Test 2 (Part2)

The nurse working in a community clinic attempts to establish a free vaccination program to refer low-income families. What is the key strategy for success when implementing a health promotion activity? A) Partnership development B) Funding for projects C) Finding an audience D) Adequate staffing

A) Partnership development

The nurse caring for a child on a pediatric intensive care unit notices that when the parents go to work the child is very angry and cries easily. What does the nurse suspect is occurring with this patient? A) Protest phase of separation anxiety B) Regressive behavior C) Detachment from the parents D) Despair

A) Protest phase of separation anxiety

The nurse is preparing to assess the pulse of an 18-month-old child. Which pulse would be most difficult for the nurse to palpate? A) Radial B) Brachial C) Pedal D) Femoral

A) Radial

The nurse is teaching the student nurse the sequence for performing the assessment techniques during a physical examination. What is the appropriate order? A) Inspection, palpation, percussion, auscultation B) Inspection, percussion, palpation, auscultation C) Palpation, percussion, inspection, auscultation D) Inspection, auscultation, palpation, percussion

A) Inspection, palpation, percussion, auscultation

The parents of a child with physical and developmental special needs state, "We wish our child could get some kind of educational experience." How should the nurse respond? A) "This must be difficult for you. Let's talk with the social worker to see what programs are available for your child." B) "I am sure it must be difficult to know that your child will never be able to go to school like other children." C) "Since all children can attend school regardless of their special need, I suggest you talk with your local school about enrolling your child." D) "It would be very difficult for your child to attend school with all of their disabilities. It's unfortunate, but it is reality."

A) "This must be difficult for you. Let's talk with the social worker to see what programs are available for your child."

A mother of three brings her children in for their vaccinations. The mother tells the nurse that her mother recently died and her husband just lost his job due to his company downsizing. Which parenting behaviors is the nurse likely to observe? Select all that apply. A) The mother rarely looks at her infant when the nurse is assessing the child. B) The mother voices pride in the academic accomplishments of her 7-year-old child. C) The mother becomes very frustrated and tells the nurse she can't handle her toddler's temper tantrum. D) The mother asks if the nurse has suggestions on ways to potty train her toddler. E) The mother utilizes the correct size of infant car seat for her 3-month-old child.

A) The mother rarely looks at her infant when the nurse is assessing the child. C) The mother becomes very frustrated and tells the nurse she can't handle her toddler's temper tantrum.

A child is admitted to the hospital with a spinal cord injury resulting in paralysis below the level of the waist. When should the nurse begin planning with the parents for rehabilitation placement for this child after acute hospitalization? A) After hospitalization when the parents are ready B) As soon after the patient is admitted as possible C) When the child starts showing improvement in their condition D) Once the child and the parent feel it is time to seek extended care

B) As soon after the patient is admitted as possible

The nurse is caring for an immunosuppressed 3-year-old girl and is providing teaching to the mother about proper oral hygiene. Which response from the mother indicates a need for further teaching? A) "I really need to carefully check for skin breakdown." B) "I must really scrub her teeth and gums well." C) "I must use a soft toothbrush." D) "I can use a soft gauze sponge to care for her gums."

B) "I must really scrub her teeth and gums well."

A teenage patient tells the nurse that she is being abused by her boyfriend but she doesn't want her parents to know because they won't let her see him any longer. What is the best response by the nurse? A) "It's my responsibility to tell your parents if you are in danger." B) "I understand your fear, but I am obligated to be sure your parents know you are in danger. Would you like for us to talk to them together?" C) "I won't tell them this time, but I must inform you that legally I must inform your parents if abuse is occurring. Next time it happens I will have to tell them." D) "You need to tell them because the abuse isn't going to get any better. It will only escalate no matter what your boyfriend says."

B) "I understand your fear, but I am obligated to be sure your parents know you are in danger. Would you like for us to talk to them together?"

The nurse is caring for an 11-year-old girl preparing to undergo a magnetic resonance imaging (MRI) scan. Which statement would best help prepare the girl for the test and decrease anxiety? A)"You won't hear a sound if you wear your headphones." B) "The machine makes a very loud rattle; however, headphones will help." C) "There are a variety of loud sounds you will hear." D) "The MRI scanner sounds like a machine gun."

B) "The machine makes a very loud rattle; however, headphones will help."

The parents of an 11-year-old boy who is dying from cancer are concerned that he is not eating. Which intervention would serve both the parents' and child's needs? A) Urging the child to eat one good meal per day B) Serving small meals of things the child likes C) Straightening up around the child before meals D) Administering antiemetics as ordered for nausea

B) Serving small meals of things the child likes

When describing organ donation to the family of a dying child, what would the nurse include in the discussion? A) Telling them that further harm may occur to the child through the process B) Tell them that their cultural and religious beliefs will be considered C) Including this topic in the discussion of impending death D) Informing the family that organ donation will delay the funeral

B) Tell them that their cultural and religious beliefs will be considered

The nurse is caring for a child involved in an automobile accident whose family has been informed that the child is brain dead. What teaching might the nurse provide the family regarding organ donation? A) The nurse should ask about organ donation when the family is informed of their child's condition. B) The nurse should explain that written consent is necessary for the organ donation. C) The nurse should make sure the parents know that procurement of organs may mar their child's appearance. D) The nurse should make sure the parents know that they will be responsible for expenses related to organ procurement.

B) The nurse should explain that written consent is necessary for the organ donation.

The nurse is preparing a presentation to a local parent group about pediatric health supervision. Which would the nurse emphasize as the focus? A) Injury prevention B) Wellness C) Health maintenance D) Developmental surveillance

B) Wellness

After teaching the mother about follow-up immunizations for her daughter, who received the varicella vaccine at age 14 months, the nurse determines that the teaching was successful when the mother states that a follow-up dose should be given at which time? A) When the child is 20 to 36 months of age B) When the child is 4 to 6 years of age C) When the child is 11 to 12 years of age D) When the child is 13 to 15 years of age

B) When the child is 4 to 6 years of age

The nurse is collecting information from the parents of a 3-year-old child about her sleeping patterns. Which question by the nurse will best elicit information from the parents? A) "How are things going at home?" B) "Is your child sleeping well at night?" C) "How many hours does your child sleep at night?" D) "What time does your child go to bed at night?"

C) "How many hours does your child sleep at night?"

The parents of a child with a developmental disability tell the nurse that they feel guilty because they sometimes find themselves feeling sad and wondering how their child would be without the disability. Which response by the nurse best shows empathy and encourages the parents to vent their feelings? A) "I'm sure it must be difficult to have a child developmentally delayed." B) "There are lots of parents that are experiencing the difficulty and feelings of hopelessness and grief you're having. Maybe if you talk to someone it might help you both." C) "I can only imagine how hard it is for you. You should know that it is common for parents to have these feelings when having a child with special needs." D) "It's important to focus on the positives that can come from the experience of being the parents of a child that has these issues."

C) "I can only imagine how hard it is for you. You should know that it is common for parents to have these feelings when having a child with special needs."

During the health history, the mother of a 4-month-old child tells the nurse she is concerned that her baby is not doing what he should be at this age. What is the nurse's best response? A) "I'll be able to tell you more after I do his physical." B) "Fill out the questionnaire and then I can let you know." C) "Tell me what concerns you." D) "All mothers worry about their babies. I'm sure he's doing well."

C) "Tell me what concerns you."

Three children in a family, ages 7 months, 4 years, and 9 years have been tested for lead poisoning. The two younger children's tests reflect elevated lead levels and they will be undergoing treatment. The children's mother questions why her younger children were not "spared" as their older sibling was. What response by the nurse is most correct? A) "Some children are better able to metabolize toxins such as lead after exposure." B) "Your older child has a stronger liver and kidneys, which have helped her to better rid her body of the lead." C) "Younger children are often impacted because of their play behaviors place them on the floors and they often put things into their mouths." D) "It is likely your older child may have had elevated levels earlier in life but has gotten over the condition."

C) "Younger children are often impacted because of their play behaviors place them on the floors and they often put things into their mouths."

The nurse is meeting with the parents of a 7-year-old boy with Down syndrome. The child's mother reports an interest in hippotherapy. The child's father reports that this seems to be a waste of money. The parents then ask the nurse for additional information. What information may be included in the nurse's response? Select all answers that apply. A) Hippotherapy has limited research demonstrating its actual effectiveness. B) This type of therapy is most helpful for teens. C) A variety of conditions including Down syndrome have used hippotherapy with success. D) Self-esteem may be improved with hippotherapy. E) The benefits of hippotherapy are both physical and psychological.

C) A variety of conditions including Down syndrome have used hippotherapy with success. D) Self-esteem may be improved with hippotherapy. E) The benefits of hippotherapy are both physical and psychological.

The nurse is caring for a 5-year-old boy who is terminally ill. Which intervention would best meet the needs of this dying child? A) Offer the child decision-making opportunities. B) Provide the child with specific details. C) Assure the child that he did nothing wrong. D) Act as a confidant for the child's concerns.

C) Assure the child that he did nothing wrong.

The mother of a 7-year-old boy with autism tearfully reports feeling as if she is not qualified to care for her child. Which initial action by the nurse is most appropriate? A) Tell the child's mother that this is a common feeling when caring for a special needs child. B) Encourage the child's mother to keep a journal to best identify areas needing improvement in the home routine. C) Recognize the mother's positive accomplishments in caring for her child. D) Recommend the child's mother seek counseling.

C) Recognize the mother's positive accomplishments in caring for her child.

The nurse is caring for a preschool child who is receiving palliative care for end-stage cancer. What would be the focus of age-appropriate interventions for this child? A) Providing unconditional love and trust B) Providing a familiar and consistent routine C) Teaching the child that death is not punishment D) Providing specific, honest details of death

C) Teaching the child that death is not punishment

The nurse is reviewing the therapist's documentation in the medical record of an assigned client who has cerebral palsy. The therapist has noted the parents may be experiencing vulnerable child syndrome. Which observation of the family unit best supports this potential diagnosis? A) The parents regularly attend a support group for parents of special needs children. B) The child has been diagnosed with pneumonia twice in the past year. C) The parents report they feel their child requires more therapy than the care team has indicated will be needed. D) The child is schooled at home with a private tutor.

C) The parents report they feel their child requires more therapy than the care team has indicated will be needed.

When speaking to a group of parents at a local elementary school, the nurse describes school nursing as a specialized practice of nursing based on the fact that a healthy child has a better chance to succeed in school. What best describes the strategy school nurses use to achieve student success? A) They coordinate all school health programs. B) They link community health services. C) They work to minimize health-related barriers to learning. D) They promote student health and safety.

C) They work to minimize health-related barriers to learning.

The nurse is looking into the Individuals with Disabilities Education Improvement Act of 2004 to help provide resources for a client with multiple chronic diseases. What are mandates of this legislation? Select all that apply. A) The law mandates government-funded care coordination and special education for children up to 8 years of age. B) This early intervention program is a state-funded program run at the federal level. C) This federal law allows each state to define "developmental disability" differently. D) An evaluation of the child's physical, language, emotional, and social capabilities is performed to determine eligibility. E) The primary care nurse manages the developmental services and special education that the child requires. F) The goal is to maintain a natural environment, so most services occur in the home or day care center.

C) This federal law allows each state to define "developmental disability" differently. D) An evaluation of the child's physical, language, emotional, and social capabilities is performed to determine eligibility. F) The goal is to maintain a natural environment, so most services occur in the home or day care center.

What would the nurse include in the plan of care for a dying child with pain? A) Administering analgesics as needed B) Using measures the nurse finds comforting C) Playing the television or radio so the child can hear it D) Changing the child's position frequently but gently

D) Changing the child's position frequently but gently

The nurse is providing anticipatory guidance to an obese teenager. Which intervention would be most likely to promote healthy weight in teenagers? A) Make the focus of the program weight centered. B) Begin directly advising children about their weight at age 6. C) Focus physical activity on competitive sports and activities. D) Obtain nutritional histories directly from the school-age child and adolescent.

D) Obtain nutritional histories directly from the school-age child and adolescent.

The nurse is providing discharge planning for a 12-year-old boy with multiple medical conditions. What would be the best teaching method for this child and his family? A) Demonstrate the care and ask for a return demonstration. B) Provide and review educational booklets and materials. C) Provide a written schedule for the child's care. D) Provide a trial period of home care.

D) Provide a trial period of home care.

The nurse is administering a hepatitis B vaccine to a child. What is the classification of this type of vaccine? A) Killed vaccines B) Toxoid vaccines C) Conjugate vaccines D) Recombinant vaccines

D) Recombinant vaccines

The nurse is examining a 2-year-old child who was adopted from Guatemala. What would be a priority screening for this child? A) Screening for congenital defects B) Screening for abuse C) Screening for childhood illnesses D) Screening for infectious diseases

D) Screening for infectious diseases

The nurse is performing a physical examination on a sleeping newborn. Which body system should the nurse examine last? A) Heart B) Abdomen C) Lungs D) Throat

D) Throat

The nurse is conducting a routine health assessment of a 3-month-old boy and notices a flat occiput. The nurse provides teaching and emphasizes the importance of tummy time. Which response by the mother indicates a need for further teaching? A) "I should have him sleep on his tummy." B) "I need to watch him during his tummy time." C) "I need to change his head position while he is in an upright chair." D) "His head has flattened due to the pressure of his head position."

A) "I should have him sleep on his tummy."

The nurse is caring for a hospitalized 13-year-old girl, who is questioning everything the medical staff is doing and is resistant to treatment. How should the nurse respond? A) "Let's work together to plan your day along with your treatments." B) "The sooner you cooperate, the sooner you are going to leave." C) "If you are more cooperative, perhaps we can arrange a visit from friends." D) "Please don't make me call your parents about this."

A) "Let's work together to plan your day along with your treatments."

The mother of a hospitalized child reports that her daughter, who is having some difficulty eating, just had a 4-ounce cup of ice chips. The nurse documents this on the child's intake flow sheet as how much? A) 2 ounces B) 4 ounces C) 6 ounces D) 8 ounces

A) 2 ounces

The nurse is aware that the community affects the health of its members. Which statements accurately reflect a community influence of health care? Select all that apply. A) A community can be a contributor to a child's health or be the cause of his or her illnesses. B) The child's health should be separated from the health of the surrounding community. C) Community support and resources are necessary for children with significant problems. D) Poverty has not been linked to an increase in health problems in communities. E) The breakdown of community and family support systems can lead to depression and violence. F) Ideally, the child's medical home is located outside the community.

A) A community can be a contributor to a child's health or be the cause of his or her illnesses. C) Community support and resources are necessary for children with significant problems. E) The breakdown of community and family support systems can lead to depression and violence.

The nurse is caring for infants having the condition failure to thrive (FTT). Which infants would be at risk for this condition? Select all that apply. A) A newborn baby with tetralogy of Fallot B) An infant with a cleft palate C) An infant born to a diabetic mother D) An infant born to an impoverished mother E) An infant with bronchopulmonary dysplasia F) An infant born to a teenage mother

A) A newborn baby with tetralogy of Fallot B) An infant with a cleft palate D) An infant born to an impoverished mother E) An infant with bronchopulmonary dysplasia

The nurse is assessing heart rate for children on the pediatric ward. What is a normal finding based on developmental age? A) An infant's rate is 90 bpm. B) A toddler's rate is 150 bpm. C) A preschooler's rate is 130 bpm. D) A school-age child's rate is 50 bpm.

A) An infant's rate is 90 bpm.

he nurse is inspecting the genitals of a prepubescent girl. Which is a normal sign of the onset of puberty? A) Appearance of pubic hair around 11 to 13 years old B) Swelling or redness of the labia minora C) Presence of labial adhesions D) Lesions on the external genitalia

A) Appearance of pubic hair around 11 to 13 years old

A 7-year-old boy has reentered the hospital for the second time in a month. Which intervention is particularly important at this time? A) Assessing his parents' coping abilities B) Seeking his parents' input about their child's needs C) Educating his family about the procedure D) Notifying the care team about his hospitalization

A) Assessing his parents' coping abilities

When assessing the vision of a 2-month-old, what would the nurse use? A) Black-and-white checkerboard B) Red and blue circles C) Gray and blue animal drawings D) Green and yellow letters

A) Black-and-white checkerboard

During a physical assessment of a 5-month-old child, the nurse observes the first tooth has just erupted and uses the opportunity to advise the mother to schedule a dental examination for her baby. When is the correct time for the dentist visit? A) By the first birthday B) By the second birthday C) By entry into kindergarten D) By entry into first grade

A) By the first birthday

The nurse is caring for a special needs infant. Which intervention will be most important in helping the child reach her maximum developmental potential? A) Directing her parents to an early intervention program B) Monitoring her progress in elementary school C) Serving on an individualized education program committee D) Preparing a plan for her to transition to college

A) Directing her parents to an early intervention program

The nurse performing a health history on a child asks the parents if their child has experienced increased appetite or thirst. What body system is the nurse assessing with this question? A) Endocrine B) Genitourinary C) Hematologic D) Neurologic

A) Endocrine

When providing care to a dying child and his family, which would be most important? A) Focusing on the family as the unit of care B) Teaching the family appropriate care measures C) Offering the child support and encouragement D) aAssisting the parents in decision making

A) Focusing on the family as the unit of care

The nurse is conducting a psychosocial assessment of a child with asthma brought to the physician's office for a check-up. Which psychosocial issues may be assessed? Select all that apply. A) Health insurance coverage B) Transportation to health care facilities C) School's response to the chronic illness D) Past medical history E) Future treatment plans F) Health maintenance need

A) Health insurance coverage B) Transportation to health care facilities C) School's response to the chronic illness

The nurse working in community nursing uses epidemiology as a tool. What information can be obtained using this process? A) Health needs of a population B) Cultural needs of a population C) Income levels of a population D) Mortality rates of a population

A) Health needs of a population

The nurse is caring for a 7-year-old girl hospitalized in isolation. The nurse notices that she has begun sucking her thumb and changing her speech patterns to those of a toddler. What condition is the girl manifesting? A) Regression B) Suppression C) Repression D) Denial

A) Regression

The nurse is examining a 15-month-old child who was able to walk at the last visit and now can no longer walk. What would be the nurse's best intervention in this case? A) Schedule a full evaluation since this may indicate a neurologic disorder. B) Note the regression in the child's chart and recheck in another month. C) Document the findings as a developmental delay since this is a normal occurrence. D) Ask the parents if they have changed the child's schedule to a less active one.

A) Schedule a full evaluation since this may indicate a neurologic disorder.

The nurse is caring for a 4-year-old girl with special care needs in the hospital. Which intervention would have the most positive effect on this child? A) Taking her on an adventure down the hall B) Helping her do a simple craft project C) Introducing her to children in the playroom D) Limiting the staff providing care for her

A) Taking her on an adventure down the hall

Which would be least effective in gaining the cooperation of a toddler during a physical examination? A) Tell the child that another child the same age wasn't afraid. B) Allow the child to touch and hold the equipment when possible. C) Permit the child to sit on the parent's lap during the examination. D) Offer immediate praise for holding still or doing what was asked.

A) Tell the child that another child the same age wasn't afraid.

The nurse is questioning the parents of a 2-year-old child to obtain a functional history. Which topics might the nurse include? Select all answers that apply. A) The child's toileting habits B) Use of car seats and other safety measures C) Problems with growth and development D) Prenatal and perinatal history E) The child's race and ethnicity F) Use of supplements and vitamins

A) The child's toileting habits B) Use of car seats and other safety measures F) Use of supplements and vitamins

The nurse referring a child to home care discusses the advantages and disadvantages with the child's family. What are disadvantages of this method of health care? Select all that apply. A) The nurse is performing care of the child in the family's home. B) The home care nurse is not always equipped to perform technical care. C) The out-of-pocket cost of home care is more expensive. D) The technical procedures may be overwhelming for the family. E) The financial burden may cause more stress for the family. F) The child does not receive continuity of care provided in the hospital setting.

A) The nurse is performing care of the child in the family's home. C) The out-of-pocket cost of home care is more expensive. D) The technical procedures may be overwhelming for the family. E) The financial burden may cause more stress for the family.

The nurse is preparing a hospitalized 7-year-old girl for a lumbar puncture. Which actions would help reduce her stress related to the procedure? Select all that apply. A)Pretend to perform the procedure on her doll. B) Explain the procedure to her in medical terms. C) Do not allow her to see or touch the equipment. D) Teach her the steps of the procedure. E) Tell her not to pay attention to any sounds she might hear. F) Introduce her to the health care personnel.

A)Pretend to perform the procedure on her doll. D) Teach her the steps of the procedure. F) Introduce her to the health care personnel.

The nurse is discussing vaccination for Haemophilus influenzae type B (Hib) with the mother of a 6-month-old child. Which comment provides the most compelling reason to get the vaccination? A) "These bacteria live in every human." B) "Young children are especially susceptible to these bacteria." C) "You have a choice of two excellent vaccines." D) "Your child needs this final dose for protection."

B) "Young children are especially susceptible to these bacteria."

For which children would the nurse conduct an immediate comprehensive health history? A) A child who is brought to the emergency room with labored breathing B) A child who is a new client in a pediatric office C) A child who is a routine client and presents with signs of a sinus infection D) A child whose condition is improving

B) A child who is a new client in a pediatric office

The nurse is performing developmental surveillance for children at a medical home. Which infants are most at risk for developmental delays? Select all that apply. A) A child whose birthweight was 1,600 g B) A child whose parent has a mental illness C) A child raised by a single parent D) A child with a lead level above 10 mg/dL E) A child with hypertonia or hypotonia F) A child with gestational age more than 33 weeks

B) A child whose parent has a mental illness C) A child raised by a single parent D) A child with a lead level above 10 mg/dL E) A child with hypertonia or hypotonia

A large portion of the nurse's efforts is dedicated to health supervision for children who use the facility as their primary medical contact. At which facility does the nurse work? A) An urgent care center B) A pediatric practice C) A mobile outreach immunization program D) A dermatology practice

B) A pediatric practice

The nurse is conducting a health history for a 9-year-old child with stomach pains. What is a recommended guideline when approaching the child for information? A) Wear a white examination coat when conducting the interview. B) Allow the child to control the pace and order of the health history. C) Use quick deliberate gestures to get your point across. D) Do not make physical contact with the child during the interview.

B) Allow the child to control the pace and order of the health history.

The mother of a 5-year-old child with eczema is getting a check-up for her child before school starts. What will the nurse do during the visit? A) Change the bandage on a cut on the child's hand B) Assess the compliance with treatment regimens C) Discuss systemic corticosteroid therapy D) Assess the child's fluid volume

B) Assess the compliance with treatment regimens

The nurse is assessing the temperature of a diaphoretic toddler who is crying and being uncooperative. What would be the best method to assess temperature in this child? A) Oral thermometer B) Axillary method C) Temporal scanning D) Rectal route

B) Axillary method

The nurse is providing home care for the family of an 8-year-old boy who is dying of leukemia. Which action will be most supportive to the parents of the child? A) Encouraging organ and tissue donation B) Being patient with parental indecision C) Getting prior authorization for treatments D) Explaining how anorexia is a natural process

B) Being patient with parental indecision

The nurse is inspecting the fingernails of an 18-month-old girl. What finding indicates chronic hypoxemia? A) Nails that curve inward B) Clubbing of the nails C) Nails that curve outward D) Dry, brittle nails

B) Clubbing of the nails

The nurse is helping a 20-year-old woman transition to adult care. Which would be the most important role of the nurse following a successful transition? A) Teacher B) Consultant C) Care provider D) Advocate

B) Consultant

The nurse is preparing to take a tympanic temperature reading of a 4-year-old. In order to get an accurate reading, what does the nurse need to do? A) Pull the earlobe back and down B) Direct the infrared sensor at the tympanic membrane C) Pull the earlobe down and forward D) Remove any visible cerumen from inside the ear canal

B) Direct the infrared sensor at the tympanic membrane

The nurse is caring for a 10-year-old boy who is in traction. The boy has a nursing diagnosis of deficient diversional activity related to confinement in bed that is evidenced by verbalization of boredom and lack of participation in play, reading, and schoolwork. What would be the best intervention? A) Offer the child reading materials. B) Enlist the aid of a child life specialist. C) Encourage the child to complete his homework. D) Ask for the parents' assistance.

B) Enlist the aid of a child life specialist.

When preparing to apply a restraint to a child, what would be most important for the nurse to do? A) Expect to keep the restraint on for at least 8 hours. B) Explain that safety, not punishment, is the reason for the restraint. C) Plan to use a square knot to secure the restraint to the side rails. D) Use a limb restraint rather than a jacket restraint for most issues.

B) Explain that safety, not punishment, is the reason for the restraint.

The nurse is caring for a 7-year-old boy who needs his left leg immobilized. What is the priority nursing intervention? A) Enlist the assistance of a child life specialist. B) Explain to the boy that he must keep his leg very still. C) Apply a clove-hitch restraint to the boy's left leg. D) Explain that a restraint will be applied if he cannot hold still.

B) Explain to the boy that he must keep his leg very still.

While auscultating the heart of a 5-year-old child, the nurse notes a murmur that is soft and quiet and heard each time the heart is auscultated. The nurse documents this finding as what grade? A) Grade 1 B) Grade 2 C) Grade 3 D) Grade 4

B) Grade 2

The nurse is caring for families with vulnerable child syndrome. Which situation would be most likely to predispose the family to this condition? A) Having a postterm infant B) Having an infant who is reluctant to feed properly C) Having a child diagnosed with impetigo at age 10 D) Having a child with juvenile diabetes

B) Having an infant who is reluctant to feed properly

The nurse is caring for an infant who had hyperbilirubinemia requiring exchange transfusion. Based on this information, this infant is at risk for what type of disorder? A) Vision loss B) Hearing loss C) Hypertension D) Hyperlipidemia

B) Hearing loss

A 2-week-old child responds to a bell during an initial health supervision examination. The child's records do not show that a newborn hearing screening was done. Which is the best action for the nurse to take? A) Do nothing because responding to the bell proves he does not have a hearing deficit. B) Immediately schedule the infant for a newborn hearing screening. C) Ask the mother to observe for signs that the infant is not hearing well. D) Screen again with the bell at the 2-month-old health supervision visit.

B) Immediately schedule the infant for a newborn hearing screening.

The nurse is teaching the student nurse how to perform a physical assessment based on the child's developmental stage. Which statements accurately describes a recommended guideline for setting the tone of the examination for a school-age child? A) Keep up a running dialogue with the caregiver, explaining each step as you do it. B) Include the child in all parts of the examination; speak to the caregiver before and after the examination. C) Speak to the child using mature language and appeal to his or her desire for self-care. D) Address the child by name; speak to the caregiver and do the most invasive parts last.

B) Include the child in all parts of the examination; speak to the caregiver before and after the examination.

The nurse is explaining the difference between active and passive immunity to the student nurse. Which statement accurately describes a characteristic of the process of immunity? A) Active immunity is produced when the immunoglobulins of one person are transferred to another. B) Passive immunity can be obtained by injection of exogenous immunoglobulins. C) Active immunity can be transferred from mothers to infants via colostrum or the placenta. D) Passive immunity is acquired when a person's own immune system generates the immune response.

B) Passive immunity can be obtained by injection of exogenous immunoglobulins.

The nurse is preparing a nursing care plan for a child hospitalized for cardiac surgery. Which are examples of interventions that nurses perform in the 'building a trusting relationship' stage? Select all that apply. A) Gathering information about the child using the child's own toys B) Preparing the child for a procedure by playing games C) Explaining in simple terms what will happen during surgery D) Allowing the child to devise an exercise plan following surgery E) Praising the child for how well he is doing following instructions F) Giving the child a favorite toy to cuddle following a painful procedure

B) Preparing the child for a procedure by playing games C) Explaining in simple terms what will happen during surgery

The nurse is caring for a 10-year-old girl who is in an isolation room. Which intervention would be a priority intervention for this child? A) Reduce noise as much as possible. B) Provide age-appropriate toys and games. C) Discourage visits from family members. D) Put on mask prior to entering the room.

B) Provide age-appropriate toys and games.

An adolescent is scheduled for outpatient arthroscopic surgery on his knee next week. As part of preparing him for the procedure, which action would be most appropriate? A) Discussing the events with the adolescent and his mother upon arrival the morning of the procedure B) Providing detailed explanations of the procedure at least a week in advance of the procedure C) Encouraging the parent to stay with the adolescent as much as possible before the procedure D) Answering the adolescent's questions with simple answers, encouraging him to ask the surgeon

B) Providing detailed explanations of the procedure at least a week in advance of the procedure

The nurse is measuring the blood pressure of a 12-year-old boy with an oscillometric device. The boy's reading is greater than the 90th percentile for gender and height. What is the appropriate nursing action? A) Repeat the reading with the oscillometric device. B) Repeat the blood pressure reading using auscultation. C) Measure the blood pressure in all four extremities. D) Measure the blood pressure with a Doppler.

B) Repeat the blood pressure reading using auscultation.

The nurse is performing a risk assessment of a 5-year-old and determines the child has a risk factor for cystic fibrosis. What type of screening would the nurse perform to confirm or rule out this disease? A) Universal screening B) Selective screening C) Hyperlipidemia screening D) Developmental screening

B) Selective screening

The nurse strives to provide culturally competent care for children in a health clinic that follows the principles of health supervision. Which nursing action reflects this type of care? A) The nurse treats all children the same regardless of their culture. B) The nurse negotiates a care plan with the child and family. C) The nurse researches the child's culture and provides care based on the findings. D) The nurse provides future-based care for culturally diverse children.

B) The nurse negotiates a care plan with the child and family.

The nurse is performing an admission of a 10-year-old boy. Which actions will help the nurse establish a trusting and caring relationship with the child and his family? Select all that apply. A) The nurse should not minimize the child's fears by smiling. B) The nurse should initiate introductions. C) The nurse should not use formal titles at the introduction. D) The nurse should maintain eye contact at the appropriate level. E) The nurse should start communication with the child first and then move on to the family. F) The nurse should use age-appropriate communication with the child.

B) The nurse should initiate introductions. D) The nurse should maintain eye contact at the appropriate level. F) The nurse should use age-appropriate communication with the child.

After teaching a group of students about therapeutic play, the instructor determines that additional teaching is needed when the students identify what as a characteristic of therapeutic play? A) Focus on coping B) Use of a highly structured format C) Dramatization of emotions D) Expression of feelings

B) Use of a highly structured format

The parents of a 2-day-old girl are concerned because her feet and hands are slightly blue. How should the nurse respond? A) "Your daughter has acrocyanosis; this is causing her blue hands and feet." B) "Let's watch her carefully to make sure she does not have a circulatory problem." C) "This is normal; her circulatory system will take a few days to adjust." D) "This is a vasomotor response caused by cooling or warming."

C) "This is normal; her circulatory system will take a few days to adjust."

The nurse is reviewing the Adolescent Health Transition Project's recommended schedule for transition planning. According to the schedule, at what age should the nurse explore health care financing for young adults? A) 12 years old B) 14 years old C) 17 years old D) 19 years old

C) 17 years old

Assessment reveals that a child weighs 73 pounds and is 4 feet, 1 inch tall. The nurse calculates this child's body mass index as: A) 19.1 B) 20.7 C) 21.4 D) 24.5

C) 21.4

The nurse is providing care for children in a pediatric medical home. What is a characteristic of care in these types of facilities? A) All insurance except Medicaid is accepted. B) Ambulatory care is not provided C) A centralized database contains all child information. D) Continuity of care is provided from infancy through adulthood.

C) A centralized database contains all child information.

he nurse is performing a vision screening for a 4-year-old child. Which screening chart would be best for determining the child's visual acuity? A) Snellen B) Ishihara C) Allen figures D) Color Vision Testing Made Easy (CVTME)

C) Allen figures

The nurse is providing developmentally appropriate care for a toddler hospitalized for observation following a fall down the steps. Which measures might the nurse consider when caring for this child? Select all that apply. A) Use the en face position when holding the toddler. B) Use a bed for toddlers who have an adult present. C) Avoid leaving small objects that can be swallowed in the bed. D) Explain activities in concrete, simple terms. E) Allow the child to select meals and activities. F) Encourage parents to stay to prevent separation anxiety.

C) Avoid leaving small objects that can be swallowed in the bed. F) Encourage parents to stay to prevent separation anxiety.

The nurse is conducting a physical examination of a child following a comprehensive health history. What should be the focus of the physical examination? A) The child B) The parents C) Chief complaint D) Developmental age

C) Chief complaint

The nurse is caring for a toddler with special needs. Which developmental tasks related to toddlerhood might be delayed in the child with special needs? A) Developing body image B) Developing peer relationships C) Developing language and motor skills D) Learning through sensorimotor exploration

C) Developing language and motor skills

The nurse is examining the posture of a male toddler and notes lordosis. What would be the appropriate reaction of the nurse to this finding? A) Explain that the child will need a back brace. B) Refer the toddler to a physical therapist. C) Do nothing; this is a normal condition for toddlers. D) Notify the primary care physician about the condition.

C) Do nothing; this is a normal condition for toddlers.

The nurse is caring for a 4-year-old girl who has been hospitalized for over a week with severe burns. Which would be a priority intervention to help satisfy this preschool child's basic needs? A) Encourage friends to visit as often as possible. B) Suggest that a family member be present with her 24 hours a day. C) Explain necessary procedures in simple language that she will understand. D) Allow her to make choices about her meals and activities as much as permitted.

C) Explain necessary procedures in simple language that she will understand.

The nurse is screening a 6-year-old child for mental ability. Which test would the nurse use to assess intelligence? A) Denver Articulation Screening B) Denver PRQ C) Goodenough-Harris Drawing Test D) Parents' Evaluation of Developmental Status (PEDS)

C) Goodenough-Harris Drawing Tes

The nurse is assessing the neck of an 8-year-old child with Down syndrome. Which finding would the nurse expect during the examination? A) Webbing B) Excessive neck skin C) Lax neck skin D) Shortened neck

C) Lax neck skin

The nurse is caring for a 13-year-old girl hospitalized for complications from type 1 diabetes. The girl has a nursing diagnosis of powerlessness related to lack of control of multiple demands associated with hospitalization, procedures, treatments, and changes in usual routine. How can the nurse help promote control? A) Ask the child to identify her areas of concern. B) Encourage participation of parents in care activities. C) Offer the girl as many choices as possible. D) Enlist the family's assistance in creating a time schedule.

C) Offer the girl as many choices as possible.

The nurse is caring for children in a physician's office where health supervision is practiced. Which are some points of focus of health supervision? Select all that apply. A) Making referrals for all health care needs B) Monitoring disease incidence C) Optimizing the child's level of functioning D) Monitoring quality of care provided E) Teaching parents to prevent injury F) Providing care developed from national guidelines

C) Optimizing the child's level of functioning E) Teaching parents to prevent injury F) Providing care developed from national guidelines

The nurse is teaching a group of parents with premature infants about the various medical and developmental problems that may occur. The nurse determines that additional teaching is needed when the group identifies what as a problem? A) Sudden infant death syndrome B) Hydrocephalus C) Peptic ulcer D) Bronchopulmonary dysplasia

C) Peptic ulcer

The nurse is providing palliative care for a 9-year-old boy in hospice. Which is unique to hospice care for children? A) Encouraging visits from friends and family B) Educating parents about terminal dehydration C) Prolonging treatment that might possibly help D) Treating constipation to relieve abdominal pain

C) Prolonging treatment that might possibly help

The nurse is working as a community health care nurse. What would be the nurse's focus when providing care of the child? A) Providing care to the individual and family in acute care settings B) Providing care to the indigent in family care settings C) Providing care in geographically and culturally diverse settings D) Providing care for particular age groups or particular diagnoses

C) Providing care in geographically and culturally diverse settings

A mother brings her 3-year-old daughter to the emergency department because the child has been vomiting and having diarrhea for the past 36 hours. When assessing this child's temperature, which method would be least appropriate? A) Oral B) Tympanic C) Rectal D) Axillary

C) Rectal

The nurse working in the emergency room monitors the admission of children. Statistically, for which disorder would children younger than 5 years most commonly be admitted? A) Mental health problems B) Injuries C) Respiratory disorders D) Gastrointestinal disorders

C) Respiratory disorders

The mother of a 15-month-old child is questioning the nurse about the need for the hepatitis B vaccination. Which comment provides the most compelling reason for the vaccine? A) "The most common side effect is injection site soreness." B) "This is a recombinant or genetically engineered vaccine." C) "Immunizations are needed to protect the general population." D) "This protects your child from infection that can cause liver disease."

D) "This protects your child from infection that can cause liver disease."

The nurse is performing a health history on a 6-year-old boy who is having trouble adjusting to school. Which question would be most likely to elicit valuable information? A) 'Do you like your new school?' B) 'Are you happy with your teacher?' C) 'Do you enjoy reading a book?' D) 'What are your new classmates like?'

D) 'What are your new classmates like?'

The nurse is assessing the heart rate of a healthy school-age child. The nurse expects that the child's heart rate will be in what ranges? A) 80 to 150 bpm B) 70 to 120 bpm C) 65 to 110 bpm D) 60 to 100 bpm

D) 60 to 100 bpm

The nurse is using pulse oximetry to measure oxygen saturation in a 3-year-old girl. The nurse understands that falsely high readings may be associated with which situation or condition? A) A nonsecure connection B) Cold extremities C) Hypovolemia D) Anemia

D) Anemia

A 3-year-old child is scheduled for a hearing screening. The nurse would prepare the child for screening by which method? A) Auditory brain stem response B) Evoked otoacoustic emissions C) Visual reinforcement audiometry D) Conditioned play audiometry

D) Conditioned play audiometry

The nurse caring for young children in a hospice setting is aware of the following statistics related to the occurrence of death in children. Which statement accurately reflects one of these statistics? A) Each year, about 50,000 children die in the United States; of those, about 15,000 are infants. B) It is unusual for a child's chronic illness to progress to the point of becoming a terminal illness. C) Despite strides made, diabetes remains the leading cause of death from disease in all children older than the age of 1 year. D) Congenital defects and traumatic injuries are the more common causes of diseases leading to death.

D) Congenital defects and traumatic injuries are the more common causes of diseases leading to death.

The nurse working with children in a hospital setting notes that they are being discharged earlier and earlier. Which is a primary reason for this trend? A) Nursing shortages B) Increased funding for home care C) National health care initiatives D) Cost containment

D) Cost containment

The nurse is providing home care for a 1-year-old girl who is technologically dependent. Which intervention will best support the family process? A) Finding an integrated health program for the family B) Teaching modifications of the medical regimen for vacation C) Assessing family expectations for the special needs child D) Creating schedules for therapies and interventions

D) Creating schedules for therapies and interventions

Which would be least appropriate to include in the discharge plan for a medically fragile child? A) Assisting with referrals for financial support B) Arranging for necessary care equipment and supplies C) Assessing the family's home environment D) Encouraging passive caregiving

D) Encouraging passive caregiving

The nurse is caring for an 8-year-old boy hospitalized for a bone marrow transplant. His parents are in and out of his room throughout the day. Which behaviors of the child would alert the nurse that he is in the second stage of separation anxiety? A) He ignores his parents when they return to his room. B) He cries uncontrollably whenever they leave. C) He forms superficial relationships with his caregivers. D) He sits quietly and is uninterested in playing and eating.

D) He sits quietly and is uninterested in playing and eating.

The nurse is weighing an underweight infant diagnosed with failure to thrive (FTT) and notes that the baby does not make eye contact and is less active than the other infants. What would be a probable cause for the FTT related to the infant's body language? A) Congenital heart defect B) Cleft palate C) Gastroesophageal reflux disease D) Maternal abuse

D) Maternal abuse

The nurse is caring for a 14-year-old girl with special health needs. What is the priority intervention for this child? A) Encouraging the parents to promote the child's self-care B) Assessing the child for signs of depression C) Discussing how her care will change as she grows D) Monitoring for compliance with treatment

D) Monitoring for compliance with treatment

The nurse is teaching the student nurse about abnormal findings when assessing the breasts of children. What may be associated with renal disorders? A) Swollen nipples upon inspection of a newborn's breasts B) Tender nodule palpated under the nipple of a 10-year-old C) Observation of enlarged breast tissue in a male adolescent D) Observation of a supernumerary nipple along the mammary ridge

D) Observation of a supernumerary nipple along the mammary ridge

The nurse is transporting a 6-month-old with a suspected blood disorder to the nursery. What is the most appropriate method of transporting the child by the nurse? A) A wagon with rails B) Cradle hold C) Football hold D) Over-the-shoulder

D) Over-the-shoulder

A mother and her 4-week-old infant have arrived for a health maintenance visit. Which activity will the nurse perform? A) Assess the child for an upper respiratory infection B) Take a health history for a minor injury C) Administer a varicella injection D) Plot the child's head circumference on a growth chart

D) Plot the child's head circumference on a growth chart

The nurse is caring for an 8-year-old girl who requires numerous venipunctures and injections daily. The nurse understands that the child is exhibiting signs of sensory overload and enlists the assistance of the child life specialist. What should the therapeutic play involve to best deal with the child's stressors? A) Puppets and dolls B) Drawing paper and crayons C) Wooden hammer and pegs D) Sewing puppets with needles

D) Sewing puppets with needles

A nurse is assessing the fontanels of a crying newborn and notes that the posterior fontanel pulsates and briefly bulges. What do these findings indicate? A) Increased intracranial pressure B) Overhydration C) Dehydration D) These are normal findings.

D) These are normal findings.

The nurse is ordered to apply restraints to a toddler who keeps pulling at the tubes in his arm. Which criteria must occur to ensure proper use of these restraints? Select all answers that apply. A) The nurse must check the restraints every 15 minutes while they are in place. B) Secure the restraints with ties to the side rails, not the bed or crib frame. C) Assess the temperature of the affected extremities, pulses, and capillary refill every 15 minutes after placement. D) Use a clove-hitch type of knot to secure the restraints with ties. E) Remove the restraint every 2 hours to allow for range of motion and repositioning. F) Encourage parent participation, providing continuous explanations about the reasons and time frame for restraints.

D) Use a clove-hitch type of knot to secure the restraints with ties. E) Remove the restraint every 2 hours to allow for range of motion and repositioning. F) Encourage parent participation, providing continuous explanations about the reasons and time frame for restraints.