse include in the toddler's plan of care? Select all that apply. 1. Temporary removal of wheat products from the diet 2. Permanent removal of oat products from the diet 3. Fat-soluble vitamin supplements 4. Avoidance of processed foods 5. Obtaining a dietary prescription

Explanation: 1. Wheat products contain gluten; therefore, these products must be removed permanently from the diet. 2. Oat products are often tolerated by clients diagnosed with celiac disease. 3. Fat-soluble vitamin supplements are often needed by clients diagnosed with celiac disease. 4. Processed foods should be avoided because they are often hidden sources of gluten. 5. A dietary prescription is often necessary for clients diagnosed with celiac disease because this allows insurance company coverage for the purchase of specialized foods.

1) The nurse is providing care to a pediatric client who is experiencing separation anxiety. Which data would support the documentation of the "despair" phase? 1. Lies quietly in bed. 2. Does not cry if his parents return and leave again. 3. Appears to be happy and content with staff. 4. Screams and cries when his parents leave.

Answer: 1 Explanation: 1. Children in the "despair" stage appear sad, depressed, or withdrawn. A child who is lying in bed might be exhibiting any of these. 2. The young child who appears to be happy and content with everyone is in the "denial" stage, as is the child who does not cry if his parents return and leave again. 3. The young child who appears to be happy and content with everyone is in the "denial" stage, as is the child who does not cry if his parents return and leave again. 4. Screaming and crying are components of the "protest" stage.

15) Which topics should the nurse include in a discussion with parents of a terminally ill child regarding parental feelings that may occur upon the child's death? Select all that apply. 1. Loneliness 2. Guilt 3. Anger 4. High energy 5. Depression

Answer: 1, 2, 3, 5 Explanation: 1. The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness. 2. The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness. 3. The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness. 4. High energy is not felt during the mourning period. 5. The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness.

18) Which age groups can best tolerate separation from parents during hospitalization? Select all that apply. 1. Infants birth to 5 months 2. Infants 5 months to 1 year 3. Toddlers and preschoolers 4. School-age children 5. Adolescents

Answer: 1, 4, 5 Explanation: 1. Infants in this age group do not recognize parents as separate from themselves so will not feel abandoned when parents do not stay. 2. Infants in this age group recognize object permanence and will be aware of the absence of their parents. 3. Both groups suffer from separation anxiety and fear of abandonment. 4. School-age children are accustomed to dealing with adults other than parents and can better tolerate separation. 5. Adolescents are able to understand separation and time and thus will not suffer from separation from parents.

17) Two hospitalized pediatric clients are working on a puzzle together in the hospital playroom. Which type of play are the clients exhibiting? 1. Solitary play 2. Associative play 3. Parallel play 4. Cooperative play

Answer: 4 Explanation: 1. Solitary play is when a child plays alone. 2. Associative play is characterized by children interacting in groups and participating in similar activities. 3. Parallel play is when two or more children play together, each engaging in his or her own activities. 4. Cooperative play is when children demonstrate the ability to cooperate with others and to play a part in order to contribute to a unified whole.

17) A child is admitted to the hospital unit for physical injuries. The mother's boyfriend is suspected of child abuse. Which is the primary role of the nurse in addition to reporting the information to the proper authorities? 1. Gathering information about how the injuries occurred. 2. Collecting evidence against the suspected abuser. 3. Encouraging the child to talk about his experience. 4. Protecting the child from further injury.

Answer: 4 Explanation: 1. This is not a priority role for the nurse. 2. This would be a police function, not the nurse's responsibility. 3. The nurse and the psychologist will be meeting with the child to help the child work through the experience, but this is not the priority action for the nurse. 4. The nurse will monitor the child while in the presence of visitors. In addition, the nurse will talk with the social worker to assist in providing for the child's safety in the future. This is a priority.