Ch. 3 Pediatric Success - NCLEX Practice Q's

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

Answer: 1. "Wash and dry the child's hands and face before he eats." Rationale: 1.Washing and drying hands and face, especially before eating, decreases lead ingestion. 2. Other measures can be taken to decrease ingestion of lead, such as washing hands and face before eating. 3. Hot water absorbs lead more readily than cold water. 4. Diet does matter; regular meals, adequate iron, calcium, and less fat help the child absorb little lead. TEST-TAKING HINT: The test taker should understand lead poisoning usually occurs with hand-to-mouth activity in toddlers.

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

Answer: 1. "Yes, it is recommended that the baby still get the Hib vaccine." Rationale: 1.The infant needs the Hib vaccine to ensure protection against many serious infections caused by Hib, such as bac- terial meningitis, bacterial pneumonia, epiglottitis, septic arthritis, and sepsis. 2. The infant needs the Hib vaccine to ensure protection against many serious infections caused by Hib, such as bacterial meningitis, bacterial pneumonia, epiglotti- tis, septic arthritis, and sepsis. 3. A nasal swab is used to diagnose a respiratory syncytial virus infection, which is unrelated to a Hib infection. 4. A blood test does not diagnose previous Hib infection in a healthy child. TEST-TAKING HINT: The test taker should understand that the Hib vaccine protects against serious infections.

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

Answer: 1. "Your child will not receive routine immunizations today." Rationale: 1. The nurse acknowledges a client's fears and then discusses the concerns to clarify any misconceptions. Immu- nizations and influenza vaccine are recommended to prevent infection. Immunocompromised HIV-infected children should not receive the varicella and MMR live vaccines. 2. Recommended immunizations for a 12-month-old include varicella and MMR (live vaccines), which are not administered to an immunocompromised child. 3. Recommended vaccines will be adminis- tered because the child is not immuno- compromised. 4. The recommendation is for the child to receive routine immunizations unless the child is immunocompromised. TEST-TAKING HINT: The test taker should know that families and patients who are HIV-positive should be taught ways to prevent infections, including the administration of immunizations.

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

Answer: 1. Ankle and knee joint pain. Rationale: 1.Joint pain or arthritis is the most common symptom of acute rheumatic fever (60% to 80% of first attacks). The joint pain usually occurs in two or more large joints (ankle, knee, wrist, or elbow). 2. Rheumatic fever usually follows group A streptococcal infection, and the culture is usually positive. 3. Large red "bull's-eye" lesions are more characteristic of Lyme disease. The rash associated with rheumatic fever is erythe- matous with a demarcated border. 4. A stiff neck with photophobia is more indicative of meningitis. TEST-TAKING HINT: The test taker should remember the major and minor criteria of rheumatic fever to answer this question.

54. The mother of a 6-month-old states that since yesterday, the infant cries when anyone touches her arm. Which would be the priority assessment after the airway, breathing, and circulation had been assessed and found stable? 1. Ask the mother if she knows what happened. 2. Assess infant for other signs of potential physical abuse. 3. Prepare for radiological diagnostic studies. 4. Establish intravenous access, and draw blood for diagnostic testing.

Answer: 1. Ask the mother if she knows what happened. Rationale: 1.The health-care provider's highest pri- ority should be to try to get the child's history information from the parent. 2. Assess the child for other signs of poten- tial physical abuse after you have deter- mined the child is stable. Children who are physically abused may have other injuries in various stages of healing. 3. Radiological studies will be ordered, but more information as to what may have caused the injury is important information to obtain. 4. Intravenous access and blood tests may not be indicated. TEST-TAKING HINT: The test taker should understand that history information is very important in trying to determine the cause of the arm pain.

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

Answer: 1. Assess airway while simultaneously maintaining cervical spine precautions. Rationale: 1.Priority nursing intervention with pediatric trauma patients is airway assessment while maintaining cervical spine precautions. If the airway is com- promised, immediate corrective action should be taken prior to assessment of breathing. 2. Assessing airway, breathing, and circula- tion will be done in that order, not simultaneously. 3. Diagnostic radiological testing is done after the child is stabilized. 4. Venous access and blood draws are done after airway, breathing, and circulation have been assessed. TEST-TAKING HINT: The test taker should understand that pediatric trauma patients can also have spinal cord injuries and what the priorities are in those situations.

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

Answer: 1. Continuous cardiovascular and oxygen-saturation monitoring. Rationale: 1. Cardiovascular manifestations of Kawasaki disease are the major complications in pediatric patients. Continuous cardiac monitoring is required to alert the nurse of any cardiovascular complications. Decreased oxygen saturation and respiratory changes have been shown to be early indicators of potential complications. 2. Vital signs would be taken every 1 to 2 hours until stable on a new admission with Kawasaki disease. 3. Strict intake and output is very important, but because the major complications with Kawasaki disease are cardiovascular, contin- uous cardiac monitoring is the priority. 4. High-dose aspirin therapy is begun and continued until the child has been afebrile for 48 to 72 hours; then the child is placed on low-dose therapy. TEST-TAKING HINT: The test taker should understand that cardiovascular manifesta- tions of Kawasaki disease are the major complications in pediatric patients.

46. Which would be appropriate anticipatory guidance during the well-care visit of a 17-year-old? 1. Discuss alcohol use and potential for alcohol poisoning. 2. Discuss secondary sex characteristics that will develop. 3. Teach about anger management and safe sex. 4. Teach about peer pressure and desire for independence.

Answer: 1. Discuss alcohol use and potential for alcohol poisoning. Rationale: 1.Developmentally appropriate anticipa- tory guidance for a 17-year-old is to discuss alcohol use and potential for alcohol poisoning. 2. The development of secondary sex charac- teristics would be discussed with a younger adolescent. 3. Discussing their thoughts about anger management and safe sex would be initiated with younger teens. 4. Discussions about peer pressure would be done with younger teens when it is more prominent. TEST-TAKING HINT: The test taker should understand that alcohol poisoning can occur with binge drinking and should be discussed during older adolescent well visits.

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

Answer: 1. Eliminate all milk and lactose-containing foods. Rationale: 1.Galactosemia is a rare autosomal- recessive disorder involving an inborn error of carbohydrate metabolism. The hepatic enzyme galactose-1-phosphate uridyl transferase is absent, causing the failure of galactose to be converted into glucose. Glucose builds up in the bloodstream, which can result in liver failure, cataracts, and renal tubular problems. Treatment of galactosemia involves eliminating all milk and lactose-containing foods, including breast milk. 2. Galactosemia is a rare autosomal-recessive disorder involving an inborn error of car- bohydrate metabolism so that all milk and lactose-containing foods including breast milk are eliminated. 3. Galactosemia is a rare autosomal-recessive disorder involving an inborn error of car- bohydrate metabolism so that all milk and lactose-containing foods including breast milk are eliminated. 4. Galactosemia is a rare autosomal-recessive disorder involving an inborn error of car- bohydrate metabolism so that all milk and lactose-containing foods including breast milk are eliminated. Soy protein is the preferred formula. TEST-TAKING HINT: The test taker should understand that galactosemia is a rare autosomal-recessive disorder involving an inborn error of carbohydrate metabolism.

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

Answer: 1. Inquire which are the favorite sports, discuss the teen's knowledge and application Rationale: 1.Adolescence is a time of need for inde- pendence and learning to make appropri- ate decisions. Safety is always a concern, and tying a safety discussion to the teen's interest in sports will help keep him safe. The nurse needs to inquire about and build on the teen's interests and knowledge. 2. Lecturing to an adolescent would not be appropriate; the nurse needs to determine what the teen knows about safety mea - sures for that sport and then build on that information. 3. Determining whether the teen drinks, smokes, or uses drugs and what he thinks about those activities is the first step. Lecturing is never appropriate. 4. The teen should be addressed directly. TEST-TAKING HINT: The test taker should understand that age and developmentally appropriate injury prevention teachings are most effective.

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

Answer: 1. Observe frequency and nature of stools. Rationale: 1.Cystic fibrosis is inherited as an autosomal-recessive trait, causing exocrine gland dysfunction. About 7% to 10% of newborns with cystic fibrosis present with meconium ileus, so assessing stool frequency and consistency is important. 2. Chest physical therapy would not be initiated in a newborn without a definitive diagnosis. 3. Assessing weight is important in newborns because they can lose up to 10% of their birth weight, and it can take up to 2 weeks for them to regain their birth weight. 4. The newborn would not be placed on fluid restriction even if diagnosed with cystic fibrosis. TEST-TAKING HINT: The test taker should understand that cystic fibrosis is inherited as an autosomal-recessive trait that causes exocrine gland dysfunction and affects the respiratory, gastrointestinal, and reproductive systems.

52. What is the most likely cause of a child's illness if it is unexplained, prolonged, recurrent, and extremely rare, and usually occurs when the mother is present? 1. Genetic disorder. 2. Munchausen syndrome by proxy. 3. Duchenne muscular dystrophy. 4. Syndrome of inappropriate antidiuretic hormone.

Answer: 2. Munchausen syndrome by proxy. Rationale: 1. Genetic disorders can usually be explained by specific testing. Munchausen syndrome by proxy may be the cause of unexplained, prolonged, rare, recurrent illnesses. It usu- ally occurs when the caregiver is present. 2.Munchausen syndrome by proxy may be the cause of unexplained, prolonged, rare, recurrent illnesses. It usually occurs when the caregiver is present. 3. Duchenne muscular dystrophy is a genetic disorder characterized by muscle weakness usually appearing in the third year of life. 4. Syndrome of inappropriate antidiuretic hormone results from hypothalamic dysfunction and is not unexplained. TEST-TAKING HINT: The test taker needs to know the definition of Munchausen syndrome by proxy or else eliminate other options and make an educated guess

45. Which would be the priority nursing intervention for a child with carbon monoxide poisoning? 1. Provide supplemental 100% oxygen. 2. Provide continuous oxygen saturation monitoring. 3. Establish intravenous access. 4. Draw blood for a STAT carbon monoxide level.

Answer: 1. Provide supplemental 100% oxygen. Rationale: 1.100% oxygen via non-rebreather mask is given as quickly as possible if carbon monoxide poisoning is suspected because the signs and symptoms of carbon monoxide poisoning are related to tissue hypoxia. 2. When carbon monoxide enters the blood, it readily combines with hemoglobin to form carboxyhemoglobin. Tissue hypoxia reaches dangerous levels because carbon monoxide does not release easily. Oxygen saturation obtained by oximetry will be normal because oxygen saturation moni- toring does not measure dysfunctional hemoglobin. 3. The priority is to provide supplemental oxygen, then establish intravenous access. 4. Although a carbon monoxide level may be ordered, the highest priority nursing intervention is to administer oxygen. TEST-TAKING HINT: The test taker should understand that 100% oxygen via non- rebreather mask is given as quickly as possible if carbon monoxide poisoning is suspected.

60. Which statement is true of shaken baby syndrome? 1. There may be absence of external signs of injury. 2. Shaken babies usually do not have retinal hemorrhage. 3. Shaken babies usually do not have signs of a subdural hematoma. 4. Shaken babies have signs of external head injury.

Answer: 1. There may be absence of external signs of injury. Rationale: 1.There may be absence of external signs of injury in shaken baby syndrome because the injury can cause retinal hemorrhage and subdural hematoma. 2. Retinal hemorrhage is indicative of shaken baby syndrome in an infant without external signs of injury. 3. Subdural hematoma is indicative of shaken baby syndrome in an infant without exter- nal signs of injury. 4. Infants with shaken baby syndrome do not usually have signs of external head injury. TEST-TAKING HINT: The test taker should understand that there may be an absence of external signs of injury in shaken baby syndrome.

48. What would be the nurse's best advice to a mother who says her 3-year-old ingested Visine eye solution? 1. "Initiate vomiting immediately." 2. "Call the Poison Control Center." 3. "Call the pediatrician right away." 4. "Dilute with milk 1:1 volume of suspected ingestion."

Answer: 2. "Call the Poison Control Center." Rationale: 1. Vomiting is contraindicated with this medication; the best advice is to call Poison Control first. Visine (topical sym- pathomimetic) can cause serious or fatal consequences if even a little is ingested. 2.Calling Poison Control is the first step for ingestion of any known or unknown substance. Visine (topical sympath- omimetic) can cause serious or fatal consequences if even a little is ingested. 3. The parents of any child who has had an unintentional ingestion should be counseled to call Poison Control to determine treat- ment. Visine (topical sympathomimetic) can cause serious or fatal consequences if even a little is ingested. 4. Overdoses are not treated with diluted milk unless indicated. TEST-TAKING HINT: The test taker should understand that in cases of drug poison- ings, Poison Control should be called immediately.

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

Answer: 2. "He will have normal development for about 6 months before progressive developmental delays occur." Rationale: 1. Tay-Sachs disease is a genetic disorder in which the infant has normal development for the first 6 months. After 6 months, developmental delays and neurological worsening occur. Dietary restriction or providing physical therapy does not change the outcome. 2.Tay-Sachs disease is a genetic disorder in which the infant has normal devel- opment for the first 6 months. After 6 months, developmental delays and neurological worsening occur. Dietary restriction or providing physical ther- apy does not change the outcome. 3. Tay-Sachs disease is a genetic disorder in which the infant has normal development for the first 6 months. After 6 months, developmental delays and neurological worsening occur. Dietary restriction or providing physical therapy does not change the outcome. 4. Tay-Sachs disease is a genetic disorder in which the infant has normal development for the first 6 months. After 6 months, developmental delays and neurological worsening occur. Dietary restriction or providing physical therapy does not change the outcome. TEST-TAKING HINT: The test taker should understand that Tay-Sachs disease is a genetic disorder in which the infant dies in childhood.

61. What would be the best response if the mother of a 10-year-old on kidney dialysis tells the nurse he has no appetite and only eats bananas? 1. "Right now his stomach is upset, and as long as he is eating something to give him strength, it is fine." 2. "Let's talk about your son and his diet." 3. "Bananas are good to eat; they are rich in needed nutrients." 4. "Did you try asking him what else he may want to eat?

Answer: 2. "Let's talk about your son and his diet." Rationale: 1. It would be most therapeutic to discuss with the mother and child the best foods to eat and to avoid on a renal diet. Bananas should be limited because of their high potassium content. Potassium is excreted in the urine. 2.It would be most therapeutic to discuss with the mother and child the best foods to eat and to avoid on a renal diet. Bananas should be limited because of their high potassium content. 3. Bananas are high in potassium, so the number needs to be limited. 4. It would be most therapeutic to discuss with the mother and child the best foods to eat and to avoid on a renal diet. Bananas should be limited because of their high potassium content. TEST-TAKING HINT: The test taker should know dietary restrictions for a child with chronic kidney disease.

57. Which statement by the mother would lead the nurse to suspect sexual abuse in a 4-year-old? 1. "She has just started masturbation." 2. "She has lots more temper tantrums." 3. "She now has an invisible friend." 4. "She wants to spend time with her sister."

Answer: 2. "She has lots more temper tantrums." Rationale: 1. Sexual exploration may be more promi- nent during this stage. 2.Increased temper tantrums, increased sleep disorders, and depression may indicate sexual abuse. 3. Children develop invisible friends about this time and this is a normal part of development. 4. Wanting to spend more time with a sibling is a part of normal development at this age. TEST-TAKING HINT: The test taker should understand that increased temper tantrums, increased sleep disorders, and depression may indicate sexual abuse.

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

Answer: 2. "Take him to the emergency department to ensure that he does not have any internal eye damage." Rationale: 1. Trauma to the eyes and surrounding structures is the leading cause of blindness in children. This incident would be con- sidered blunt force trauma to the eyes, and the child should receive immediate medical attention. 2.This type of eye injury is considered blunt force trauma to the eyes, and the child should be evaluated medically for assessment and prevention of eye damage. Slight blurring could indicate eye injuries, such as detached retina and hyphema, which need immediate medical intervention. 3. This type of eye injury is considered blunt force trauma to the eyes, and the child should be evaluated medically for assessment and prevention of eye damage. Slight blurring could indicate eye injuries, such as detached retina and hyphema, which need immediate medical intervention. 4. This type of eye injury is considered blunt force trauma to the eyes, and the child should be evaluated medically for assess- ment and prevention of eye damage. Slight blurring could indicate eye injuries, such as detached retina and hyphema, which need immediate medical intervention. TEST-TAKING HINT: The test taker should understand that trauma to the eyes and supporting structures are the leading cause of blindness in children.

58. What would be the priority intervention when a 10-year-old comes to the nurse's office because of a headache, and the nurse notices various stages of bruising on the inner aspects of the upper arms? 1. Call her mother and ask if acetaminophen can be given for the headache. 2. Ask the child what happened to her arms, and have her describe the headache. 3. Inquire about the child's headache and bruising on her arms; file mandatory reporting forms. 4. Call her mother to pick her up from school, and complete required school nurse visit forms.

Answer: 2. Ask the child what happened to her arms, and have her describe the headache. Rationale: 1. The priority at this time is to ensure her safety. Coming to the school nurse may be a cry for help 2.Her safety should be ensured first, then discuss physical complaints. School nurses are mandatory reporters of any suspected child abuse. 3. Ensuring the child's safety is the highest priority when a health professional sus- pects child abuse. 4. Ensuring the child's safety is the highest priority when a health professional suspects child abuse. TEST-TAKING HINT: Accurate assessment, description, and documentation should be recorded by the nurse. Child protective personnel should be notified.

56. Which would be the nurse's priority intervention if a 7-year-old's mother tells the nurse she has noticed excessive masturbation? 1. Tell her it is normal development for children of this age. 2. Ask the mother if anyone is abusing the child. 3. Talk with the child and find out why she is touching herself down there. 4. Investigate thoroughly the circumstances in which she masturbates.

Answer: 2. Ask the mother if anyone is abusing the child. Rationale: 1. Masturbation is most common in 4-year-olds and during adolescence. 2.Masturbation may indicate sexual abuse. It is imperative that the nurses do a thorough investigation if a parent is concerned about a child's masturbation. 3. Talking with the child to find out why she is masturbating would be one component of a thorough investigation. Children do not have insight into their behaviors, how- ever, so she may not be able to state why. 4. Masturbation may indicate sexual abuse. It is imperative that the nurse do a thorough investigation if a parent is concerned about a child's masturbation. TEST-TAKING HINT: The test taker should understand that masturbation may indicate sexual abuse.

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

Answer: 2. Avoid Caladryl lotion while taking diphenhydramine (Benadryl). Rationale: 1. To help decrease itching, a cool bath is a better option. Soap and warm water can cause more itching. 2.Caladryl lotion contains diphenhy- dramine (Benadryl), and the child would be at risk for toxicity if the Caladryl is applied to open lesions. 3. Caladryl lotion is applied in an amount to cover the lesions. 4. A cool shower can be soothing and decrease itching. Mild soap is drying to the lesions and can cause more itching. TEST-TAKING HINT: The test taker should understand that Caladryl lotion contains Benadryl.

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

Answer: 2. Consumption of decreased amounts of protein and dairy products is advised. Rationale: 1. PKU is a genetic autosomal-recessive inherited trait. Phenylalanine is an essential amino acid, which makes it impossible to remove totally from the diet. Treatment is a low-phenylalanine diet, which includes some vegetables, fruits, juice, bread, and starches. 2.Many high-protein foods such as meats and dairy products are restricted or eliminated from the diet due to the high phenylalanine content. 3. High-protein foods such as meat and dairy products are restricted to small amounts or eliminated because of their high pheny- lalanine content. 4. Breast milk contains PKU and, if the mother wanted to breast feed, the infant would need careful monitoring of PKU levels. TEST-TAKING HINT: The test taker should understand that PKU is a genetic autosomal-recessive inherited trait. Strict, lifelong dietary restrictions and monitoring are required. Diet management includes meeting the child's nutritional and growth needs while maintaining phenylalanine levels within a safe range.

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

Answer: 2. Contact and droplet respiratory precautions. Rationale: 1. The primary source of transmission is secre- tions from the respiratory tract (droplet) of infected persons (airborne). Transmission occurs by direct contact, skin lesions to a lesser extent, and contaminated objects. 2. Varicella (chickenpox) is highly contagious. Contact and droplet respiratory precau- tions should be started immediately because the primary source of transmission is secretions of the respiratory tract (droplet) and also by contaminated objects. 3. Droplet precaution is very important because that is the primary source of transmission. Transmission also occurs by direct contact and contaminated objects. 4. Standard precautions (formerly universal precautions) should always be maintained; the term refers to protecting oneself from patient's blood or body fluids. TEST-TAKING HINT: The test taker understands that the primary source of transmission of varicella (chickenpox) is secretions of the respiratory tract of infected persons (airborne). Transmission occurs by direct contact, skin lesions to a lesser extent, and contaminated objects.

49. What would be the best response to a mother who tells the nurse that the only way she can get her 2-year-old to take medicine is to call it candy? 1. Tell her that is fine as long as the child takes all of the medicine. 2. Discuss the importance of not calling medicine candy to prevent accidental drug ingestion. 3. Discuss with the mother that the child does not have to take the medicine if she does not want it. 4. Tell the mother her child will have to go to "time-out" if she does not take her medicine.

Answer: 2. Discuss the importance of not calling medicine candy to prevent accidental drug ingestion. Rationale: 1. Medications should never be called candy to prevent the accidental ingestion of medication by children who think it is candy. 2.Medications should never be called candy to prevent the accidental inges- tion of medication by children who think it is candy. 3. This is one of those instances when the toddler has to do something he may not want to do. 4. The medication has to be taken, and the toddler is not given an option. Going to "time-out" delays the administration of the medication. TEST-TAKING HINT: The test taker should understand that medication should never be called candy to prevent accidental ingestion.

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

Answer: 2. Do not administer this batch of vaccine. Rationale: 1. Varicella vaccine should be kept frozen in the lyophilized form. After reconstitution, the varicella vaccine should be given within 30 minutes to ensure viral potency. The five rights of patient medication should always be followed prior to administration. 2.The varicella vaccine integrity cannot be assured if the vaccine is at room temperature, so do not administer. 3. Varicella vaccine should be kept frozen in the lyophilized form. After reconstitution, the varicella vaccine should be given within 30 minutes to ensure viral potency. If the vaccine is not frozen, do not administer. 4. This is an important question to ask the mother but does not address the questions of the nurse finding the varicella vaccine at room temperature. TEST-TAKING HINT: Varicella vaccine should be kept frozen in the lyophilized form. The vaccine diluents can be kept at room temperature.

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

Answer: 2. Elevate head of bed, side rails up, and safety measures in place. Rationale: 1. The head of the bed should be elevated to decrease intracranial pressure. Side rails should be up to help ensure the child stays in bed, and age-appropriate safety measures should be instituted. 2.The head of the bed should be elevated to decrease intracranial pressure. Side rails should be up to help ensure the child stays in bed, and age-appropriate safety measures should be instituted. 3. Drainage from the nose or ear would indicate more severe head injury and would be reported to the physician. The priority would be elevating the head of the bed to decrease intracranial pressure. 4. The child may sleep, but frequent assess- ments will be made, and the child will be awakened often. TEST-TAKING HINT: The test taker should understand that the appropriate nursing intervention would be to elevate the head of the bed to decrease intracranial pressure.

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

Answer: 2. Give the infant the hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth. Rationale: 1. Infants born to mothers of unknown hepatitis B antigen status should be given the hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth. If the mother is positive for hepatitis B antigen, then the baby should receive the hepatitis B immune globulin as soon as possible within 12 hours of birth. Timely administration of the hepatitis B vaccine is important to prevent passive acquisition of hepatitis B from the mother. 2.Infants born to mothers of unknown hepatitis B antigen status should be given the hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth. If the mother is positive for hepatitis B antigen, then the baby should receive the hepatitis B immune globulin as soon as possible within 12 hours of birth. Timely administra- tion of the hepatitis B vaccine is important to prevent passive acquisi- tion of hepatitis B from the mother. 3. Infants born to mothers of unknown hepatitis B antigen status should be given the hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth. If the mother is positive for hepatitis B antigen, then the baby should receive the hepatitis B immune globulin as soon as possible within 12 hours of birth. Timely administration of the hepatitis B vaccine is important to prevent passive acquisition of hepatitis B from the mother. 4. Infants born to mothers of unknown hepatitis B antigen status should be given the hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth. If the mother is positive for hepatitis B antigen, then the baby should receive the hepatitis B immune globulin as soon as possible within 12 hours of birth. Timely administration of the hepatitis B vaccine is important to prevent passive acquisition of hepatitis B from the mother. TEST-TAKING HINT: The test taker should understand that infants born to mothers with unknown hepatitis B antigen status should be given the hepatitis B vaccine within 12 hours of birth.

42. Which intervention would be most appropriate for a 3-year-old who has just ingested dish detergent? 1. Discuss childproofing measures in the home in a nonthreatening manner. 2. Inquire about the circumstances of the ingestion. 3. Discuss having ipecac and the Poison Control phone number in the home. 4. Tell the mother you will be giving the boy medicine to make him throw up.

Answer: 2. Inquire about the circumstances of the ingestion. Rationale: 1. This is not the time to teach about child- proofing the home. The parent will feel guilty, and anxiety would prevent the parent from remembering the advice. 2.The most therapeutic approach is to inquire about the circumstances of the ingestion in a nonjudgmental manner. 3. Ipecac is no longer recommended to be kept in the home because of the increasing number of medications where its use is contraindicated. All households should have the Poison Control number beside a telephone or on speed-dial. 4. This is not the time to teach about child- proofing the home. The parent will feel guilty, and anxiety would prevent the parent from remembering the advice. TEST-TAKING HINT: The test taker needs knowledge of therapeutic communication to answer this question.

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

Answer: 2. Low-protein, limited amino-acid diet. Rationale: 1. Maple syrup urine disease is a genetic inborn error of metabolism. It is a defi- ciency of decarboxylase, which is needed to degrade some amino acids. If left untreated, altered tone, seizures, and death can occur. 2.A child with maple syrup urine disease will be on a low-protein, limited amino-acid diet for life. Patients need a diet high in thiamine. 3. A child with maple syrup urine disease will be on a low-protein, limited amino-acid diet for life. Patients need a diet high in thiamine. 4. A child with maple syrup urine disease will be on a low-protein, limited amino-acid diet for life. Patients need a diet high in thiamine. TEST-TAKING HINT: Maple syrup urine dis- ease is a genetic disorder with restricted branched-chain amino acids, for example, valine, leucine, and isoleucine.

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

Answer: 2. Neurovascular integrity. Rationale: 1. Neurovascular integrity should be assessed first and frequently because neurovascular compromise may cause serious conse- quences. Neurovascular integrity should be assessed using the 5 Ps: increased Pain out of proportion with injury, Pallor of extremity, Paresthesia, Pulselessness at distal part of extremity, and Paralysis post cast application. Cast integrity would be assessed, but neurovascular integrity is the highest priority. 2.Neurovascular integrity should be assessed first and frequently because neurovascular compromise may cause serious consequences. Neurovascular integrity should be assessed using the 5 Ps: increased Pain out of proportion with injury, Pallor of extremity, Paresthesia, Pulselessness at distal part of extremity, and Paralysis post cast application. 3. Neurovascular integrity should be assessed first and frequently because neurovascular compromise may cause serious conse- quences. Neurovascular integrity should be assessed using the 5 Ps: increased Pain out of proportion with injury, Pallor of extremity, Paresthesia, Pulselessness at distal part of extremity, and Paralysis post cast application. Musculoskeletal integrity would be assessed after neurovascular integrity. 4. Neurovascular integrity should be assessed first and frequently because neurovascular compromise may cause serious conse- quences. Neurovascular integrity should be assessed using the 5 Ps: increased Pain out of proportion with injury, Pallor of extremity, Paresthesia, Pulselessness at distal part of extremity, and Paralysis post cast application Soft-tissue integrity is assessed last. TEST-TAKING HINT: The test taker should understand that neurovascular integrity should be assessed first.

17. Which signs and symptoms would the nurse expect to assess in a newborn with congenital hypothyroidism? 1. Preterm, diarrhea, and tachycardia. 2. Post-term, constipation, and bradycardia. 3. High-pitched cry, colicky, and jittery. 4. Lethargy, diarrhea, and tachycardia.

Answer: 2. Post-term, constipation, and bradycardia. Rationale: 1. Congenital hypothyroidism clinical manifestations may include bradycardia, constipation, poor feeding, lethargy, galactose-1-phosphate uridyl transferase, jaundice prolonged for more than 2 weeks, cyanosis, respiratory difficulties, hoarse cry, large anterior/posterior fontanels, post- term, birth weight greater than 4000 g. 2.Congenital hypothyroidism clinical manifestations may include bradycardia, constipation, poor feeding, lethargy, jaundice prolonged for more than 2 weeks, cyanosis, respiratory difficul- ties, hoarse cry, large anterior/posterior fontanels, post-term, and birth weight greater than 4000 g. 3. High-pitched cry, being colicky and jittery usually indicate drug withdrawal or a neurological problem. 4. Congenital hypothyroidism clinical manifestations may include bradycardia, constipation, poor feeding, lethargy, jaundice prolonged for more than 2 weeks, cyanosis, respiratory difficulties, hoarse cry, large anterior/posterior fontanels, post-term, and birth weight greater than 4000 g. TEST-TAKING HINT: The test taker needs to know clinical manifestations of hypothyroidism to answer this question.

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

Answer: 2. Provide the vaccine information statement handout, and answer all questions. Rationale: 1. Written information about the vaccine should always be given prior to any immunization administered as well as allowing time for questions. Accurate documentation should always occur after immunizations are given. 2.Written information about the vaccine should always be given prior to any immunization administered as well as allowing time for questions. 3. Administer the most painful immunization last. 4. The word "shots" has a negative connotation to parents and should be avoided. TEST-TAKING HINT: The test taker should understand that the vaccine information statement must be given and discussed with the parent before administering the vaccine.

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

Answer: 2. Serial assessments of level of consciousness. Rationale: 1. History of loss of consciousness and length of time unconscious is important information, but serial assessments give current information. 2.Serial assessments of level of consciousness are the most important observations of a child after any injury. That information tells you if the child's condition is changing. 3. Initial neurological assessments are impor- tant but only provide a baseline. 4. Initial vital signs and oxygen saturation level give a baseline and help when looking at serial assessments. TEST-TAKING HINT: The test taker should understand that serial observations of the child's level of consciousness are the most important nursing observations.

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

Answer: 2. The child does not need to be isolated from the older siblings. Rationale: 1. The rash is pink and maculopapular, not vesicular. The incubation period is 5 to 15 days and more commonly seen in children 6 months to 3 years of age. Isolating the siblings is not necessary. 2. Roseola transmission is unknown and more commonly seen in children 6 months to 3 years of age, so siblings do not need to be isolated. 3. Because the siblings have no history of seizures, it is not necessary to administer acetaminophen to prevent seizures. 4. Febrile seizures are not usually seen in children older than 6 years, and because they have no history of seizures, it is not necessary to monitor them for seizure development. TEST-TAKING HINT: The test taker should understand that exanthema subitum (roseola) transmission is unknown, and usually limited to children 6 months to 3 years of age; isolation is not necessary.

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

Answer: 2. The newborn should receive the hepatitis B vaccine and hepatitis B immune Rationale: 1. The newborn should receive both hepati- tis B vaccine and hepatitis B immune globulin within 12 hours of birth to prevent hepatitis B infection. 2.The newborn should receive both hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth to prevent hepatitis B infection. 3. The newborn should receive both hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth to prevent hepatitis B infection. 4. The newborn should receive both hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth to prevent hepatitis B infection. TEST-TAKING HINT: The test taker should understand that infants born to mothers positive for hepatitis B antigen should receive hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth to prevent infection.

59. Which statement is true of abused children? 1. They will tell the truth if asked about their injuries. 2. They will repeat the same story that their parents tell. 3. They usually are not noted to have any changes in behavior. 4. They will have outgoing personalities and be active in school activities.

Answer: 2. They will repeat the same story that their parents tell. Rationale: 1. Abused children frequently lie about their injuries from fear about what will happen to them. 2.Abused children frequently repeat the same story that their parents tell. 3. Changes in behavior may suggest abuse. 4. Children who are abused may become withdrawn and not participate in school activities. TEST-TAKING HINT: The test taker should understand that abused children commonly repeat the same story that their parents tell to avoid being punished.

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

Answer: 3. "Call the physician if he develops a bloody stool or diarrhea." Rationale: 1. There is a very small incidence of infants developing intussusception, signaled by the onset of bloody stool or diarrhea, after receiving oral rotovirus vaccine. Cough is not associated with this vaccine. 2. This is an oral vaccine, not an injectable vaccine. 3.There is a very small incidence of infants developing intussusception, signaled by the onset of bloody stool or diarrhea after receiving oral rotavirus vaccine. 4. There is a very small incidence of infants developing intussusception, signaled by the onset of bloody stool or diarrhea after receiving oral rotavirus vaccine. TEST-TAKING HINT: The test taker should know potential adverse effects from the oral rotavirus vaccine.

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

Answer: 3. "Never leave the baby unattended on a raised, unguarded area." Rationale: 1. The priority is to prevent the infant from rolling off a raised surface. Placing safety locks is done when the infant is a few months old. 2. The infant should be transported in the middle of the back seat of the vehicle, which is considered the safest place. 3.The highest priority in newborn injury prevention is never to leave the baby unattended on a raised, unguarded surface. Involuntary reflexes may cause the infant to move and fall. 4. Placing safety guards is the priority when the infant is a few months old and mobile. TEST-TAKING HINT: The test taker knows developmentally appropriate injury prevention and then discusses it with the parent.

53. Which statement would be most therapeutic to a child the nurse suspects has been abused? 1. "Who did this to you? This is not right." 2. "This is wrong that your mother did not protect you." 3. "This is not your fault; you are not to blame for this." 4. "I will not tell anyone."

Answer: 3. "This is not your fault; you are not to blame for this." Rationale: 1. Immediately asking who did this is not therapeutic. 2. Blaming the mother for not protecting the child is inappropriate. 3.When communicating with a child you think may have been abused, it is the most therapeutic to tell the child it is not the child's fault. 4. Someone has to be told, so lying to the child is not appropriate or therapeutic. TEST-TAKING HINT: The test taker should understand that if someone verbalizes abuse, therapeutic communication is extremely important to use.

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

Answer: 3. "You should rest, apply ice wrapped in a towel, elevate the wrist above the heart, Rationale: 1. For the first 24 hours, rest, ice, compres- sion, and elevation (RICE) are recom- mended for acute injury. The wrist should be kept immobile and elevated. 2. The wrist should be kept immobile and elevated. 3.For the first 24 hours, rest, ice, compression, and elevation (RICE) are recommended for acute injury. 4. For the first 24 hours, rest, ice, compres- sion, and elevation are recommended for acute injury. TEST-TAKING HINT: The test taker should remember the acronym RICE (rest, ice, compression, and elevation) or ICES (ice, compression, elevation, support).

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

Answer: 3. A low-phenylalanine diet. Rationale: 1. PKU is inherited as an autosomal- recessive trait. The enzyme phenylalanine hydroxylase controlling the conversion of phenylalanine to tyrosine is missing. A low-phenylalanine diet is the treatment to prevent brain damage. 2. PKU is inherited as an autosomal- recessive trait. The enzyme phenylalanine hydroxylase controlling the conversion of phenylalanine to tyrosine is missing. A low-phenylalanine diet is the treatment to prevent brain damage. 3.PKU is inherited as an autosomal- recessive trait. The enzyme phenylala- nine hydroxylase controlling the con- version of phenylalanine to tyrosine is missing. A low-phenylalanine diet is the treatment to prevent brain damage. 4. Breast milk has low amounts of phenylala- nine, so the mother can breastfeed with monitoring of phenylalanine levels in the infant. TEST-TAKING HINT: The test taker should understand that PKU is a genetic inher- ited autosomal-recessive trait caused by a missing enzyme. This enzyme is needed to metabolize the essential amino-acid phenylalanine.

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

Answer: 3. All-terrain vehicles are not recommended for those younger than 16 years of age. Rationale: 1. The teen may be at the developmental stage of seeking independence, but adolescents do not yet have the emotional or physical development to operate all-terrain vehicles. The American Academy of Pediatrics states that those younger than 16 years should not operate all-terrain vehicles. Wearing safety apparel is important in all sports. 2. The teen may be at the developmental stage of seeking independence, but adolescents do not yet have the emotional or physical development to operate all-terrain vehicles. The American Academy of Pediatrics states that those younger than 16 years should not operate all-terrain vehicles. 3.The teen may be at the developmental stage of seeking independence, but adolescents do not yet have the emotional or physical development to operate all-terrain vehicles. The American Academy of Pediatrics states that those younger than 16 years should not operate all-terrain vehicles. 4. The teen may be at the developmental stage of seeking independence, but adolescents do not yet have the emotional or physical development to operate all-terrain vehicles. The American Academy of Pediatrics states that those younger than 16 years should not operate all-terrain vehicles. TEST-TAKING HINT: The test taker should understand that in early adolescence the teen does not have the physical or emotional development to handle all- terrain vehicles.

43. Which would be the most appropriate intervention for a 4-year-old brought to the emergency department after ingesting a small watch battery? 1. No treatment would be needed; assess and monitor airway, breathing, circulation, and abdominal pain. 2. Ask the mother the time of the ingestion; if it was more than 2 hours ago, it will probably pass in his bowel movement. 3. Assess and monitor airway, breathing, circulation, and abdominal pain; anticipate admission and prepare for surgical intervention. 4. Discuss childproofing measures needed in the home with a 4-year-old child; provide anticipatory guidance concerning other possible poisonous ingestions.

Answer: 3. Assess and monitor airway, breathing, circulation, and abdominal pain; anticipate admission and prepare for surgical intervention. Rationale: 1. A battery is considered a corrosive poison, and medical attention should be sought. 2. Determining the time of ingestion is im- portant, but treatment should be started when a battery is ingested. 3.Batteries are considered corrosives; the child will be admitted, and surgery may be necessary for removal. 4. This is not the time to discuss childproof- ing measures. The parent would be anx- ious and feel guilty about the ingestion. TEST-TAKING HINT: The test taker should understand that a battery is considered a poison and that medical attention is required.

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

Answer: 3. Epinephrine 1:1000 injection. Rationale: 1. Epinephrine 1:10,000 injection should be given intravenously only. Most children in a clinic or office setting receive immuniza- tions during their well-child visit and do not have intravenous catheters in place for immediate access. It's important to have Benadryl available also but not as impor- tant as having epinephrine. 2. Epinephrine 1:10,000 injection should be given intravenously only. Most children in a clinic or office setting receive immuniza- tions during their well-child visit and do not have intravenous catheters in place for immediate access. 3.Epinephrine 1:1000 injection would be the drug of choice for subcutaneous injection if a severe allergic reaction occurs in an office or clinic setting. 4. Epinephrine 1:10,000 injection should be given intravenously only. Most children in a clinic or office setting receive immuniza- tions during their well-child visit and do not have intravenous catheters in place for immediate access. Benadryl liquid is important to have available also, but it is not as important as having epinephrine available. TEST-TAKING HINT: The test taker understands that in all offices and clinics offering immunizations, epinephrine is the most important medication to have on hand in the event of an allergic reaction. Epinephrine's usual dose is 0.01 mg/kg of 1:1000 subcutaneous solution.

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

Answer: 3. Immediately initiate droplet face-mask precautions, and isolate the infant. Rationale: 1. Weighing the child would be important but not the priority when concerned about an infectious cause. Initiating droplet precau- tions to prevent infecting others would be a priority, then weighing the infant. 2. The symptoms are not suggestive of a cold but something more serious. Infants do not usually lose weight, nor are they irritable with a simple cold. 3. Children with tuberculosis may have a history of living in a crowded home or could be homeless. Other symptoms may include a cough, cold symptoms, low-grade fever, irritability, poor appetite, and exposure to a person with tuberculosis. Initiation of droplet precautions and isolation of the infant would be warranted in this situation. 4. Taking the infant's temperature is important, but initiating droplet precautions would be the priority. TEST-TAKING HINT: The test taker should be highly suspicious of tuberculosis given the family and patient history. Health-care personnel need to be vigilant to contain and prevent further spread of communicable diseases. This child could have meningitis, which would also require isolation and respiratory precautions.

50. Which nursing plan would be most successful if the nurse has to administer activated charcoal to a 5-year-old? 1. Have the parents tell him he has to drink it while providing a movie to distract him. 2. Tell him it is candy, it tastes good, do not let him look at it, and he will get a toy after he takes it all down. 3. Mix it with a sweetening flavoring, provide a straw, and give it in an opaque cup with a cover. 4. Have his mother take some first to show the boy it does not taste too bad, and then administer it to him quickly.

Answer: 3. Mix it with a sweetening flavoring, provide a straw, and give it in an opaque cup with a cover. Rationale: 1. Charcoal is odorless and tasteless, but the black color should be masked. Providing a movie is a good distraction but is not the best answer. 2. Never tell a child that medicine is candy in order to prevent accidental overdose. 3.Mixing charcoal with a sweetening agent may help the child ingest it. Children usually like sweeter drinks. Hiding the black color in an opaque container with a lid may also make it more palatable. 4. A parent can help by tasting the charcoal first, but getting the child to drink it quickly probably will not happen. TEST-TAKING HINT: The test taker should understand that masking the taste and black color will make the activated charcoal more tolerable.

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

Answer: 3. Perform initial and serial neurological assessments. Rationale: 1. Airway, breathing, and circulation are part of the primary patient assessment. Neurological assessment is the next assessment to perform. 2. The child has been diagnosed with encephalitis. Unless there is a concern about the child's having strep throat, a throat culture would not be obtained. 3.Initial and serial neurological assessments would be a priority nursing intervention in a child with a neurological problem. It is to monitor for changes in neurological status. 4. Encephalitis is usually caused by a virus therefore, antibiotics are not ordered. Antipyretics may be used to help control fevers. TEST-TAKING HINT: The test taker should understand that the primary assessment includes ensuring patent airway, breathing, circulation, and intact neurological status. In a child with a neurological problem, continue monitoring for changes in neurological status.

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

Answer: 3. Symmetrical burns on both feet. Rationale: 1. Burns on both feet are more indicative of a child being held in hot water, thus indi- cating abuse. 2. Burns on the arm may or may not indicate abuse. History information is important to determine that. 3.Physical abuse has certain characteris- tics. Symmetrical burns on both feet indicate abuse. 4. Burns mainly on the right foot might indi- cate the child got into a tub of hot water and then got out without putting the other foot in, which would not indicate abuse. TEST-TAKING HINT: The test taker should understand that physical signs suggestive of abuse are symmetrical burns with absence of splash marks.

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

Answer: 4. "I understand you are afraid. Can we can talk about your concerns?" Rationale: 1. Having the physician come back and talk with the pregnant mother of a 2-year-old with fifth disease is appropriate, but these are certainly concerns the nurse can address by using therapeutic communication. 2. Acknowledging the mother's fear is thera- peutic, and it is appropriate to intervene. 3. Informing the obstetrician would be appro- priate after dealing therapeutically with the mother's concerns. 4.There is less risk of fetal death in the second half of the pregnancy. It is more therapeutic to acknowledge a client's fears. After acknowledging her fears, the appropriate response would be to discuss concerns and clarify any misconceptions. TEST-TAKING HINT: The test taker should understand there is a 10% risk of death if a mother is exposed to erythema infectiosum (fifth disease) during the first half of her pregnancy.

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

Answer: 4. "Penicillin and other drugs that contain lactose as fillers need to be avoided." Rationale: 1. Galactosemia is a rare genetic autosomal- recessive disorder involving an inborn error of carbohydrate metabolism that may affect future children. 2. Infants usually appear normal at birth, but within a few days of ingesting milk begin to vomit and lose weight. 3. Many drugs, such as penicillin, contain unlabeled lactose as filler and need to be avoided. 4.Many drugs, such as penicillin, contain unlabeled lactose as filler and need to be avoided. TEST-TAKING HINT: The test taker should understand that galactosemia is a rare genetic autosomal-recessive disorder involving an inborn error of carbohydrate metabolism that may affect future children.

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

Answer: 4. "Would you mind if we discussed your concerns?" Rationale: 1. A common reaction to the DTaP vaccine is local swelling and redness at the injection site, which disappears in a few days. The nurse should not speak for the physician. 2. This local reaction is not considered an allergic reaction or an indication the child should not receive this immunization again. 3. The nurse is interpreting what the mother is stating to include refusal of all vaccines. 4.This is the therapeutic response, discussing the mother's concerns about the immunizations and local reactions. TEST-TAKING HINT: The test taker needs to know common local reactions to immunizations.

27. Which is the nurse's best response to the mother of a 2-month-old who is going to get IPV immunization when the mother tells the nurse the older brother is immunocompromised? 1. "Your baby should not be immunized because your immunocompromised son could develop polio." 2. "Your baby should receive the oral poliovirus vaccine instead so your immuno- compromised son does not get sick." 3. "You should separate your 2-month-old child from the immunocompromised son for 7 to 14 days after the IPV." 4. "Your baby can be immunized with the IPV; he will not be contagious."

Answer: 4. "Your baby can be immunized with the IPV; he will not be contagious." Rationale: 1. IPV does not contain live poliovirus, so the virus cannot be transmitted to the immunocompromised sibling. 2. The oral polio vaccine contains weakened poliovirus; rarely, the virus can be trans- mitted to someone immunocompromised. The virus is shed in the stool. 3. There is no need to isolate the sibling from the child receiving the inactive poliovirus vaccine because the virus cannot be transmitted. 4.The infant's sibling can and should be immunized as recommended. The infant will not shed the poliovirus. TEST-TAKING HINT: The test taker under- stands that household contacts and siblings of immunocompromised children are able to receive the IPV. They should not receive the oral poliovirus vaccine because there is a rare risk of vaccine-associated polio paralysis.

38. Which is the most appropriate teaching to the parents of a child in the emergency department after a near drowning if the child is awake, alert, and has no respiratory distress? 1. "Your child will most likely be discharged, and you should watch for any cough or trouble breathing." 2. "Your child will need to have a preventive tube for breathing and ventilation to ensure the lungs are clear." 3. "Your child will be fine but sometimes antibiotics are started as a preventive." 4. "Your child will most likely be admitted for at least 24 hours and observed for respiratory distress or any swelling of the brain."

Answer: 4. "Your child will most likely be admitted for at least 24 hours and observed for respiratory distress or any swelling of the brain." Rationale: 1. Any child who has had a near-drowning experience should be admitted for obser- vation. Even if a child does not appear to have any injury from the event, complica- tions can occur within 24 hours. Respira- tory compromise and cerebral edema can be delayed complications. 2. A ventilation tube would not be inserted unless she needs it as determined by her blood gases, x-rays, and clinical picture. 3. Any child who has had a near-drowning experience should be admitted for observation. Even if a child does not appear to have any injury from the event, complications can occur within 24 hours. Respiratory compromise and cerebral edema can be delayed complications. 4.Any child who has had a near-drowning experience should be admitted for observation. Even if a child does not appear to have any injury from the event, complications can occur within 24 hours after the event. Respiratory compromise and cerebral edema can be delayed complications. TEST-TAKING HINT: The test taker should understand that respiratory compromise and cerebral edema may occur 24 hours after near-drowning. This means that children with a near-drowning event should be admitted.

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

Answer: 4. "Your foster child will receive only the Hib and DTaP vaccines today." Rationale: 1. The option is to try to determine immu- nization status by contacting previous health-care providers for a record of vaccines received. If previous providers are unknown, then the child will receive recommended immunizations for age. 2. MMR, Hib, IPV, or hepatitis B vaccines would not routinely be due at this visit. 3. There are usually no harmful effects to a child with unknown immunization status if revaccinated. 4.Vaccines routinely due at 15 months include Hib and DTaP. To catch up missed immunizations the nurse would need the child's immunization record to verify what he has received. TEST-TAKING HINT: The test taker would need to know what to do when the child's immunization status is unknown.

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

Answer: 4. Couple with a history of multiple miscarriages. Rationale: 1. Macrosomia (large for gestational age) does not require genetic counseling. 2. Neonatal abstinence syndrome is a term used to describe a set of symptoms displayed by infants exposed to chemicals in utero. 3. Couples with planned abortions would not need genetic counseling unless there were genetic problems with children and/or adults in their families. 4.Couples with a history of multiple miscarriages, stillbirths, or infertility should be referred for genetic counsel- ing to try to determine the cause of their problems with maintaining a pregnancy. TEST-TAKING HINT: The test taker should understand that couples with multiple miscarriages, stillbirths, or infertility should be referred to genetic counseling to assist in a successful pregnancy.

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

Answer: 4. Diet soda or anything with the sweetener aspartame should be avoided. Rationale: 1. High-protein foods like meats and dairy products are restricted because of their high phenylalanine content. 2. The sweetener aspartame (NutraSweet, Equal) should be avoided because it is converted to phenylalanine in the body. 3. Because of their high-protein content, dairy products are limited or eliminated from the diet. 4.The artificial sweetener aspartame (NutraSweet, Equal) should be avoided because it is converted to phenylala- nine in the body. TEST-TAKING HINT: The test taker should understand how PKU is treated to successfully answer this question.

51. Which statement most accurately describes child abuse? 1. Intentional physical abuse and neglect. 2. Intentional and unintentional physical and emotional abuse and neglect. 3. Sexual abuse of children, usually by an adult. 4. Intentional physical, emotional, and sexual abuse and neglect.

Answer: 4. Intentional physical, emotional, and sexual abuse and neglect. Rationale: 1. Child abuse is intentional physical, emo- tional, and/or sexual abuse and/or neglect. 2. Child abuse is intentional physical, emo- tional, and/or sexual abuse and/or neglect. 3. Child abuse is intentional physical, emo- tional, and/or sexual abuse and/or neglect. 4.Child abuse is intentional physical, emo- tional, and/or sexual abuse and/or neglect. TEST-TAKING HINT: The test taker needs to know the definition.

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

Answer: 4. Provide continuous cardiac monitoring. Rationale: 1. Continuous cardiac monitoring would be the priority because of the bradycardia and dysrhythmias that can occur with digoxin toxicity. Oxygen may be needed if there is enough bradycardia causing a decrease in oxygen saturation. 2. The priority is to establish continuous cardiac monitoring. If it is determined that venous access is necessary, then that can be established. 3. The digoxin level would be good to know, but that is not the priority. 4.Bradycardia and cardiac dysrhythmias are common signs of digoxin toxicity in children. Continuous cardiac monitor- ing is the highest priority to detect dysrhythmias before they became lethal. TEST-TAKING HINT: The test taker should understand that bradycardia and cardiac dysrhythmia are common signs of digoxin toxicity in children.

3. Which clinical assessment of a neonate with bacterial meningitis would warrant immediate intervention? 1. Irritability. 2. Rectal temperature of 100.6°F (38.1°C). 3. Quieter than usual. 4. Respiratory rate of 24 breaths per minute.

Answer: 4. Respiratory rate of 24 breaths per minute. Rationale: 1. Cardiovascular manifestations of Kawasaki disease are the major complications in pediatric patients. Continuous cardiac monitoring is required to alert the nurse of any cardiovascular complications. Decreased oxygen saturation and respiratory changes have been shown to be early indicators of potential complications. 2. Vital signs would be taken every 1 to 2 hours until stable on a new admission with Kawasaki disease. 3. Strict intake and output is very important, but because the major complications with Kawasaki disease are cardiovascular, continuous cardiac monitoring is the priority. 4. High-dose aspirin therapy is begun and continued until the child has been afebrile for 48 to 72 hours; then the child is placed on low-dose therapy. TEST-TAKING HINT: The test taker should understand that cardiovascular manifestations of Kawasaki disease are the major complications in pediatric patients.

47. Which would be the best response to a 10-year-old who asks if she can take acetaminophen daily if she gets aches and pains? 1. Tell her it is better not to take medication if she gets aches and pains; she should check with her mother before taking any medication. 2. Teach her that nonprescription drugs like acetaminophen can be a poisoning hazard if too many are taken; it is best for her to check with her mother. 3. Encourage her to keep a log of when she takes acetaminophen to try to establish what is causing her aches and pains. 4. Sometimes it is okay to take acetaminophen daily, but it depends on why she has aches and pains.

Answer: 4. Sometimes it is okay to take acetaminophen daily, but it depends on why she has aches and pains. Rationale: 1. Tell the child occasional use of acetamino- phen for aches and pains is recommended. Daily use can cause rebound so that when she stops taking the medication, her aches and pains will be worse. At this age, her parents should be involved in her over-the-counter drug use. 2. Too much acetaminophen can cause liver damage; she should check with her mother before taking it. 3. Keeping a log can be helpful in determin- ing what triggers her aches and pains. The priority would be to recommend that she not take pain medication daily. 4.If she needs pain medication daily, a cause needs to be determined. TEST-TAKING HINT: The test taker needs to know what would be considered thera- peutic management of the child's pain.