306- questions on cumulative material

9) A child diagnosed with hemophilia presents to the emergency department (ED) with multiple injuries following a motor vehicle crash. Which injury is the priority when conducting the nursing assessment? 1. Occipital hematoma 2. Radial fracture 3. Dislocated shoulder 4. Abdominal abrasions

Answer: 1 Explanation: 1. A potential intracranial bleed would receive highest priority because of the danger of increased intracranial pressure and potential neurologic damage. 2. Although at risk for bleeding, this would not take priority over a head injury. 3. A dislocation is not at high risk for bleeding or tissue ischemia. 4. Although at risk for bleeding, this would not take priority over a head injury.

23) A school-age child is admitted to the hospital in a sickle-cell crisis. Which actions should the nurse include in the plan of care to address the child's pain? 1. Administering opioid analgesics, per order 2. Administering nonsteroidal anti-inflammatory drugs (NSAIDs), per order 3. Applying cold packs to affected joints, prn 4. Encouraging oral fluid intake 5. Maintaining bed rest

Answer: 1, 2, 4, 5 Explanation: 1. Narcotics, such as morphine, are used to control the pain and reduce sickling. 2. NSAIDs may be used in combination with narcotics to control the pain. 3. Cold application is inappropriate in this situation as it would increase the sickling. 4. Oral fluids will help "thin" the blood and reduce sickling. 5. Bed rest will reduce the oxygen requirements of the body and prevent further sickling. Page Ref: 1265-1268

19) Which pediatric client diagnoses necessitate close monitoring for respiratory acidosis? Select all that apply. 1. Aspiration 2. Epiglottitis 3. Sepsis 4. Meningitis 5. Cystic fibrosis

Answer: 1, 2, 5 Explanation: 1. Aspiration places the pediatric client at risk for respiratory acidosis. 2. Epiglottitis places the pediatric client at risk for respiratory acidosis. 3. Sepsis places the pediatric client at risk for respiratory alkalosis. 4. Meningitis places the pediatric client at risk for respiratory alkalosis. 5. Cystic fibrosis places the pediatric client at risk for respiratory acidosis.

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.

19) A school-age child diagnosed with classic hemophilia is admitted to the hospital for hemorrhage into the knee joint. Which nursing diagnosis should the nurse use to plan care for this child? 1. Risk for Impaired Physical Mobility related to joint stiffness and contractures 2. Risk for Impaired Tissue Perfusion (cerebral) related to blood loss. 3. Activity Intolerance related to bleeding 4. Disturbed Body Image related to swollen knee

Answer: 1 Explanation: 1. A bleed into the joint can lead to permanent contracture of the joint. Bone changes can result from the immobility associated with the bleed. 2. Bleeding into the knee joint tends to be limited and decreased blood flow to the brain is unlikely. 3. Activity intolerance is not the best diagnosis for this child. 4. Although the knee will be swollen, body image is not the priority diagnosis at this time.

2) Which nursing diagnosis should the nurse include in the plan of care for an infant diagnosed with acute bronchiolitis due to respiratory syncytial virus (RSV)? 1. Activity Intolerance 2. Ineffective Peripheral Tissue Perfusion 3. Acute Pain 4. Decreased Cardiac Output

Answer: 1 Explanation: 1. Activity Intolerance is a problem because of the imbalance between oxygen supply and demand. 2. Tissue perfusion (peripheral) is not affected by this respiratory disease process. 3. Acute Pain is not usually associated with acute bronchiolitis. 4. Cardiac Output is not compromised during an acute phase of bronchiolitis.

1) Which instruction from the nurse is appropriate when conducting teaching to new parents regarding infant care and feeding? 1. Delay supplemental foods until the infant is 4 to 6 months old. 2. Begin diluted fruit juice at 2 months of age, but wait 3 to 5 days before trying a new food. 3. Add rice cereal to the nighttime feeding if the infant is having difficulty sleeping after 2 months of age. 4. Delay supplemental foods until the infant reaches 15 pounds or greater.

Answer: 1 Explanation: 1. Age 4 to 6 months is the optimal age to begin supplemental feedings. The infant does not need supplemental foods earlier, and introducing supplemental foods earlier does not promote sleep. 2. Fruit juice and rice cereal are not well tolerated by infants at 2 months of age as they lack the digestive enzymes to take in and metabolize many food products. 3. Fruit juice and rice cereal are not well tolerated by infants at 2 months of age as they lack the digestive enzymes to take in and metabolize many food products. Introducing cereal at this stage will not help promote sleep. 4. Earlier feeding of nonformula foods, regardless of the infant's weight, is more likely to cause the development of food allergies.

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.

11) The nurse is providing care to a child diagnosed with hemophilia who states, "I am going to join a bike club at school." Which recommendation should the nurse give to the child? 1. Wear knee pads, elbow pads, and a helmet while bicycling. 2. Consider a swim club instead of the bicycling club. 3. Do not join the club. 4. Participate only in the social activities of the club.

Answer: 1 Explanation: 1. Children with hemophilia should be encouraged to participate in noncontact sports activities. Bicycling is an excellent option, and is recommended, along with swimming. However, the child should always use knee pads, elbow pads, and a helmet when participating in any physical sport. 2. Biking is an acceptable sport as long as protective equipment is worn, and the child should be encouraged to make choices when possible. 3. Discouraging a child from joining a club would not foster growth and development. 4. Participating only in the social aspects of the club would not encourage physical activity.

16) As a result of opioid administration, a child's respirations are slow and shallow. Which should the nurse anticipate when assessing the child's arterial blood gas? 1. Increased PCO2 and respiratory acidosis 2. Decreased PCO2 and respiratory alkalosis 3. Low pH and low PCO2 4. High pH and high PCO2

Answer: 1 Explanation: 1. Due to inadequate respirations, the child retains CO2 and develops respiratory acidosis. 2. This statement is incorrect as the child retains carbon dioxide. 3. The pH would be acidic, but the pH would be high. 4. The child would have a low pH (acidosis) and high PCO2.

10) Which nursing action is appropriate when treating a school-age child, diagnosed with hemophilia, for a superficial wound above the knee? 1. Applying pressure to the area 2. Applying a warm, moist pack to the area 3. Performing some passive range-of-motion to the affected leg 4. Keeping the affected extremity in a dependent position

Answer: 1 Explanation: 1. If a child with hemophilia experiences a bleeding episode, superficial bleeding should be controlled by applying pressure to the wound. 2. Heat would increase the bleeding by dilating the superficial blood vessels. A cool compress should be applied. 3. The extremity should be immobilized to prevent further bleeding; passive range-of-motion could cause further bleeding at the site. 4. The extremity should be elevated, if possible, to prevent swelling at the site.

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.

11) The nurse is preparing to administer an intramuscular injection to a toddler-age client. Which is the most appropriate statement by the nurse prior to this procedure? 1. "It is all right to cry. After we are done, you can go to the box and pick out your favorite sticker." 2. "We will give you your shot when your mommy comes back." 3. "I will wipe your skin with a magic wipe and then hold the needle like this and say 'one, two, three, go' and give you your shot. Are you ready?" 4. "This is a magic sword that will give you your medicine and make you all better."

Answer: 1 Explanation: 1. The most appropriate response would be to acknowledge the child's feelings and allow the child to pick out a sticker at the conclusion of the injection. 2. Waiting for the mother to come back would be inappropriate because toddlers do not have an understanding of time. 3. Giving elaborate descriptions and using colorful language are inappropriate because the instructions are unclear and lengthy. 4. The nurse should not make statements that are not true and might confuse the child.

7) A nurse is providing care for a pediatric client in the intensive care unit (ICU) who has been on opioids for an extended period of time. Which assessment finding indicates to the nurse that the child is experiencing withdrawal symptoms related to the opioid weaning process? 1. Hyperactive deep tendon reflexes, vomiting, and abdominal cramps. 2. Bradycardia and pallor. 3. Decreased blood pressure and drowsiness. 4. Voracious appetite and hypotonicity.

Answer: 1 Explanation: 1. These are symptoms of withdrawal resulting from reducing the dose too quickly. 2. A child who is being withdrawn from opioids too quickly will be tachycardic and have hot flashes and sweating. 3. The child who is being withdrawn from opioids too quickly will be hypertensive and wakeful. 4. Nausea, abdominal pain, diarrhea, and hypertonicity would be symptoms of withdrawal.

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.

7) Which nursing intervention is contraindicated for a pediatric client who is experiencing thrombocytopenia secondary to chemotherapy treatments? 1. Administering intramuscular injections 2. Monitoring intake and output 3. Palpating during the assessment 4. Providing oral hygiene

Answer: 1 Explanation: 1. When the child is thrombocytopenic (decreased platelets) from chemotherapy, the nurse should not administer intramuscular injections because of the risk of bleeding. 2. Monitoring intake and output is not contraindicated for a pediatric client who is experiencing thrombocytopenia as a result of chemotherapy treatments. 3. Palpation during the assessment is not contraindicated due to thrombocytopenia. This action is contraindicated for a child who is diagnosed with Wilms tumor. 4. Providing oral hygiene is not contraindicated for a pediatric client who is experiencing thrombocytopenia as a result of chemotherapy treatments.

14) The nurse is planning care for a preschool-age child who is intellectually disabled and is scheduled for surgery the next day. Which should the nurse consider when choosing a pain assessment tool? Select all that apply. 1. The child's language skills 2. The child's ability to understand the concept of more and less 3. The child's ability to sit for a 10-minute evaluation 4. The child's ability to perceive pain 5. The child's ability to understand pain

Answer: 1, 2 Explanation: 1. In order to report pain, the child needs adequate verbalization skills to communicate to the nurse. 2. The child who understands more or less can be given a three-option pain scale. The child who cannot understand more or less may need a behavioral pain scale. 3. The assessment does not require the child to sit still. 4. Children perceive pain. The issue is if the nurse can recognize the child's pain. 5. Children do not need to understand pain in order to feel pain.

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 5. Bike safety

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.

21) The nurse is assessing a pediatric client who is experiencing metabolic acidosis. Which assessment questions should the nurse include when interviewing the child's parents? Select all that apply. 1. "Has your child consumed any aspirin?" 2. "Has your child consumed any boric acid?" 3. "Has your child consumed any antifreeze?" 4. "Has your child consumed any baking soda?" 5. "Has your child consumed any antacids?"

Answer: 1, 2, 3 Explanation: 1. An overdose of aspirin is associated with metabolic acidosis. 2. Consumption of boric acid can cause metabolic acidosis. 3. Accidental consumption of antifreeze can cause metabolic acidosis. 4. Consumption of baking soda is associated with metabolic alkalosis. 5. Consumption of antacids is associated with metabolic alkalosis.

18) What is the purpose of making general observations during the assessment process for an infant during a scheduled health maintenance visit? Select all that apply. 1. To invite discussion with the parents 2. To validate positive parenting efforts 3. To promote a partnership between healthcare providers and parents 4. To decrease the risk of communicable diseases 5. To meet standards required for The Joint Commission accreditation

Answer: 1, 2, 3 Explanation: 1. One purpose for making general observations during the infant assessment process is to invite discussion with the parents. 2. One purpose for making general observations during the infant assessment process is to validate positive parenting efforts. 3. One purpose for making general observations during the infant assessment process is to promote a partnership between healthcare providers and parents. 4. Decreasing the risk for communicable diseases is not the purpose for making general observations during the assessment process for an infant. 5. Meeting The Joint Commission accreditation standards is not the purpose for making general observations during the assessment process for an infant.

23) The nurse is providing care to a child who experienced an anaphylactic reaction to an unknown allergen. Which high-risk foods should the nurse question the family about regarding recent consumption? 1. Peanut butter 2. Shrimp 3. Eggs 4. Milk 5. Soda

Answer: 1, 2, 3 Explanation: 1. Peanut products, such as peanut butter, are considered a high-risk food allergen. The nurse should question the family about the consumption of this product. 2. Shellfish, such as shrimp, is considered a high-risk food allergen. The nurse should question the family about the consumption of this product. 3. Egg whites are considered a high-risk food allergen. The nurse should question the family about the consumption of this product. 4. While milk allergies are common, they rarely cause anaphylaxis. 5. Soda is not a high risk for the nurse to include in the assessment process.

16) The nurse is teaching the parents of a 6-month-old infant about the introduction of solid foods. Which foods will the nurse include in the teaching session? Select all that apply. 1. Rice cereal 2. Fruits 3. Vegetables 4. Meats 5. Nut products

Answer: 1, 2, 3 Explanation: 1. Rice cereal is typically the first solid food that is introduced at 6 months of age. It is appropriate to include this food in the teaching session. 2. Fruits are introduced at 6 to 8 months of age. It is appropriate to include this food in the teaching session. 3. Vegetables are introduced at 6 to 8 months of age. It is appropriate to include this food in the teaching session. 4. Meats are not introduced until 8 to 10 months of age. 5. Nut products are not introduced until 2 to 3 years of age.

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.

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.

5) An infant with tetralogy of Fallot (TOF) is having a hypercyanotic episode ("tet" spell). Which nursing interventions are appropriate? Select all that apply. 1. Administer oxygen. 2. Place the child in knee-chest position. 3. Administer morphine and propranolol intravenously as ordered. 4. Draw blood for a serum hemoglobin. 5. Administer diphenhydramine (Benadryl) as ordered.

Answer: 1, 2, 3 Explanation: 1. When an infant with TOF has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). 2. When an infant with TOF has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). 3. When an infant with TOF has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). 4. The nurse would not draw blood until the episode had subsided because unpleasant procedures are postponed. 5. Benadryl is not appropriate for this child.

17) Which actions are appropriate when the nurse is performing general observations during the 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.

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.

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.

24) Which defense mechanisms should the nurse include in the parental teaching session regarding common pediatric responses to a life-threatening illness? Select all that apply. 1. Regression 2. Anticipating 3. Denial 4. Repression 5. Bargaining

Answer: 1, 3, 4, 5 Explanation: 1. Regression is a common defense mechanism portrayed by the pediatric client in response to a life-threatening illness. 2. Anticipating is a coping mechanism, not a defense mechanism, that may be portrayed by the pediatric client in response to a life-threatening illness. 3. Denial is a common defense mechanism portrayed by the pediatric client in response to a life-threatening illness. 4. Repression is a common defense mechanism portrayed by the pediatric client in response to a life-threatening illness. 5. Bargaining is a common defense mechanism portrayed by the pediatric client in response to a life-threatening illness.

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) 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.

) 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

Answer: 2 Explanation: 1. Personal opinions will not carry much weight with a group of adolescents. 2. Whatever the setting, the nurse partners with the adolescent, the parents, and other persons, such as teachers or school counselors, to plan appropriate goals and related interventions. Appropriate interventions include applying communication skills effective with teens, such as listening to concerns, allowing for discussion, and bringing peers who have had experiences related to the topic being discussed. 3. Lecturing without discussion will not draw in the adolescent to the content. 4. Discussing sex education from a religious viewpoint is not appropriate.

14) Which nursing action is best when teaching adolescent health promotion and health maintenance topics? 1. Contacting the parents and asking what issues they have with their adolescents 2. Having the adolescents identify a personal health goal 3. Asking the advice of the counselors at school 4. Telling the adolescents information that will be included in the lecture

Answer: 2 Explanation: 1. Talking to the parents first is not necessary. Common issues that arise for adolescents should be discussed in general and not according to specific individuals. 2. Teaching topics will be directed at both health promotion and health maintenance. A good starting point is to have the adolescent identify a personal health goal, and begin teaching there. 3. It is not necessary for the nurse to ask the counselors at school for advice on health topics. 4. Lecturing an adolescent group is not as effective as having an honest and open discussion with adequate time for questions.

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.

4) A 5-year-old child is hospitalized with a fractured femur. Which tool should the nurse use to assess this child's pain? 1. CRIES Scale 2. Faces Pain Rating Scale 3. SUN Scale 4. PIPP Scale

Answer: 2 Explanation: 1. The CRIES Scale was developed for preterm and full-term neonates. 2. A 5-year-old child should be able to use the Faces Scale to choose which face best matches the child's pain level. 3. The SUN Scale was developed for use in newborns. 4. The PIPP Scale was developed for premature infants.

3) Which statement should the nurse include when teaching parents of an infant about normal growth and development regarding weight gain? 1. "Your baby's weight should triple by 9 months of age." 2. "Your baby's weight should double by 5 months of age." 3. "Your baby's weight should triple by 6 months of age." 4. "Your baby's weight should double by 1 year of age."

Answer: 2 Explanation: 1. The normal infant's birth weight triples by 1 year of age. 2. It is expected that the infant would double in weight by 5 months of age. 3. The infant's birth weight should double by 5 months of age. A child whose weight triples by 6 months of age has gained weight too rapidly. 4. The child's birth weight should triple by 1 year of age. This child may not be growing adequately.

12) During a health maintenance visit an adolescent states, "I have no friends in my new school, and I no longer want to go to college. I know I will be lonely there, too." Which is the priority nursing action? 1. Stressing the importance of remaining in a close parent-child relationship during these stressful times 2. Promoting healthy mental health outcomes 3. Acknowledging the fact that it takes several months to make new friends at a new school due to adolescent exclusion behaviors 4. Helping the adolescent realize the value of postsecondary education

Answer: 2 Explanation: 1. The parent-child relationship should not be used as a substitute for the development of new peer relationships. 2. The adolescent is obviously lonely with the move to the new school. The nurse should focus on appropriate coping skills, which will enhance good mental health outcomes for the child. 3. It would be more upsetting to the adolescent if the nurse made this comment. 4. It would not be appropriate to discuss the importance of a college education at this time because the adolescent must deal with the loss of friends and with developing new friends first.

4) The nurse is teaching the parents of a 4-month-old infant about good feeding habits. Which is the rationale for not letting the baby go to sleep with the bottle? 1. To decrease the risk for aspiration 2. To decrease the risk for dental caries 3. To decrease the risk for malocclusion problems 4. To decrease the risk for sleeping disorders

Answer: 2 Explanation: 1. There have been limited data to date showing a positive correlation to putting a baby to sleep with a bottle and increased risk of aspiration. 2. Infants should not be put to bed with a bottle as this increases the risk for developing dental caries. 3. The primary concerns related to putting an infant to bed with a bottle are dental caries and otitis media. Poor dental alignment is not a significant problem. 4. Sleeping disorders have not been found to be related to letting an infant go to sleep with a bottle.

3) Which is the priority nursing assessment for a pediatric client who is postoperative for tonsillectomy? 1. Arrhythmias 2. Dehydration 3. Increased blood sugar 4. Increased urinary output

Answer: 2 Explanation: 1. Unless the child has a heart condition prior to surgery, arrhythmias is not a possible postoperative complication 2. The child is at risk for dehydration due to deficient fluid volume related to inadequate intake after surgery. The child will anticipate having pain if she tries to swallow. 3. Increased blood sugar will result only if the child is a diabetic. 4. Increased urinary output is not an expected complication of surgery.

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.

20) Which nonpharmacologic interventions are appropriate for the nurse to use when treating pediatric clients in pain? Select all that apply. 1. Regional nerve block 2. Cutaneous stimulation 3. Application of heat 4. Electroanalgesia 5. Use of EMLA cream

Answer: 2, 3, 4 Explanation: 1. A regional nerve block involves injecting medications in an area that controls pain for a region of the body. It does not provide nonpharmacologic relief. 2. Massage and rubbing of the skin as well as swaddling and kangaroo care are nonpharmacologic means of relieving pain. 3. The use of heat (and cold) may help reduce pain sensations and utilizes no pharmacologic agents. 4. Electrical stimulation to the skin uses the gate control theory to relieve pain. 5. EMLA cream is a mixture of lidocaine and prilocaine that is applied to the intact skin. It is a pharmacologic pain relief method.

4) Which parental statements regarding precipitating factors for sickle-cell disease indicate correct understanding of the discharge information presented by the nurse? Select all that apply. 1. "My child should avoid regular exercise." 2. "We should provide acetaminophen or ibuprofen to treat fever." 3. "Our child needs to drink lots of fluid to avoid dehydration when playing sports." 4. "High altitudes can cause exacerbation and should be avoided." 5. "Fluid restriction is necessary to avoid exacerbations from occurring."

Answer: 2, 3, 4 Explanation: 1. Regular exercise and increased fluid intake are recommended activities for a child with sickle-cell disease and will not contribute to a sickle-cell crisis. 2. Fever, dehydration, and altitude are all precipitating factors contributing to a sickle-cell crisis. 3. Fever, dehydration, and altitude are all precipitating factors contributing to a sickle-cell crisis. 4. Fever, dehydration, and altitude are all precipitating factors contributing to a sickle-cell crisis. 5. Regular exercise and increased fluid intake are recommended activities for a child with sickle-cell disease and will not contribute to a sickle-cell crisis.

9) Which parental statement indicates correct understanding regarding pancreatic enzyme administration in the treatment of cystic fibrosis? 1. "I will administer this medication 4 times each day." 2. "I will administer this medication twice each day." 3. "I will administer this medication with meals and snacks." 4. "I will administer this medication every 6 hours around the clock."

Answer: 3 Explanation: 1. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients. 2. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients. 3. Pancreatic enzymes are administered with meals and large snacks. 4. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

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.

11) Which parental statement indicates correct understanding of discharge instructions for a pediatric client after a tonsillectomy? 1. "We will call the healthcare provider for any indication of ear pain." 2. "We will be sure to give our child adequate amounts of citrus juices." 3. "We will plan on administering acetaminophen (Tylenol) for pain." 4. "We will keep our child on bed rest for 10 days after the surgery."

Answer: 3 Explanation: 1. Ear pain 4 to 8 days after a tonsillectomy might be experienced and does not indicate an ear infection. 2. Citrus juices should be avoided for the first week because highly acidic foods and beverages can cause irritation. 3. Acetaminophen (Tylenol) is recommended for pain after a tonsillectomy. 4. Children do not need to be confined to bed. They can return to school in 10 days.

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.

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.

14) Which is the priority teaching point for the nurse to include in the discharge instructions for the parents of a child who was admitted in a sickle-cell crisis? 1. Rapid weaning of pain medications 2. A diet high in protein 3. Adequate hydration 4. Restriction of activities

Answer: 3 Explanation: 1. Rapid weaning is not necessary; reduction of pain medication should proceed at a rate dictated by the child's pain. 2. A high-protein diet is not necessary; a well-balanced diet should be promoted. 3. Adequate hydration will help prevent further sequestration and crisis. 4. Normal activities are not restricted.

9) A child with croup has an increased PCO2, a decreased pH, and a normal HCO3 blood gas value. Which does the nurse report to the healthcare provider based on these data? 1. Uncompensated metabolic alkalosis 2. Uncompensated metabolic acidosis 3. Uncompensated respiratory acidosis 4. Uncompensated respiratory alkalosis

Answer: 3 Explanation: 1. Uncompensated metabolic alkalosis has an increased pH, normal PCO2, and increased HCO3. 2. Uncompensated metabolic acidosis has a decreased pH, normal PCO2, and normal HCO3. 3. If the pH is decreased and the PCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. Also, croup can be a disease process that causes respiratory acidosis. 4. Uncompensated respiratory alkalosis has an increased pH, decreased PCO2, and normal HCO3.

20) Which pediatric client diagnoses necessitate close monitoring for respiratory alkalosis? Select all that apply. 1. Aspiration 2. Epiglottitis 3. Sepsis 4. Meningitis 5. Cystic fibrosis

Answer: 3, 4 Explanation: 1. Aspiration places the pediatric client at risk for respiratory acidosis. 2. Epiglottitis places the pediatric client at risk for respiratory acidosis. 3. Sepsis places the pediatric client at risk for respiratory alkalosis. 4. Meningitis places the pediatric client at risk for respiratory alkalosis. 5. Cystic fibrosis places the pediatric client at risk for respiratory acidosis.

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.

10) A 6-year-old postoperative client's IV infiltrates and has to be restarted immediately for medication. There is no time for placing local anesthetic cream on the skin. Which complementary therapy would be helpful when placing this IV? 1. Restraints 2. Moderate sedation 3. Anesthesia 4. Distraction

Answer: 4 Explanation: 1. Restraints are used only as a last resort and are not appropriate for an IV start. 2. Moderate sedation has its own side effects and possible complications and should not be used for quick procedures. 3. Drugs may not be used for quick procedures, such as a dressing change or an unexpected intravenous insertion, injection, or venipuncture. 4. Complementary therapies—especially guided imagery, relaxation techniques, and distraction—can reduce the anxiety associated with the anticipation of the procedure.

3) The nurse is caring for a postoperative toddler-age child. Which pain assessment tool should the nurse use to assess this child's pain? 1. Poker Chip Tool 2. Oucher Scale 3. Faces Pain Rating Scale 4. FLACC Behavioral Pain Assessment Scale

Answer: 4 Explanation: 1. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales and can usually be used with children 3 years and older. 2. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales and can usually be used with children 3 years and older. 3. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales and can usually be used with children 3 years and older. 4. The FLACC scale is an appropriate tool for infants and young children who cannot report pain.

2) A nurse is taking care of four different pediatric clients. Which child is at greatest risk for dehydration? 1. 7-year-old child with migraine headaches 2. 4-year-old child with a broken arm 3. 2-year-old child with cellulitis of the left leg 4. 18-month-old child with tachypnea

Answer: 4 Explanation: 1. The pediatric client with a chronic or acute condition that does not directly affect the GI or electrolyte system is at a lower risk than is a toddler with a condition that increases insensible water loss. 2. The pediatric client with an acute condition that does not directly affect electrolytes is at a lower risk than is a client with a condition that increases insensible water loss. 3. The pediatric client with an acute condition, such as a client with cellulitis that does not affect the GI or electrolyte system, is at a lower risk than is a toddler with a condition that increases insensible water loss. 4. The pediatric client with the greatest risk is under 2 years of age and with a condition that increases insensible fluid loss.

17) The nurse is planning care for an overweight adolescent. Which topic may also be appropriate for the nurse to include in the adolescent's plan of care? 1. Substance abuse 2. School phobia 3. Spiritual distress 4. Negative self-esteem

Answer: 4 Explanation: 1. This is not the major mental health issue associated with obesity. 2. While the adolescent may dislike attending school, this is not the mental health problem the nurse should be evaluating. 3. Adolescents may have issues related to spirituality, but this is not associated with obesity. 4. Self-esteem is tied closely to body image, a common source of distress among obese adolescents. Therefore, the nurse will monitor the adolescent for issues with self-esteem.

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.

22) The nurse is assessing a pediatric client who is experiencing metabolic alkalosis. Which assessment questions should the nurse include when interviewing the child's parents? Select all that apply. 1. "Has your child consumed any aspirin?" 2. "Has your child consumed any boric acid?" 3. "Has your child consumed any antifreeze?" 4. "Has your child consumed any baking soda?" 5. "Has your child consumed any antacids?"

Answer: 4, 5 Explanation: 1. An overdose of aspirin is associated with metabolic acidosis. 2. Consumption of boric acid can cause metabolic acidosis. 3. Accidental consumption of antifreeze can cause metabolic acidosis. 4. Consumption of baking soda is associated with metabolic alkalosis. 5. Consumption of antacids is associated with metabolic alkalosis.