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The child with Down syndrome should be evaluated for which condition before participating in some sports ? a . Hxnerflexibility b . Cutis macmarata c . Atlantaesial instability d . Speckling of iris ( Brusbild , spots ) :

: C Children with Down syndrome are at risk for aslensoaxial instability . Before participating in sports that put stress on the head and neck , a radiologic examination should be done . Although bxperflexibility is characteristic of Down syndrome , it does not affect the child's ability to participate in sports . Although cutis marmarata is characteristic of Down syndrome , it does not affect the child's ability to participate in sports . Although Brushfield spots are characteristic of Down syndrome , they do not affect the child's ability to participate in sports .

A child who has symptoms of irritable mood , changes in sleep and appetite patterns , decreased self esteem , and disengagement from family and friends lasting 3 weeks meets the criteria for which depressive disorder ? a . Major depressive disorder b . Dysthymic disorder c . Cyclothymic disorder d . Panic disorder

ANS : A A 2 - week ( or longer ) episode of depressed or irritable mood in addition to disturbances in appetite , sleep , energy , or self - esteem meets the criteria for a major depressive disorder . A dysthymic disorder is associated with a depressed or irritable mood for at least a year . A cyclothymic or bipolar mood disorder is characterized by chronic , fluctuating mood disturbances between depressive lows and highs for a year . A panic disorder is a type of anxiety disorder .

A parent asks the nurse why a developmental assessment is being conducted for a child during a routine well - child visit . The nurse answers based on the knowledge that routine developmental assessments during well - child visits are a . not necessary unless the parents request them . b . the best method for early detection of cognitive disorders . c . frightening to parents and children and should be avoided . d . valuable in measuring intelligence in children .

ANS : 8 Early detection of cognitive disorders can be facilitated through assessment of development at each well - child examination Developmental assessment is a component of all well - child examinations , Developmental assessments are not as frightening when the parent and child are educated about the purpose of the assessment . Developmental assessments are not intended to measure intelligence .

A nurse working on the pediatric unit should be aware that children admitted with which of the following assessment findings are suggestive of physical child abuse ? ( Select all that apply . ) a . Bruises in various stages of healing b . Bruises over the shins or bony prominences c . Burns on the palms of the hands d . A fracture of the right wrist from a sports accident e . Rib fractures in an infant

ANS : A , C , E Bruises in various stages of healing and burns on the palms of the hand may be indicative of physical . abuse . Rib fractures in an infant are another indicator of physical abuse . Bruises over the shins or bony prominences are seen in children beginning to walk . A fracture of the right wrist can occur as the child begins to participate in sports activities .

Which statements about performing a pediatric physical assessment are correct for a school - age child ? ( Select all that apply . ) a . Physical examinations proceed systematically from head to toe . b . The physical examination should be done with parents in the waiting room . c . Measurement of head circumference is obtained . d . The physical examination is done only when the child is cooperative . e . Remove clothing and have the child put on an examination gown .

ANS : A , D , E Physical assessment usually proceeds from head to toe ; however , if developmental delays exist , considerations dictate that the least threatening assessments be done first to obtain accurate data . School - age children are at a developmental stage when they should be cooperative for the physical examination . Children of this age are usually modest , and an examination gown should be provided . Having parents in the examining room with adolescents is not appropriate , but it is appropriate for children of other age - groups . Parents usually are not kept in the waiting room . Measurement of head circumference is obtained on children 36 months of age or less .

A nurse should plan to implement which interventions for a child admitted with inorganic failure to thrive ? ( Select all that apply . ) a . Observation of parent - child interactions b . Assignment of different nurses to care for the child from day to day c . Use of 28 - calorie - per - ounce concentrated formulas d . Administration of daily multivitamin Hivitamin supplements e . Role - modeling appropriate adult - child interactions

ANS : A , D , E The nurse should plan to assess parent - child interactions when a child is admitted for nonorganic failure to thrive . The observations should include how the child is held and fed , how eye contact is initiated and maintained , and the facial expressions of both the child and the caregiver during interactions . Role modeling and teaching appropriate adult - child interactions ( including holding , touching , and feeding the child ) will facilitate appropriate parent - child relationships , enhance parents confidence in caring for their child , and facilitate expression by the parents of realistic expectations based on the child's developmental needs . Daily multivitamin supplements with minerals are often prescribed to ensure that specific nutritional deficiencies do not occur in the course of rapid growth . The nursing staff assigned to care for the child should be consistent . Providing a consistent caregiver from the nursing staff increases trust and provides the child with an adult who anticipates his or her needs and who is able to role - model child care to the parent . Caloric enrichment of food is essential , and formula may be concentrated in titrated amounts up to 24 calories ounce . Greater concentrations can lead to diarrhea and dehydration .

A child who has symptoms of irritable mood , changes in sleep and appetite patterns , decreased self esteem , and disengagement from family and friends lasting 3 weeks meets the criteria for which depressive disorder ? a . Major depressive disorder b . Dysthymic disorder c . Cyclothymic disorder +d . Panic disorder

ANS : A A 2 - week ( or longer ) episode of depressed or irritable mood in addition to disturbances in appetite , sleep , energy , or self - esteem meets the criteria for a major depressive disorder . A dysthymic disorder is associated with a depressed or irritable mood for at least a year . A cyclothymic or bipolar mood disorder is characterized by chronic , fluctuating mood disturbances between depressive lows and highs for a year . A panic disorder is a type of anxiety disorder .

Which nursing diagnosis is appropriate for the 5 - year - old child in isolation because of immunosuppression ? a . Spiritual distress b . Social isolation c . Deficient diversional activity d . Sleep deprivation

ANS : C Children in isolation need extra attention to avoid boredom . A 5 - year - old child is not developmentally advanced enough to feel spiritual distress . The main social system for a 5 - year old child is the family , who should be allowed liberal visitation . Sleep deprivation may occur during hospitalization but is not specific to isolation .

A parent of a child with an anxiety disorder states , -I don't know how my child developed this problem . On what information should the nurse base a response ? a . Genetic factors , hormonal imbalances , and societal influences all contribute to the development of anxiety disorders in children . b . Like many conditions affecting children , the etiology of anxiety disorders is unknown . c . The majority of anxiety disorders has a clear pattern of genetic inheritance . d . Dysfunctional family patterns are usually identified as the cause of an anxiety disorder .

ANS : A Anxiety disorders are responses to stress and may be manifested as disturbances in feeling , body functions , behavior , or performance . Children with a history of verbal , physical , or sexual abuse ; frequent separation from or loss of loved ones ; drug use , incarceration , or lower socioeconomic status ; homosexuality : chronic illness ; behavioral disorders ; and dysfunctional families are more likely than peers healthy family patterns to have anxiety disorders . The etiology of many anxiety disorders in children can be identified . Some anxiety disorders are inheritable disorders . Others have been identified as having other origins . Research consistently shows that psychosocial disorders are caused by a combination of predisposing or inherent factors and environmental or interactional factors .

A parent of a child with an anxiety disorder states , I don't know how my child developed this problem . On what information should the nurse base a response ? a . Genetic factors , hormonal imbalances , and societal influences all contribute to the development of anxiety disorders in children . b . Like many conditions affecting children , the etiology of anxiety disorders is unknown c . The majority of anxiety disorders has a clear pattern of genetic inheritance . d . Dysfunctional family patterns are usually identified as the cause of an anxiety disorder

ANS : A Anxiety disorders are responses to stress and may be manifested as disturbances in feeling , body functions , behavior , or performance . Children with a history of verbal , physical , or sexual abuse ; frequent separation from or loss of loved ones ; drug use , incarceration , or lower socioeconomic status ; homosexuality : chronic illness ; behavioral disorders ; and dysfunctional families are more likely than peers healthy family patterns to have anxiety disorders . The etiology of many anxiety disorders in children can be identified . Some anxiety disorders are inheritable disorders . Others have been identified as having other origins . Research consistently shows that psychosocial disorders are caused by a combination of predisposing or inherent factors and environmental or interactional factors .

A student nurse is working with a child in foster care . The child was removed from the home due to abuse . The child is crying for the parents and the student is confused . What information does the registered nurse provide ? a . Children will grieve the loss of parents , even if they were abusive . b . The child needs therapy from a qualified therapist . c . Play therapy will alleviate this behavior . d . The parents may not have been the abusers .

ANS : A Children removed from the home will grieve that loss . Play therapy can be beneficial , but its purpose is not to alleviate displays of grief . The child probably does need therapy , but this does not explain the behavior to the student . Stating that someone else may have abused the child also does not explain the situation .

Which sign or symptom is likely to be manifested by an adolescent with a depressive disorder ? a . Abuse of alcohol b . Impulsivity and distractibility c . Carelessness and inattention to details d . Refusal to leave the house

ANS : A Depression often manifests in conjunction with substance abuse , so children who abuse substances should be evaluated for depression as well . Impulsivity and distractibility are manifestations of attention deficit / hyperactivity disorder ( ADHD ) . A diminished ability to think or concentrate , carelessness , and inattention to details is a clinical manifestation of ADHD . A refusal to leave the house , even to play with friends , is characteristic of separation anxiety disorder

Which sign or symptom is likely to be manifested by an adolescent with a depressive disorder ? a . Abuse of alcohol b . Impulsivity and distractibility . c . Carelessness and inattention to details d . Refusal to leave the house

ANS : A Depression often manifests in conjunction with substance abuse , so children who abuse substances should be evaluated for depression as well . Impulsivity and distractibility are manifestations of attention deficit / hyperactivity disorder ( ADHD ) . A diminished ability to think or concentrate , carelessness , and inattention to details is a clinical manifestation of ADHD . A refusal to leave the house , even to play with friends , is characteristic of separation anxiety disorder .

procedure A nurse is reviewing pediatric physical assessment techniques Which statement about performing a pediatric physical assessment is correct ? a . Physical examinations proceed systematically from head to toe unless developmental considerations dictate otherwise . b . The physical examination should be done with parents in the examining room for children of any age . c . Measurement of head circumference done until the child is 5 years old . d . The physical examination is done only when the child is cooperative .

ANS : A Physical assessment usually proceeds from head to toe ; however , developmental considerations with infants and toddlers dictate that the least threatening assessments be done first to obtain accurate data . Having parents in the examining room with adolescents is not appropriate . Head circumference is routinely measured until 36 months of age . Children will not always be cooperative during the physical examination . The examiner will need to incorporate communication and play techniques to facilitate cooperation .

Which finding noted by the nurse on a physical assessment is most suggestive that a child has been sexually abused ? a . Swelling of the genitalia and pain on urination b . Smooth ghiltrum and thin upper lip c . Speech and physical development delays d . History of constipation , drowsiness , and constricted pupils

ANS : A Physical indicators of sexual abuse may include swelling or itching of the genitalia and pain on urination . Other indicators may include bruises , bleeding , or lacerations of the external genitalia , vagina , or anal area . The infant with fetal alcohol syndrome may have mirceshthalmia or abnormally small eyes or short palpebral fissures , a thin upper lip , and a poorly developed ghiltcum , Children who have been emotionally abused may exhibit speech disorders , lags in physical development , failure to thrive , or hyperactive and disruptive behaviors . Although there is a possibility for speech and developmental delays , these are not more suggestive of sexual abuse than swollen genitalia and pain on urination . Opiates can cause detachment and apathy , drowsiness , constricted pupils , constipation , slurred speech , and impaired judgment .

What should be the major consideration when selecting toys for a child with an intellectual or developmental disability ? a . Safety b . Age appropriateness c . Ability to provide exercise d . Ability to teach useful skills

ANS : A Safety is the primary concern in selecting recreational and exercise activities for all children . This is especially true for children who are intellectually disabled . Age appropriateness should be considered in the selection of toys , but safety is of paramount importance since their intellectual age will be less than their chronological age . Ability to provide exercise and teach skills is also important but not as vital as safety .

Which statement about suicide is correct ? a . Children younger than 10 years of age are least likely to attempt suicide . b . Suicide risk decreases with age . c . Suicide is usually an isolated event in a school community . d . The prevalence of suicide attempts is higher among males .

ANS : A Suicide by children under the age of 10 is uncommon although it is the third leading cause of death in children ages 5 to 10. The risk of suicide increases with age . It is common for suicide to occur in a cluster within a community ( e.g. , schools ) . Males have a 4 % rate of suicide attempts compared to 8 % in females ; however , males are more likely to die after a suicide attempt .

The nurse is preparing a 12 - year - old girl for a bone marrow aspiration . She tells the nurse she wants her mother with her - like before Which response by the nurse is most appropriate ? a . Grant her request . b . Explain why this is not possible . c . Identify an appropriate substitute for her mother . d . Offer to provide support to her during the procedure .

ANS : A The parents ' preferences for assisting , observing , or waiting outside the room should be assessed as well as the child's preference for parental presence . The child's choice should be respected . If the mother and child are agreeable , then the mother is welcome to stay . An appropriate substitute for the mother is necessary only if the mother does not wish to stay . Support is offered to the child regardless of parental presence .

The nurse has a 2 - year - old boy sit in a - tailor position during palpation for the testes . What is the rationale for this position ? a . It prevents Sremasteris reflex . b . Undescended testes can be palpated . c . This tests the child for an inguinal hernia . d . The child does not yet have a need for privacy .

ANS : A The tailor position stretches the muscle responsible for the scemasteris reflex . This prevents its contraction , which pulls the testes into the pelvic cavity .

The long - term treatment plan for an adolescent with an eating disorder focuses on which of the following ? a . Managing the effects of malnutrition b . Establishing sufficient calloric intake c . Improving family dynamics d . Restructuring perception of body image

ANS : A The treatment of eating disorders is initially focused on reestablishing physiologic homeostasis . Once body systems are stabilized , the next goal of treatment for eating disorders is maintaining adequate caloric intake . Although family therapy is indicated when dysfunctional family relationships exist , the primary focus of therapy for eating disorders is to help the adolescent cope with complex issues . The focus of treatment in individual therapy for an eating disorder involves restructuring cognitive perceptions about the individual's body image .

The long - term treatment plan for an adolescent with an eating disorder focuses on which of the following ? a . Managing the effects of malnutrition b . Establishing sufficient caloric intake c . Improving family dynamics d . Restructuring perception of body image

ANS : A The treatment of eating disorders is initially focused on reestablishing physiologic homeostasis . Once body systems are stabilized , the next goal of treatment for eating disorders is maintaining adequate caloric intake . Although family therapy is indicated when dysfunctional family relationships exist , the primary focus of therapy for eating disorders is to help the adolescent cope with complex issues . The focus of treatment in individual therapy for an eating disorder involves restructuring cognitive perceptions about the individual's body image .

What is appropriate to include in the teaching plan for a family of a child with a tracheostomy ? a . Suction the tracheostomy as needed . b . Apply powder around the stoma to decrease irritation . c . Limit suctioning time to 30 seconds . d . Provide showers and discourage baths .

ANS : A To maintain a patent airway in a child with a tracheostomy , assessing respiratory status and suctioning as needed using Standard Precautions is an important intervention to teach families . Talc powder should be avoided because of the risk of inhalation injury from breathing the powder particles . Catheter insertion for suctioning should be less than 5 seconds to prevent hypoxia . The family should be taught to avoid getting water in the tracheostomy during bath time . Showers should be discouraged to include in the teaching plan for a family of a child with a tracheostomy ?

What is critical for the nurse to know when using restraints on a child ? a . Use the least restrictive type of restraint . b . Tie knots securely so they cannot be untied easily . c . Secure the ties to the mattress or side rails . d . Remove restraints every 4 hours to assess skin integrity .

ANS : A When restraints are necessary , the nurse should institute the least restrictive type of restraint possible to meet goals . Knots must be tied so that they can be easily undone for quick access to the child . The ties are never tied to the mattress or side rails . They should be secured to a stable device , such as the bed frame . Restraints are removed every 2 hours to allow for range of motion , position changes , and assessment of skin integrity .

A nurse is performing an assessment on a newborn . Which vital signs indicate a normal finding for this age - group ? ( Select all that apply . ) a . Pulse of 80 to 125 a minute b . B / P of systolic 65 to 95 and diastolic 30 to 60 c . Temperature of 36.5 to 37.3 C ( axillary ) d . Temperature of 36.4 % to 37 C ( axillary ) e . Respirations of 30 to 60 a minute

ANS : B , C , E The blood pressure , temperature , and respiratory rate are all normal for this child . The pulse of 80 to 125 and the temperature of 36.88 to 378 C ( axillary ) are both too low for a well newborn .

The nurse is preparing for the admission of an infant who will have several procedures performed . In which situations is informed consent required ? ( Select all that apply . ) a . Catheterized urine collection b . IV line insertion c . Oxygen administration d . Lumbar puncture e . Bone marrow aspiration

ANS : D , E Informed consent is required for invasive procedures that involve a risk to a child such as lumbart puncture and bone marrow aspiration . Informed consent is not required for procedures that are covered under the general consent to treat that is signed at admission by a parent or a guardian . These include catheterized urine collection , IV insertion , and oxygen administration .

What should the nurse recognize as a possible indicator of child abuse in a 4 - year - old child being treated for ear pain at the emergency department on a cold winter day ? ( Select all that apply . ) a . The child extends his arms to be hugged by the nurse . b . The child is wearing clean , baggy shorts , sandals , and an oversized T - shirt . c . The child answers all questions in complete sentences and smiles afterward . d . The child has dirty , broken teeth . e . The child states - L'm so fat when the nurse tells his mother he weighs 25 lb.

ANS : B , D , E These clothes are inappropriate for the weather and possibly too big . Dirty , broken teeth possibly show neglect of basic needs . Body image distortion is another possible clue to child abuse . Although it may be unusual for this child to want to be hugged by the nurse , it is not an indicator of child abuse . Answering questions using complete sentences and smiling is appropriate for a 4 - year - old .

Which nursing action is the most appropriate when applying a face mask to a child for oxygen therapy ? a . The oxygen flow rate should be less than 6 L / min . b . Make sure the mask fits properly . c . Keep the child warm . d . Remove the mask for 5 minutes every hour .

ANS : B A properly fitting face mask is essential for adequate oxygen delivery . The oxygen flow rate should be greater than 6 L / min to prevent rebreathing of exhaled carbon dioxide . Oxygen delivery through a face mask does not affect body temperature . A face mask used for oxygen therapy is not routinely removed.to new foods.the child from the menu .

Which action by the nurse indicates that the correct procedure has been used to measure vital signs in a toddler ? a . Measuring oral temperature for 5 minutes b . Counting apical heart rate for 60 seconds c . Observing chest movement for respiratory cate d . Recording blood pressure as P / 80

ANS : B Apical pulse measurement when the child is quiet for 1 full minute is the preferred method for measuring vital signs in infants and children ages 2 years and younger . A child younger than 6 years may not be able to hold a thermometer under the tongue . The respiratory rate should be auscultated on the quiet infant or young child for 1 full minute . The nurse should be able to auscultate the blood pressure of a toddler , so this would not be the correct way to document it

The parents of a teen suspect their child is using amphetamines . Manifestations of amphetamine use include ( Select all that apply . ) a . weight gain . b . excessive talking and activity . c . excessive sleeping . d . insomnia e . Agitation

ANS : B DE Euphoria , hyperactivity , agitation , irritability , insomnia , weight loss , tachycardia , and hypertension are expected behaviors and effects of amphetamine abuse . The adolescent using amphetamines is likely to have weight loss , not weight gain . Excessive sleeping may be associated with alcohol abuse or abuse of barbiturates .

In preparing to give enemas to a 4 - year - old child , what action by the nurse is best ? a . Use tap water . b . Only use normal saline c . Insert 120 120 the tip of the tube at least 3 inches d . Instill of 240 ml of solution

ANS : B Isotonic solutions should be used in children . Saline is the solution of choice . Plain water is not used . This is a hypotonic solution and can cause fluid and electrolyte disturbances . The tip of the tubing should be inserted 3 inches ( 7.5 cm ) maximum . 240 to 360 mL is appropriate for this age group .

A parent wants to know why acetaminophen should only be given for 2 days for a fever without checking with the provider . What response by the nurse is best ? a . Acetaminophen is a dangerous drug with bad side effects . b . Long - term acetaminophen use can cause liver damage . c . There may be better fever relievers you could use . d . What if there were something seriously wrong with your child ?

ANS : B Long - term use of acetaminophen can lead to liver damage . It is not a particularly dangerous drug and , like all drugs , has side effects . The provider needs to see the child to determine if something is more seriously wrong , but this statement sounds like a threat . There may be other medications the parent could try , but the main concern is liver damage .

The nurse is assessing a 4 - year - old child's visual acuity . The results indicate a visual acuity of 20/40 in both eyes . The child's father asks the nurse about his son's results . Which response , if made by the nurse , is correct ? a . - Your child will need a referral to the ophthalmologist before he can attend preschool next week . b . - Your child's visual acuity is normal for his age . c . -The results of this test indicate your child may be color blind . d . - Your child did not pass ; he will need to see an eye doctor

ANS : B Normal visual acuity for a 4 - year - old is 20/40 to 20/50 . This finding is normal . No other action is needed .

Which behavior verbalized by a school - age child should alert the school nurse to a problem of possible obsessive - compulsive disorder ( OCD ) ? a . States feelings of worthlessness and sadness every day b . Feels need to ride a bike around the tree in front of the house seven times every day before entering the house c . Recurrent episodes of chest pain , heart palpitations and shortness of breath when entering the computer classroom . d . Deterioration of relationships with family members

ANS : B Obsessive - compulsive disorder ( OCD ) manifests repetitive unwanted thoughts ( obsessions ) or ritualistic actions ( compulsions ) or both . Feelings of worthlessness and sadness are suggestive of a depressive disorder . Panic disorders often cause recurrent episodes of chest pain , heart palpitations , and shortness of breath . These symptoms may be accompanied by a feeling of impending doom . Deterioration of relationships with family members , irregular school attendance , low grades , rebellious or aggressive behavior , and excessive dependence on peer influence are behaviors that may indicate substance abuse .

Which assessment finding is considered a neurologic soft sign in a 7 - year - old child ? a . Plantar reflex b . Poor muscle coordination c . Stereognostic function d . Graphesthesia

ANS : B Poor muscle coordination is a neurologic soft sign . The plantar reflex is a normal response . Stereognostic function refers to the ability to identify familiar objects placed in each hand . Granbesthesia is the ability to identify letters or numbers traced on the palm or back of the hand with a blunt point .

Anticipatory guidance for the family of a preadolescent with a cognitive dysfunction should include information about a . institutional placement b . sexual development c . sterilization . d . appropriate clothing

ANS : B Preadolescents who have a cognitive dysfunction may have normal sexual development without the emotional and cognitive abilities to deal with it . It is important to assist the family and child through this developmental stage . The child may or may not need institutional placement at some point . Sterilization . is not an appropriate intervention when a child has a cognitive dysfunction . By the time a child reaches preadolescence , the family should have received counseling on age - appropriate clothing .

Appropriate interventions to facilitate socialization of the cognitively impaired child include a . providing age - appropriate toys and play activities . b . providing peer experiences , such as scouting , when older . c . avoiding exposure to strangers who may not understand cognitive development . d . emphasizing mastery of physical skills because they are the most delayed .

ANS : B The acquisition of social skills is a complex task . Children of all ages need peer relationships . Parents should enroll the child in preschool . When older , they should have peer experiences similar to other children such as group outings , Boy and Girl Scouts , and Special Olympics . Providing age - appropriate toys and play activities is important . However , peer interactions will better facilitate social development . Parents should expose the child to strangers so that the child can practice social skills . Verbal skills are delayed more than physical skills

An important nursing consideration when performing a bladder catheterization on a young child is to a . use clean technique , not Standard Precautions . b . insert 2 % lidocaine lubricant into the urethra . c . lubricate catheter with water - soluble lubricant such as K - Y Jelly d . delay catheterization for 20 minutes while anesthetic lubricant is absorbed

ANS : B The anxiety , fear , and discomfort experienced during catheterization can be significantly decreased by preparation of the child and parents , by selection of the correct catheter , and by appropriate technique of insertion . Generous lubrication of the urethra before catheterization and use of lubricant containing 2 % lidocaine may reduce or eliminate the burning and discomfort associated with this procedure . Catheterization is a sterile procedure . Water - soluble lubricants do not provide appropriate local anesthesia . Catheterization should be delayed only 2 to 3 minutes . This provides sufficient local anesthesia for the procedure .

Kimberly is having a checkup before starting kindergarten . The nurse asks her to do the - finger - to - nosell test . The nurse is testing for a , deep tendon reflexes . b . cerebellar function . c . sensory discrimination . d . ability to follow directions .

ANS : B The finger - to - nose - test is an indication of cerebellar function . This test checks balance and coordination . It does not assess DTRS , sensory discrimination , or the ability to follow directions .

A nurse is giving a parent information about autism . Which statement made by the parent indicates understanding of the teaching ? a . Autism is characterized by periods of remission and exacerbation . b . The onset of autism usually occurs before 3 years of age . c . Children with autism have imitation and gesturing skills . d . Autism can be treated effectively with medication .

ANS : B The onset of autism usually occurs before 3 years of age . Autism does not have periods of remission and exacerbation . Autistic children lack imitative skills . Medications are of limited use in children with autism .

A parent whose child has been diagnosed with a cognitive deficit should be counseled that intellectual impairment a . is usually due to a genetic defect . b . may be caused by a variety of factors . c . is rarely due to first trimester events . d . is usually caused by parental intellectual impairment .

ANS : B There are a multitude of causes for intellectual impairment In most cases , a specific cause has not been identified . Only a small percentage of children with intellectual impairment are affected by a genetic defect . One third of children with intellectual impairment are affected by first trimester events . Intellectual impairment can be transmitted to a child only if the parent has a genetic disorder .

A newborn assessment shows separated sagittal suture , oblique palpebral fissures , depressed nasal bridge , protruding tongue , and transverse palmar creases . These findings are most suggestive of a . microcephaly . b . Down syndrome . c . cerebral palsy . d . fragile X syndrome .

ANS : B These are characteristics associated with Down syndrome . The infant with microcephaly has a small head . Cerebral palsy is a diagnosis not usually made at birth . No characteristic physical signs are present . The infant with fragile X syndrome has increased head circumference ; long , wide , and / or protruding ears ; long , narrow face with prominent jaw ; hypotonia ; and high arched palate .

The school nurse observes an unkempt child dressed in inappropriate clothing who repeatedly asks for food . About which problem is the nurse concerned ? a . Physical abuse b . Physical neglect c . Emotional abuse d . Sexual abuse

ANS : B These physical and behavioral indicators suggest that parental attention is not being given to the child's physical needs . The child is being neglected . There are no indicators of physical , emotional , or sexual abuse in this scenario .

A teen has told the school nurse about recent suicidal thoughts . What action by the nurse is best ? a . Call the police and the teen's parents . b . Ask if the teen has access to weapons . c . Assess the teen for substance abuse . d . Report the finding to the principal .

ANS : B When a child or adolescent ( or adult ) admits to having suicidal thoughts , the nurse must ensure that person's safety . Along with asking if the person has a definite plan , the nurse must assess for access to weapons . The teen's parents and principal should be notified , but the police do not need to be called . Assessing for substance abuse is not the priority .

Which action by the nurse is appropriate when preparing a child for a procedure ? a . Discourage the child from crying during the procedure . b . Use professional terms so the child will understand what is happening . c . Give the child choices whenever possible . d . Discourage the parents from staying in the room during the procedure .

ANS : C Allowing children to make choices gives them a sense of control . Children ( and adults ) should be given permission to cry . Age - appropriate language should always be used . Parents should be encouraged to stay in the room and give support to the child .

What should the nurse keep in mind when planning to communicate with a child who has autism ? a . The child has normal verbal communication . b . Expect the child to use sign language . c . The child may exhibit monotone speech and echolalia . d . The child is not listening if she is not looking at the nurse .

ANS : C Children with autism have abnormalities in the production of speech such as a monotone voice or echolalia or inappropriate volume , pitch , rate , rhythm , or intonation . The child has impaired verbal communication and abnormalities in the production of speech . Some autistic children may use sign language , but it is not assumed . Children with autism often are reluctant to initiate direct eye contact .

Which action is appropriate when the nurse is assessing breath sounds of an 18 - month - old crying child ? a . Ask the parent to quiet the child so the nurse can listen . b . Auscultate breath sounds and chart that the child was crying . c . Let the child play with the stethoscope for distraction . d . Document that data are not available because of crying .

ANS : C Distracting the child with an interesting activity can assist the child to calm down so an accurate assessment can be made . Asking a parent to quiet the child may or may not work . Auscultating while the child is crying typically results in suboptimal data . The assessment needs to be completed so documenting that data are not available is not appropriate.so that the child can then observe during the procedure .

A home health care nurse is perat working with a child whose parents seem to be quite rigid in their rules and expectations , and seem very distrustful of the nurse . What action by the nurse is most appropriate ? a . Ask the parents why they don't trust outsiders . b . Interview the parents separately . c . Monitor the child for signs of abuse . d . Assess the parents for substance abuse .

ANS : C Families that hold very rigid rules and expectations and who are distrustful of outsiders fit some of the characteristics of an abusive family . The nurse should be alert for signs of abuse in the child . Asking -whyll questions puts people on the defensive . There is no need to separate the parents to interview them . Substance abuse is not indicated .

What heart sound is produced by vibrations within the heart chambers or in the major arteries from the back - and - forth flow of blood ? a . S1,S2 b . Snaps and clicks c . Murmur d . Physiologic splitting

ANS : C Murmurs are the sounds that are produced in the heart chambers or major arteries from the turbulence . of blood flow . Murmurs create a blowing and swooshing sound . S1 and 52 are the normal heart sounds . Snaps and clicks are short , high - pitched sounds heard with valve disorders and do not vary with respirations . The physiologic splitting of 52 , an audible pause between the closing of the aortic and pulmonic valves , frequently heard in children of all ages , is considered normal .

A nurse must dosaax a venipuncture on a 6 - year - old child . An important consideration in providing atraumatic care is to a . use an 18 - gauge needle if possible . b . wait 10 minutes after applying EMLA cream . c . restrain child only as needed to perform venipuncture safely . d . have the parents choose the child's favorite bandage afterward .

ANS : C Restrain child only as needed to perform the procedure safely . Smaller needles are used . After applying EMLA cream , the nurse must wait a minimum of 60 minutes . Allow the child to choose a favorite bandage .

Throughout their life span , cognitively impaired children are less capable of managing environmental challenges and are at risk for a . nutritional deficits . b . visual impairments . c . physical injuries . d . psychiatric problems

ANS : C Safety is a challenge for cognitively impaired children . Decreased capability to manage environmental challenges may lead to physical injuries . Nutritional deficits are related more to dietary habits and the caregivers understanding of nutrition . Visual impairments are unrelated to cognitive impairment . Psychiatric problems may coexist with cognitive impairment ; however , they are not environmental challenges .

Throughout their life span , cognitively impaired children are less capable of managing environmental challenges and are at risk for a . nutritional deficits . b . visual impairments . c . physical injuries . d . psychiatric problems .

ANS : C Safety is a challenge for cognitively impaired children . Decreased capability to manage environmental challenges may lead to physical injuries . Nutritional deficits are related more to dietary habits and the caregivers understanding of nutrition . Visual impairments are unrelated to cognitive impairment . Psychiatric problems may coexist with cognitive impairment ; however , they are not environmental challenges .

An 8 - year - old girl asks the nurse how the blood pressure equipment works . The most appropriate nursing action is to a . ask her why she wants to know . b . determine why she is so anxious . c . explain in simple terms how it works . d . tell her she will see how it works as it is used .

ANS : C School - age children require explanations and reasons for everything . They are interested in the functional aspect of all procedures , objects , and activities . It is appropriate for the nurse to explain how equipment works and what will happen to the child . -Whyl questions are not therapeutic , plus this question makes it sound like the nurse thinks the child does not need this information . The child is not exhibiting anxiety , just requesting clarification of what will be occurring . The nurse must explain how the blood pressure cuff works

Which manifestation is atypical of attention deficit hyperactivity disorder ( ADHD ) ? a . Talking incessantly b . Blurting out the answers to questions before the questions have been completed c . Acting withdrawn in social situations d . Fidgeting with hands or feet

ANS : C The child with ADHD tends to be talkative , often interrupting conversations , rather than withdrawn in social situations . Talking excessively , blurting out the answers to questions , and fidgeting are all characteristics of impulsivity / hyperactivity .

What action is contraindicated when a child with Down syndrome is hospitalized ? a . Determine the child's vocabulary for specific body functions . b . Assess the child's hearing and visual capabilities . c . Encourage parents to leave the child alone to encourage adaptation . d . . Have Have meals served at the child's usual meal times

ANS : C The child with Down syndrome needs routine schedules and consistency . Having familiar people present , especially parents , helps to decrease the child's anxiety . To communicate effectively with the child , it is important to know the child's particular vocabulary for specific body functions . Children with Down syndrome have a high incidence of hearing loss and vision problems and should have hearing and vision assessed whenever they are in a health care facility . Routine schedules and consistency are important to children .

The most appropriate nursing diagnosis for a child with a cognitive dysfunction is a . impaired social interaction . b . deficient knowledge . c . risk for injury . d . ineffective coping .

ANS : C The nurse needs to know that limited cognitive abilities to anticipate danger lead to risk for injury . Safety is a priority for all children with cognitive dysfunction . Impaired social interaction is indeed a concern for the child with a cognitive disorder but does not address the limited ability to anticipate danger . Because of the child's cognitive deficit , knowledge will not be retained and will not decrease the risk for injury . Ineffective individual coping does not address the limited ability to anticipate danger .

The most appropriate nursing diagnosis for a child with a cognitive dysfunction is a . impaired social interaction . b . deficient knowledge . c . risk for injury . d . ineffective coping .

ANS : C The nurse needs to know that limited cognitive abilities to anticipate danger lead to risk for injury . Safety is a priority for all children with cognitive dysfunction . Impaired social interaction is indeed a concern for the child with a cognitive disorder but does not address the limited ability to anticipate danger . Because of the child's cognitive deficit , knowledge will not be retained and will not decrease the risk for injury Ineffective individual coping does not address the limited ability to anticipate danger

A student nurse in the emergency department is preparing to obtain a throat culture on a child with suspected epiglottis secondary to a strep infection . What action by the registered nurse is best ? a . Remind the student to wear personal protective equipment . b . Tell the student to get the child to say - ahhh . c . Consult with the provider prior to obtaining the culture . D inform the parents and child that a sore throat culture is needed

ANS : C The nurse never obtains a throat culture on a child in whom spiglottitis is suspected because it may precipitate sudden airway obstruction . The nurse consults with the provider about this issue . Wearing personal protective equipment , having the child say - ahhh , and informing the child and parents of the needed culture would all be appropriate when obtaining it .

In counseling an adolescent who is abusing alcohol , the nurse explains that alcohol abuse primarily affects which organ of the body ? a . Heart b . Liver c . Brain d . Lungs

ANS : C The primary effect of substance abuse is on the brain , and residually , on the rest of the body . Alcohol affects the entire brain by decreasing its responsiveness . Although an excessive amount of a chemical can cause cardiac abnormalities , the brain is the most commonly affected organ . Long - term alcohol use is known to impair the liver ; however , brain function is decreased by any amount of alcohol intake . The pulmonary system is not the primary target ; however , one commonly abused drug known to cause pulmonary problems is tobacco .

In counseling an adolescent who is abusing alcohol , the nurse explains that alcohol abuse primarily affects which organ of the body ? a . Heart b . Liver c . Brain d . Lungs

ANS : C The primary effect of substance abuse is on the brain , and residually , on the rest of the body Alcohol affects the entire brain by decreasing its responsiveness . Although an excessive amount of a chemical can cause cardiac abnormalities , the brain is the most commonly affected organ . Long - term alcohol use is known to impair the liver ; however , brain function is decreased by any amount of alcohol intake . The pulmonary system is not the primary target ; however , one commonly abused drug known to cause pulmonary problems is tobacco

Which nursing action is most appropriate when treating a child who has a fever of 102.5 " F ( 39.1 " C ) ? a . Restrict fluid intake . b . Administer an aspirin . c . Administer acetaminophen . d . Bathe the child in tepid water .

ANS : C Treatment of a fever can include administration of an antipyretic such as acetaminophen . Dehydration can occur from insensible water loss . Offer the child fluids frequently and evaluate the need for IV therapy . Aspirin is avoided because of the potential association with Bexe syndrome . A sponge or tub bath with tepid water to reduce fever can cause shivering and ultimately increase the child's temperature .

7.A 14 - year - old admits to using marijuana every day with friends after attending school . What phase of substance abuse does this behavior exemplify ? a . Experimentation b . Early drug use c . True drug addiction d . severe drug addiction

ANS : C True drug addiction is identified as regular use of drugs . Physical dependence may be present . Social functioning has a drug focus . With experimentation , the individual tries the drug to see what it is like or to satisfy peers . Early drug use is identified as using drugs with some degree of regularity for their desirable effects . In severe drug addiction , the physical condition of the individual deteriorates , and d a all activities are related to drug use .

7.A 14 - year - old admits to using marijuana every day with friends after attending school . What phase of substance abuse does this behavior exemplify ? a . Experimentation b . Early drug use c . True drug addiction d . Severe drug addiction d . severe drug addiction

ANS : C True drug addiction is identified as regular use of drugs . Physical dependence may be present . Social functioning has a drug focus . With experimentation , the individual tries the drug to see what it is like or to satisfy peers . Early drug use is identified as using drugs with some degree of regularity for their desirable effects . In severe drug addiction , the physical condition of the individual deteriorates , and d a all activities are related to drug use .

Which action is appropriate to promote a toddler's nutrition during hospitalization ? a . Allow the child to walk around during meals . b . Require the child to empty his or her plate . c . Ask the child's parents to bring a cup and utensils from home . d . Select new foods for

ANS : C Using familiar items during mealtimes increases the toddler's sense of security and control and may encourage eating . For safety reasons , -roaming while eating should not be permitted . The child should be seated during meals . Toddlers often use food as a source of control . Forcing a toddler to eat only increases the child's sense of powerlessness . Toddlers also experience food jags , a normal phenomenon when they will only eat certain foods . Hospitalization is a stressful experience for the toddler . It is not the time to introduce the child

The father of a child recently diagnosed with developmental delay is very rude and hostile toward the nurses . This father was cooperative during the child's evaluation a month ago . What is the best explanation for this change in parental behavior ? a . The father is exhibiting symptoms of a psychiatric illness . b . The father may be abusing the child . c . The father is resentful of the time he is missing from work for this appointment . d . The father is experiencing a symptom of grief .

ANS : D After a child is diagnosed with a developmental delay , families typically experience a cycle of grieving that is repeated when developmental milestones are not met . One cannot determine that a parent is exhibiting symptoms of a psychiatric illness on the basis of a single situation . The scenario does not give any information to suggest child abuse . Although the father may have difficulty balancing his work schedule with medical appointments for his child , a more likely explanation for his behavior change is that he is grieving the loss of a normal child .

Many of the physical characteristics of Down syndrome present feeding problems . Care of the infant should include a . delaying feeding solid foods until the tongue thrust has stopped . b . modifying diet as necessary to minimize the diarrhea that often occurs c . providing calories appropriate to child's age . d . using special bottles that may assist the infant with feeding .

ANS : D Breastfeeding may not be possible if the infant's muscle tone or sucking reflex is immature . Mothers should be encouraged to pump breast milk and use special bottles for assistance with feeding Some children with Down syndrome can breastfeed adequately . The child has a protruding tongue , which makes feeding difficult . The parents must persist with feeding while the child continues the physiologic response of the tongue thrust . The child is predisposed to constipation . Calories should be appropriate to the child's weight and growth needs , not age .

Which behavior demonstrated by an adolescent should alert the school nurse to a problem of substance abuse ? a . Reports feelings of worthlessness b . Increased desire for social conformity c . Does not feel need for peer approval d . Deterioration of relationships with family members

ANS : D Deterioration of relationships with family members , irregular school attendance , low grades , rebellious or aggressive behavior , and excessive dependence on peer influence are behaviors that may indicate substance abuse . Feelings of worthlessness are suggestive of a depressive disorder . An adolescent with a substance abuse problem may be depressed , but this behavior is not a manifestation of substance abuse . The clinical manifestations of substance abuse are marked by an increase in antisocial behavior as the desire for social conformity decreases and the need for the substance increases . The adolescent with a substance abuse problem may demonstrate an excessive dependence on peer influence .

During examination of a toddler's extremities , the nurse notes that the child is bowlegged . The nurse should recognize that this finding is a . abnormal , requiring further investigation . b . abnormal unless it occurs in conjunction with knock - knee . c . normal if the condition is unilateral or asymmetric . d . normal , because the lower back and leg muscles are not yet well developed .

ANS : D Genu.varum . ( bowlegged ) is common in toddlers when they begin to walk . It usually persists until all of their lower back and leg muscles are well developed , usually by age 3

When palpating the child's cervical lymph nodes , the nurse notes that they are tender , enlarged , and warm . What is the best explanation for this ? a . Some form of cancer b . Local scalp infection common in children c . Infection or inflammation distal to the site d . Infection or inflammation close to the site .

ANS : D Small grotender , nodes are normal . Tender , enlarged , and warm lymph nodes may indicate infection or inflammation close to their location . They are not indicative of cancer or scalp infection .

Examination of the abdomen is performed correctly by the nurse in which order ? a . Inspection , palpation , and auscultation b . Palpation , inspection , and auscultation c . Palpation , auscultation , and inspection d . Inspection , auscultation , and palpation

ANS : D The correct order of abdominal examination is inspection , auscultation , and palpation . If the nurse percusses the abdomen , that is done prior to palpation . Palpation is always last because it may distort the normal abdominal sounds .

The nurse is providing counseling to the mother of a child diagnosed with fragile X syndrome . She explains to the mother that fragile X syndrome is a . most commonly seen in girls . b . acquired after birth . c . usually transmitted by the male carrier . d . usually transmitted by the female carrier

ANS : D The gene causing fragile X syndrome is transmitted by the mother . Fragile X syndrome is most common in males . Fragile X syndrome is congenital . Fragile X syndrome is not transmitted by a male carrier .

The infant with Down syndrome is closely monitored during the first year of life for what serious condition ? a . Thyroid complications b . Orthopedic malformations c . Dental malformation d . Cardiac abnormalities

ANS : D The high incidence of cardiac defects in children with Down syndrome makes assessment for signs and symptoms of these defects important during the first year . Clinicians recommend the child be monitored frequently throughout the first 12 months of life , including a full cardiac workup . Infants with Down syndrome are not known to have thyroid complications although they can manifest later . Orthopedic malformations may be present , but special attention is given to assessment for cardiac and gastrointestinal abnormalities . Dental malformations are not a major concern compared with the life threatening complications of cardiac defects .

What is the goal of therapeutic management for a child diagnosed with Attention deficit hyperactivity . disorder ( ADHD ) ? a . Administer stimulant medications . b . Assess the child for other psychosocial disorders . c . Correct nutritional imbalances . d . Reduce the frequency and intensity of unsocialized behaviors .

ANS : D The primary goal of therapeutic management for the child with ADHD is to reduce the intensity and frequency of unsocialized behaviors . Although medications are effective in managing behaviors associated with ADHD , all families do not choose to give their child medication .

An adolescent states , -I am very sad . I wish I was not alive . What is the best response by the nurse ? a . -Everyone feels sad once in a while b . - You are just trying to escape your problems.ll c . - Have you told your parents how you feel ?! d . -Have you thought about hurting yourself ?

ANS : D This response acknowledges the adolescent's suicide gesture and further assesses the adolescent's condition . It is judgmental and belittles the teen's feelings to tell the teen that everyone is sad once in a while or to accuse the teen of trying to escape problems . The parents should be made aware of an

An adolescent states , -I am very sad . I wish I was not alive . What is the best response by the nurse ? a . -Everyone feels sad once in a while b . - You are just trying to escape your problems.ll c . - Have you told your parents how you feel ?! d . -Have you thought about hurting yourself ?

ANS : D This response acknowledges the adolescent's suicide gesture and further assesses the adolescent's condition . It is judgmental and belittles the teen's feelings to tell the teen that everyone is sad once in a while or to accuse the teen of trying to escape problems . The parents should be made aware of an adolescent's precarious mental state ; however , this response does not address the adolescent's statement . It also does not begin to provide safety for the teen .