peds exam 3
22. The school nurse is observing a child in the classroom. The child is speaking and then suddenly stops and stares for about 5 seconds and then continues speaking. The nurse charts this as what type of seizure? A. tonic-clonic B. febrile C. absence D. partial (focal) seizures
C
24. A nursing is caring for a child who had a complete spinal cord injury at lumbar 2 (L-2). The parent reports seing the child move the left leg twice. What response is best? A. "Leg function is not impaired with this type of injury." B. "You have observed something very important." C. "That is wonderful. Function must be returning." D. "That is most likely only a reflex. I am sorry."
D
25. A nurse is preparing a class for a group of parents of school-age children about language development and problems with speech articulation, specifically difficulty pronouncing specific letters. The nurse would inform the parents that a referral for initiating speech therapy may be necessary for these problems after which which age? A. 5 years B. 6 years C. 7 years D. 8 years
D
1. The developmental task of the school-aged period, according to Erikson, is gaining a sense of: A. autonomy versus shame. B. independence versus dependence. C. industry versus inferiority. D. identity versus failure.
C
20. While receiving a transfusion of packed red blood cells, a school-aged child begins to experience itchy skin, hives, and wheezes. What should the nurse do first for this child? A. Stop the transfusion. B. Obtain a blood culture. C. Slow the transfusion rate. D. Provide a diuretic as prescribed.
A
7. An adolescent wears a body brace for scoliosis. Which client education should the nurse provide? A. to continue with age-appropriate activities B. to stand absolutely still when not wearing the brace C. to wear the brace a maximum of 20 hours each day D. that secondary sex changes will stop until the brace is removed
A
12. While making a visit to the home of a family with a school-age child, the nurse observes a hunting rifle leaning against the wall in the dining room. Which nursing diagnosis should the nurse use to guide interventions for the family at this time? A. anxiety B. risk for injury C. health-seeking behaviors D. readiness for enhanced parenting
B
20. The nurse is planning care for a preschool-age child diagnosed with bacterial meningitis. What should the nurse identify as a priority goal for this client's care? A. Inspect the teeth for obvious caries. B. Reduce the pain related to nuchal rigidity. C. Provide an opportunity for therapeutic play. D. Increase stimulation opportunities to prevent coma.
B
4. The nurse is caring for a child with a broken wrist that has just been placed in a cast. The nurse would elevate the arm to: A. promote healing. B. prevent edema. C. discourage infection. D. ensure proper bone alignment.
B
9. Any individual taking phenobarbital for a seizure disorder should be taught: A. to brush his or her teeth four times a day. B. never to discontinue the drug abruptly. C. never to go swimming. D. to avoid foods containing caffeine.
B
24. The nurse is caring for a child diagnosed with scoliosis. What actions by the child would indicate a need for intervention by the nurse? Select all that apply. A. placement of the brace over a t-shirt B. removal of the brace at bedtime C. Reports of, "I feel taller with the brace on." D. Loosening of the straps on the brace prior to bedtime. E. removal of the brace while playing a soccer game
B, D
1. An infant with nonorganic failure to thrive stares at the nurse constantly while she cares for her. This is probably occurring as a result of: A. poor vision from vitamin deficiency. B. potassium deficiency from an inadequate diet. C. previous lack of stimulation. D. searching for her mother from loneliness.
C
11. The nurse is caring for a 4-year-old with meningitis. A primary nursing goal would be to: A. increase stimulation opportunities to prevent coma. B. provide an opportunity for therapeutic play. C. reduce the pain related to nuchal rigidity. D. inspect the teeth for obvious caries.
C
16. The nurse observes a school-age child categorize specific desk and clothing items in his hospital room. What cognitive behavior has this child mastered? A. decentering B. conservation C. class inclusion D. accommodation
C
19. The nurse is instructing the parents of a child with sickle cell anemia on safety precautions. What should the nurse emphasize during this teaching? A. Suggest the child participate in sports activities without restriction. B. Treat upper respiratory infections with over-the-counter medication. C. Ensure a consistent and daily intake of adequate fluids to prevent dehydration. D. Remind parents that the child should avoid immunizations to prevent the introduction of bacteria into the body.
C
3. Typical development for the school-aged child includes playing games with friends. At what age are children typically ready for games that include playing on a team that has a winner or loser? A. 5 years B. 7 years C. 10 years D. 13 years
C
8. An 18-month-old is brought to the emergency room by her babysitter. The babysitter states, "She fell from the sofa an hour ago and has not been herself since." Upon questioning, the babysitter appears to be unsure of time and other facts about the incident. Which of the following questions would be most effective in obtaining more information about the child's injuries? A. "Why did you leave the baby alone on the couch?" B. "Have you taken a course in safe babysitting?" C. "Tell me what was happening before she fell." D. "Where are her parents? Do they know this happened?"
C
8. An adolescent girl has spinal instrumentation surgery at 16 years of age. Immediately after this procedure, the nurse would teach her to: A. sit up, although this may hurt. B. always sleep prone. C. wait to be log-rolled before turning from one side to the other. D. plan on 6 months of hospitalization.
C
10. Fractures in children are always potentially serious injuries. Which child with a fracture would you observe most closely for complication? A. one who has a greenstick radial injury B. one who has an ulnar fracture C. one who has a fractured patella D. one who has an elbow fracture
D
11. The nurse is concerned that a school-aged child has iron-deficiency anemia. What did the nurse assess in this client? A. Shyness B. Thumb-sucking C. Asking many questions D. Craving for ice cubes
D
13. A school-aged child is scheduled for a bone marrow aspiration to confirm the diagnosis of aplastic anemia. What should the nurse instruct the child about this procedure? A. Leg pain will occur after the procedure. B. It will be done under general anesthesia. C. A narrow needle is used so there is no pain. D. The child will have to lie on the stomach for the procedure.
D
13. An infant is placed in Bryant traction. For Bryant traction to be effective, the infant must be positioned on the: A. back with hips flat on the bed. B. stomach with both legs extended. C. back with the injured hip flexed and the uninjured one extended. D. back with hips up off the bed.
D
16. The nurse is evaluating a school-age child's ability to crutch walk so that no weight is placed on an injured leg. Which walking technique indicates that teaching has been effective? A. walking gait B. two-point gait C. single-crutch support gait D. three-point swing-through gait
D
3. Some children with iron-deficiency anemia may be prescribed iron dextran by injection. This should be injected: A. intradermally. B. subcutaneously. C. intramuscularly. D. via Z-track technique.
D
23. A new mother asks the nurse, "Are there any medicines that I can or cannot take since I'm breastfeeding?" Which response by the nurse would be best? A. "Always check with your provider because almost all drugs are excreted to some extent in breast milk." B. "You can take medicines but stop breastfeeding for 1 week after taking it." C. "It shouldn't be a problem if you take any common over-the-counter medicines." D. "You need to stay away from any opioid pain medicines and sedatives while breastfeeding."
A
5. A child with hypoplastic anemia develops hemosiderosis. The therapy for this is: A. ferrous sulfate. B. deferoxamine. C. prednisone. D. aspirin.
B
13. When planning activities for school-age children, the nurse organizes games that include competition. At which age are these kinds of games preferred by children? A. 7 years old B. 8 years old C. 10 years old D. 12 years old
C
25. A new parent is concerned that the infant is not going to receive enough calories from breast milk to grow. When teaching the parent about caloric requirements, how many total calories per day are required by the infant? A. 50 to 55 B. 75 to 100 C. 110 to 120 D. 150 to 200
C
2. Dexamethasone is often prescribed for the child who has sustained a severe head injury. Dexamethasone is a(n): A. diuretic. B. antihistamine. C. anticonvulsant. D. steroid.
D
1. A new mother asks the nurse how soon she can breastfeed after delivery. Which of the following would be the nurse's best answer (barring unforeseen complications)? A. immediately after birth B. after the infant is allowed to rest C. once the infant has a first feeding of formula D. in 24 hours after her infant is given water
A
1. The nurse is assigned an infant with a possible neurological disorder. Which assessment finding would the nurse communicate to the health care provider as a late sign of increased intracranial pressure? A. Decorticate posturing and fixed and dilated pupils B. Decreased pupil reaction and decreased respiration. C. Headache and sunset eyes D. Dizziness and irritability
A
11. The nurse is caring for an 8-year-old girl who is hospitalized. To promote acievement of the child's developmental task, which activity would the nurse encourage? A. Sewing a pillow that can be completed in one afternoon. B. Downloading the child's favorite movies for watching over the next few days. C. Planning and designing a puppet show over the next 2 weeks. D. Working on creating a scrapbook that will take 3 weeks to complete.
A
12. When teaching a woman about ingesting drugs while breastfeeding, which statement is most accurate? A. Almost all drugs are excreted to some extent in breast milk. B. A mother can plan on taking common over-the-counter drugs without difficulty. C. A mother has to limit her exposure to opioids and sedatives while breastfeeding. D. A mother should halt breastfeeding for 1 week after taking any drug.
A
13. A client who is in labor in planning to breastfeed the newborn. The client asks the nurse, "I an really excited to breastfeed my newborn. When can I do it?" Which response by the nurse is appropriate? A. "You can breastfeed within 1 hour of your newborn's birth." B. "You can start once the newborn has been allowed to rest." C. "For the first 24 hours, your newborn will get water and then you can breastfeed." D. "Breastfeeding can start after your newborn has had one feeding of formula."
A
13. At the completion of a health interview, the nurse is concerned that a newborn is at risk for maltreatment. Which observation caused the nurse to come to this conclusion? A. Mother does not look at the baby. B. Mother helps the nurse loosen the baby's clothing for a physical examination. C. Mother explains that the husband helps with feeding the baby during the night. D. Mother quickly changes a dirty diaper and uses personal supplies to cleanse the child.
A
14. When beginning care for a victim of rape, the nurse asks the client to "talk about what happened" to her. For which nursing diagnosis is the nurse using this approach? A. Anxiety related to recent rape B. Fear related to repeated episodes of maltreatment C. Disabled family coping related to recent rape of family member D. Risk for other-directed violence related to admitted poor self-control
A
17. A 9-year-old girl tells the nurse about belonging to a girls' social media club. How does belonging to this group support the child's development? A. fulfills peer group needs B. teaches the child leadership skills C. helps the child develop autonomy D. encourages the child to learn rules
A
17. The nurse is assessing a school-aged child with sickle-cell anemia. Which assessment finding is consistent with this child's diagnosis? A. Slightly yellow sclera B. Enlarged mandibular growth C. Increased growth of long bones D. Depigmented areas on the abdomen
A
17. The nurse is caring for a child who has just received a cast for a broken wrist. The parents ask, "Why do we need to keep the arm up on a pillow?" Which response by the nurse is appropriate? A. "Keeping the arm raised helps to lessen the swelling." B. "Using a pillow helps to promote healing." C. "There is less chance of infection when the arm is kept elevated." D. "Positioning the arm like upward helps to make sure the bones stay aligned."
A
17. The nurse is caring for an 8-month-old baby diagnosed with spastic cerebral palsy. Which assessment finding supports this medical diagnosis? A. The child has a strong Moro reflex when startled. B. The child bears weight on both feet when held upright. C. The child cries when held in a ventral suspension position. D. The child holds the back very straight when in a sitting position.
A
18. A preadolescent child with ataxia-telangiectasia is demonstrating an exacerbation of choreoathetosis. What should the nurse do to help this client? A. Provide comfort measures. B. Assist the client to walk several times a day. C. Encourage the client to increase independence. D. Recommend transferring the client to a rehabilitation facility.
A
18. The nurse is concerned that a preschool-age child is demonstrating signs of Duchenne muscular dystrophy. What did the nurse assess in this child? A. Gower sign B. facial weakness C. inability to whistle D. inadequate use of respiratory muscles
A
19. An 8-year-old child is being treated for tonic-clonic seizures. What should the nurse emphasize when teaching the parents about this disorder? A. The child should maintain an active lifestyle. B. Immediately provide medication if a seizure begins. C. Have the child carry a padded tongue blade with her at all times. D. Ensure quiet time late in the day, when seizure activity is most likely to occur.
A
20. A 10-year-old child spends 2 hours alone every afternoon before the parents arrive home from work. Which safety measure should the nurse suggest the parents teach the child? A. preparing a no-cook snack after school B. lighting candles in case there is a power failure C. wearing the house key prominently around the neck D. telling people at school about being home alone for added safety
A
20. The nurse is caring for a school-age child newly diagnosed with juvenile idiopathic arthritis. Which diagnosis would be a priority for this client? A. Knowledge deficit related to care needs B. Risk for inefficient peripheral tissue perfusion C. Ineffective coping related to physical limitations D. Imbalanced nutrition: less than body requirements
A
21. A mother is concerned that a school-age child will pick up the habit of smoking because so many children in the school smoke. What should the nurse instruct the mother about this behavior? A. Be a role model and do not smoke. B. Remind the child that smoking costs money. C. Discuss other tobacco choices that can be used instead. D. Explain that the child can experiment with smoking when older.
A
21. The nurse in the emergency department is documenting the appearance and care provided to a victim of rape. Which statement should the nurse include when documenting this care? A. Victim has blood stains on both inner thighs. B. Victim claims to be raped but does not appear fearful or traumatized. C. Victim handling the incident well by talking with the male police officers. D. Victim wearing provocative low-cut lace blouse and bra and short skirt with high heels.
A
22. The nurse is caring for a hospitalized 10-year-old client. Which nursing action is most appropriate? A. Consistently reinforce the child's self-worth. B. Discourage the child from assisting with dressing change. C. Correct each of the child's mistakes to ensure learning. D. Structure a competitive environment between clients.
A
23. The community nurse is visiting a victim of rape at home. Which observation indicates that crisis intervention goals have not been met? A. Husband hopes to meet the rapist in a back alley one day. B. Victim and husband sit with the nurse at the kitchen table and discuss feelings. C. Victim states that an intimate relationship with the husband has resumed without incident. D. Husband holds the victim's hand and expresses endearing terms while the victim smiles.
A
23. When providing care for a child immediately after a bone marrow aspiration, which nursing action is priority? A. Monitor the site dressing and vital signs. B. Evaluate pain and administer medication. C. Educate the family on proper handwashing. D. Allow the child to play with a doll and syringe.
A
24. The nurse is teaching new parents how to calculate the amount of formula to feed their newborn each day. The baby weighs 8 lb. How much formula should the nurse teach the parents to provide each day? A. 20 to 24 oz B. 30 to 36 oz C. 42 to 54 oz D. 60 to 72 oz
A
25. The nurse has received morning report on a group of pediatric clients. Which pediatric client will the nurse see first? A. a child with hemophilia reporting knee pain and edema B. a child with sickle cell anemia requesting a cool compress C. a child experiencing a palpable purpural rash and arthralgia D. a child reporting lethargy with a history of thalassemia major
A
26. A 16-year-old girl presents to the emergency department following a rape. Which action will the nurse complete first? A. Provide the client privacy and assess for injuries. B. Counsel the client to help increase self-esteem. C. Arrange for a follow-up visit for treatment. D. Assist the client with showering and hygiene.
A
26. The nurse is obtaining a health history on a child diagnosed with idiopathic thrombocytopenic purpura (ITP). After asking about a viral illness, what question should the nurse ask next to gather more information? A. "Has your child recently had the measles, mumps, rubella (MMR) vaccine?" B. "When did the bruising begin?" C. "Has your child experienced any nose bleeds?" D. "Has your child had any bloody stools?"
A
26. The nurse is preparing an educational session for adolescents to best ensure a lifelong healthy musculoskeletal system. Which teaching will be beneficial to the most attendees? A. importance of daily exercise B. need for early diagnosis of painful joints C. need for at least 8 hours of sleep each night D. adequate intake of calcium in dietary or supplement form
A
3. A child with pauciarticular juvenile idiopathic arthritis is scheduled for an eye examination every 6months. When stressing the importance of the visit, which instruction is most accurate? A. Uveitis is possible, leading to severe blindness. B. The eye globe does not continue to grow, impacting sight. C. Continuous drug therapy causes corneal opacity. D. Eye infection may develop easily due to medication administration.
A
4. A child with hemophilia A is scheduled for surgery. Which precautions would the nurse institute with this client? A. Handle the child gently when transferring to a stretcher. B. Caution the child not to brush the teeth before surgery. C. Do not allow a dressing to be applied postoperatively. D. Mark the client's chart to receive no analgesia.
A
5. On physical examination, the nurse discovers that a 6-year-old child's palatine tonsils are somewhat enlarged in the back of the throat. What would be the nurse's best action? A. Record this as a normal finding in an early school-age child. B. Suggest the health care provider examine the child for breathing difficulty. C. Take the child's temperature; this must be tonsillitis. D. Give the child something for pain.
A
5. Which of the following correctly identifies the daily caloric requirement per pound for a newborn? A. 50 to 55 B. 100 to 120 C. 150 to 170 D. 200 to 225
A
6. A 14-year-old adolescent is suspected of having scoliosis. When doing scoliosis screening, what observation would be important for the nurse to note? A. The posterior spine when bending forward B. The angle of the iliac crest when bending forward C. The posterior spine when bending sideways D. The angle of the lower chest when sitting down
A
6. A 7-year-old child has taken money from a sibling's dresser on two occasions. When counseling the parent about this behavior, what would the nurse advise? A. "You may need to remind your child about property rights." B. "You should buy your other child a bank that cannot be opened." C. "Stealing is unusual for a 7-year-old child." D. You should talk to the child's teacher about putting less pressure on your child."
A
7. To prevent further sickle cell crisis, the nurse would advise the parents of a child with sickle cell anemia to: A. notify a health care provider if the child develops an upper respiratory infection. B. prevent the child from drinking an excess amount of fluids per day. C. encourage the child to participate in school activities, such as long-distance running. D. administer an iron supplement daily.
A
8. An infant is diagnosed as having cerebral palsy. When planning care, which would the nurse stress to the parents? A. Their child probably will benefit from early schooling to increase ability for selfcare. B. Administering an anti-acetylcholinergic drug to decrease muscle spasms is crucial. C. The parent should be tested during future pregnancies to predict similar involvement. D. The infant's disease will cause progressive brain cell degeneration with age.
A
8. Which nursing diagnosis would be most appropriate for a child with idiopathic thrombocytopenic purpura? A. Ineffective tissue perfusion related to poor platelet formation B. Risk for altered urinary elimination related to kidney impairment C. Risk for infection related to abnormal immune system D. Ineffective breathing pattern related to decreased white blood count
A
9. While planning care for a 7-year-old client, the nurse reminds the parents that children at this age are experiencing the "eraser" year. What does this mean? A. The child wants to perform well. B. The child believes in magical thinking. C. The child is learning to write during this year. D. The child tends to "erase" misdeeds or lie excessively.
A
15. The nurse is caring for a school-age child recovering from an allogeneic stem cell transplant. What nursing action best ensures the child does not develop an infection after the transplant? Select all that apply. A. Restrict all visits from other children. B. Provide sterilized age-appropriate play materials. C. Send for total body irradiation immediately after the transplant. D. Arrange time for studying while in the hospital. E. Encourage eating raw vegetables for each meal after the procedure.
A, B
24. A nurse is preparing to conduct a class for a group of parents with school-age children about healthy nutrition. Which nutrients would the nurse include as especially important for this age group? Select all that apply . A. calcium B. iron C. flouride D. vitamin B E. vitamin C
A, B, C
24. During a routine well-child visit, the mother of a preadolescent client asks the nurse to explain signs of sexual abuse. The mother is concerned because an older male neighbor has been making comments and overtly admiring the child when playing outdoors. What signs of sexual abuse should the nurse tell the mother to look out for? Select all that apply. A. Child reports abdominal pain. B. Child has a change in school performance. C. Child demonstrates anxiety or trouble sleeping. D. Child does not want to be left alone with a certain adult. E. Child spends a great deal of time with peer-group friends.
A, B, C, D
10. The nurse has been asked to participate in a community health teaching session. Which interventions would the nurse include to help achieve the 2030 National Health Goals to reduce the incidence of anemias? Select all that apply. A. Explain the importance of healthy eating for adolescent participants. B. Instruct pregnant women to take iron supplementation as prescribed. C. Emphasize ways to reduce unintentional injuries at home, work, and play. D. Review foods that are rich in iron that should be a part of a school-age child's diet. E. Examine strategies for elderly community members to improve the quality of life.
A, B, D
19. The nurse is evaluating a new mother's ability to breastfeed her infant. Which criteria indicate that the mother is able to breastfeed independently? Select all that apply. A. Nipples are everted. B. Breasts are soft and nontender. C. Mother holds the nipple in the baby's mouth. D. Baby swallows spontaneously and frequently. E. Nurse places pillows under the baby for support.
A, B, D
19. The nurse is instructing the mother of a school-age child with a leg cast about cast care at home. What should the nurse include in this teaching? Select all that apply. A. Cover the cast with a plastic bag to bathe. B. Remind the mother that nothing is to be put down the cast. C. Recommend using magic markers for autographs. D. Use the cool setting on a hair dryer to ease itchy skin. E. Encourage usual activities but restrict strenuous actions.
A, B, D, E
23. A parent of a child diagnosed with seizures states, "I've heard about a special diet that may control seizures, I think it's called ketogenic. What can you tell me about it?" Which are appropriate responses by the nurse? Select all that apply. A. "About 40% to 50% of children who follow the diet have really good results." B. "The diet consists of high fat foods." C. "Children are encouraged to eat a lot of breads and pasta on this diet." D. "Most families find this diet is easy to incorporate into their life." E. "Protein is limited in this diet."
A, B, E
23. The nurse is caring for a school-age child recovering from an open reduction for a fractured femur. Which assessment findings indicate that the child is developing an infection? Select all that apply. A. lethargy B. increased pulse rate C. reduced pulse in the ankle D. cyanosis of the casted foot E. increased body temperature
A, B, E
12. The nurse is evaluating the effectiveness of teaching provided to the parents of a school-age child prescribed liquid ferrous sulfate for iron-deficiency anemia. Which observations indicate that teaching has been effective? Select all that apply. A. Parent places medication in orange juice. B. Parent provides medication with a glass of milk. C. Child consumes fresh raw fruit and drinks water. D. Parent provides liquid-prepared medication to the child with a straw. E. Child goes to the bathroom to brush teeth immediately after taking the medication.
A, C, D, E
18. An 18-month-old child is diagnosed with insufficient platelets. What instructions should the nurse give the parents to reduce the risk of the child bleeding when at home? Select all that apply. A. Check that all toys have soft corners. B. Engage in limited amounts of rough play each day. C. Ensure mouth care is performed with a soft toothbrush. D. Do not apply Band-Aids or adhesive tape onto the skin. E. Pad the side and crib rails on the bed at home to prevent bruising.
A, C, D, E
1. A 7-year-old is seen with pauciarticular juvenile idiopathic arthritis. She notices extreme pain when she wakes in the morning. The best advice the nurse can give her parents would be to: A. have her take 325 mg of aspirin immediately on arising. B. encourage her to take a warm bath each morning before school. C. have her do isotonic exercises until the pain is gone. D. encourage her to remain in bed until the pain is gone.
B
1. The nurse is assessing children in an ambulatory clinic. Which child would be most likely to have iron-deficiency anemia? A. A 3-month-old infant who is totally breastfed B. A 15-year-old adolescent who has heavy menstrual periods C. An 8-year-old child who carries lunch to school D. A 7-month-old infant who has started table food
B
10. If one of the parents of a child who has been abused is found to be the abuser, what would the nurse implement as a long-term intervention for that parent? A. returning to school for mandated parenting classes B. participating in an organization such as Parents Anonymous C. placing the child in a home with a relative until parents are capable of handling a child
B
11. The nurse meets a child with a slipped capital femoral epiphysis. In what type of child does this usually occur? A. Tall, thin girls B. Obese adolescent boys C. Preadolescent girls D. Active school-age children
B
12. The nurse is planning care for a preschool-aged child with spastic cerebral palsy. Which nursing diagnosis should the nurse identify to guide care for this client's musculoskeletal status? A. Risk for self-care deficit related to impaired mobility B. Risk for disuse syndrome related to spasticity of muscle groups C. Impaired verbal communication related to neurologic impairment D. Risk for delayed growth and development related to activity restriction
B
14. A toddler is diagnosed with osteomyelitis. What should the nurse anticipate as a priority intervention when planning this child's care? A. assisting the child with crutch walking B. maintaining intravenous antibiotic therapy C. keeping the child quiet while in skeletal traction D. restricting fluid to encourage red cell production
B
14. The nurse knows that being able to tell time helps a child become more independent. At which age should the nurse expect a school-age child to begin to tell time? A. 6 years old B. 7 years old C. 8 years old D. 9 years old
B
16. A child with hypoplastic anemia develops hemosiderosis. What nursing instruction promotes the treatment goals? A. Avoid all products containing aspirin B. Infuse deferoxamine at home C. Administer daily doses of ferrous sulfate D. Adhere to a strict schedule of prednisone
B
16. The nurse instructs the parents of a child with Guillain-Barré syndrome on care that will be needed once the child is discharged home. Which statement made by the parents indicates that teaching has been effective? A. "We need to be sure to change our child's body position at least twice a day." B. "Our child might experience weakness even after recovering from the illness." C. "It will take about 10 days for our child to be back normal and return to school." D. "This disease affects the heart and lungs, so our child will have limited ability going forward."
B
16. While making a home visit, the nurse suspects that a child is experiencing psychological maltreatment. What did the nurse observe in the home? A. scolding one child for playing with matches B. belittling the child in front of the nurse and other siblings C. punishing one child for crossing the street without assistance D. asking one child to perform a song on the piano for the nurse
B
17. The mother of a toddler experiencing stomach pain insists that the child be admitted to find out the cause of the pain. The child has been in the emergency room three other times in the past 6 months for the same complaint. What other information should alert the nurse to investigate the situation further? A. The mother is a single parent. B. The mother is in nursing school. C. The child has a 1-year-old sister. D. The child verbalizes abdominal pain when the mother is not present.
B
17. The nurse is teachinga new mother about the nutritional value of breast milk. What information should the nurse include about the number of calories in a fluid ounce? A. 12 B. 20 C. 24 D. 30
B
19. The nurse has been caring for a family with a school-age child who has school phobia. Which observation indicates that interventions have been successful? A. The child stays home from school. B. The child attends school every day. C. The child decides daily about attending school. D. The child's teacher is asked if attending school is a requirement.
B
20. The nurse is preparing a seminar on breastfeeding for a group of pregnant clients. Which information should the nurse include during this seminar? A. Uterine involution is slowed by breastfeeding. B. Breastfeeding enhances bonding with the infant. C. Breastfeeding might increase the risk of breast cancer. D. Breastfeeding mothers have a decreased risk of developing thrombophlebitis.
B
21. Which nursing diagnosis should the nurse identify as being the most appropriate for a child with idiopathic thrombocytopenic purpura? A. Risk for infection related to abnormal immune system B. Risk for bleeding related to insufficient platelet formation C. Risk for altered urinary elimination related to kidney impairment D. Ineffective breathing pattern related to decreased white blood count
B
22. The nurse decides to spend extra time with a pregnant client in the prenatal clinic in an effort to determine if the client is a victim of intimate partner violence. What caused the nurse to make this plan prior to assessing the client? A. She is chatting with another client in the waiting room. B. The client is wearing a long-sleeved jacket on a hot summer day. C. The client is periodically looking at her watch to check the time. D. The client is unconsciously rubbing her abdomen while reading a magazine.
B
22. The nurse is planning teaching for the parents of a child with Legg-Calvé- Perthes disease. On what should the nurse emphasize when conducting this teaching? A. Surgery is needed with supporting rods. B. The child will have a non-weight-bearing period. C. The child will need passive range-of-motion exercises three times a day. D. The child will need to exercise to increase muscle strength of the knee joint.
B
23. The nurse is discussing home safety with the parents of a 10-year-old client. Which statement by the client's parents most concerns the nurse? A. "Our child is home alone for an hour each day." B. "Our child swims alone before we get home from work." C. "Our child refuses to eat any green vegetables." D. "We do our best to keep no-cook snacks in the home."
B
25. A preadolescent girl with scoliosis is prescribed a body brace. What should the nurse teach the child about the purpose of the brace? A. prevents torticollis B. improves spinal stability C. corrects existing spinal curvature D. prevents herniation of a spinal disk
B
25. A teenage client has been undergoing individual psychotherapy following a sexual assault a few days ago. The nurse would determine that the early stage of therapy is successful when the client meets which outcome? A. The client makes the decision to press legal charges against the rapist. B. The client is able to describe what happened and express feelings. C. The victim states that the nightmares have decreased in severity. D. The client is able to return to school and participate in social activities.
B
25. During shift handoff, the nurse provides report on a 14-year-old client who has a cervical neck injury after a fall at gymnastics practice. The nurse verbalizes the assessment of the cranial nerves including a deficit in cranial nerve III. Upon baseline assessment, which assessment technique will the nurse use? A. Assess hand grasps. B. Assess pupil reactivity. C. Have the client smile. D. Whisper in the client's ear.
B
3. Physical neglect of children occurs in various ways. In which family below would you suspect neglect? A. A woman feeds her daughter a total vegetarian diet. B. A father allows his child to stay home from school whenever she chooses. C. A woman worries that immunizations will be painful for her son. D. A father encourages his son to play high school football.
B
4. A 1-year-old is a victim of child abuse (child maltreatment). Which factor obtained on history is most apt to be associated with the risk of medical child abuse (formerly Munchausen syndrome by proxy) in children? A. The family has a low socioeconomic level. B. The mother was abused as a child. C. The parents are outgoing, gregarious people. D. The family is an extended one.
B
4. A breastfeeding mother asks the nurse how long her baby should breastfeed at each breast after she is home. What would be the nurse's best answer? A. no longer than 3 minutes each feeding to prevent soreness B. The average baby empties a breast in 15 minutes. C. at least a half-hour at each breast to ensure emptying D. 1 or 2 minutes is an average time interval
B
5. The nurse is caring for a 7-year-old who is in the second stage of recovery from a spinal cord injury. When evaluating the child's status, which is noted as the result of consistent care by the family? A. The child has had no urinary infections. B. All joints are movable without contractures. C. The client has not had a fever. D. The client has clear lung sounds.
B
6. A newborn is being breastfed. To evaluate nutritional adequacy, you should be aware that breast milk contains an average of how many calories? A. 12 calories per ounce B. 20 calories per ounce C. 24 calories per ounce D. 30 calories per ounce
B
7. A newborn infant has loose, yellow stools. Although the infant is healthy, his mother is concerned that this means he is allergic to breast milk. The nurse would explain to her that: A. she might try burping the infant more frequently. B. the stools of breastfed infants are normally loose. C. she might consider changing to a soybean formula. D. her child may need to be investigated for bile duct disease.
B
7. A school-aged child develops school phobia. When counseling her mother, the nurse would advise her that the accepted action is to: A. keep her child home until this fear passes. B. make her child attend school every day. C. allow her child to decide daily if she wants to go to school or not. D. ask the teacher to decide if the child should come to school or not each day.
B
8. The parents of a school-aged child with school refusal have received professional guidance by the school psychologist, pediatrician, and three different psychiatrists. Based on this, which nursing diagnosis would be most appropriate? A. Disturbed thought processes related to delusional behavior B. Compromised parental coping related to inability to assist with school fears C. Noncompliance with expected school behavior related to school phobia D. Ineffective tissue perfusion, cerebral, related to anxiety over attending school
B
8. Which of the following statements is true about breastfeeding? A. Breastfeeding increases the risk of breast cancer. B. Breastfeeding offers a good chance for bonding with the infant. C. Uterine involution is slowed by breastfeeding. D. Breastfeeding mothers have a decreased risk of developing thrombophlebitis.
B
9. The nurse is planning care for a child with idiopathic thrombocytopenic purpura. Which client education should be included? A. What foods are high in folic acid B. Not to pick or irritate the nose C. To use mainly cold water to wash D. To apply a soothing cream to lesions
B
9. Which of the following is an advantage of breastfeeding for the infant? A. Breast milk is more difficult to digest, so it makes the infant feel fuller longer. B. Breast milk contains antibodies and thus decreases the possibility of gastrointestinal illnesses. C. It takes less effort for an infant to suck at a breast than from a bottle. D. Breast milk leads to firmer stools, increasing bowel tone.
B
18. The school district is planning an educational program for high school students to reduce the incidence of rape. When planning this program, which information should the school nurse include? Select all that apply. A. Carry a weapon or mace at all times. B. When leaving school after dark, walk on the street. C. Lock car doors when waiting in it and after parking it. D. Keep all doors and windows locked when home alone. E. Avoid taking illegal substances when in social situations.
B, C, D, E
12. The nurse manager of an urban health care clinic is designing a series of presentations for staff to address the 2030 National Health Goals to reduce child abuse (child maltreatment) and intimate partner violence. Which topics should the manager include in these presentations? Select all that apply. A. caring for victims of rape B. indications of child neglect C. recognizing victims of violence D. environments where rape occurs E. manifestations of child maltreatment
B, C, E
10. The school nurse is reviewing content to include in an assembly planned for school-age children that focuses on the 2020 National Health Goals for safety. What should the school nurse include in this presentation? Select all that apply. A. Encourage the children to play outdoors and get exercise every day. B. Stress the need to sit in age-appropriate seats in cars and wear seatbelts. C. Remind children how important it is to brush the teeth and see the dentist. D. Explain how important it is for children to wear safety helmets when bicycling. E. Offer suggestions to ensure an adequate intake of fruits and vegetables each day.
B, D
14. The nurse is explaining the process of breast milk production with a client pregnant with her first child. What should the nurse include when providing this teaching? Select all that apply. A. Breast milk is thin, yellow, and watery. B. For the first 3 to 4 days, the breast milk is colostrum. C. Uterine cramping is a contraindication to breastfeeding. D. True breast milk comes in by the 10th day after giving birth. E. Most mothers have breast milk by the first day after giving birth.
B, D
14. The nurse is planning a program for a community that focuses on the 2030 National Health Goals for neurologic health. Which topics should the nurse include in this presentation? Select all that apply. A. ensuring a diet adequate in vitamins and protein B. use of helmets for bicycle and motorcycle safety C. learning the signs and symptoms of inflammatory disorders D. practicing good handwashing technique and infection control E. importance of proper emergency care to protect the head and neck
B, D, E
18. The mother of a school-age child is distraught because the child has been diagnosed with obesity. What actions should the nurse suggest to the mother to help the child with this problem? Select all that apply. A. Explain that obesity will lead to an early death. B. Maintain a balanced eating approach in the home. C. Purchase books explaining the latest ways to lose weight. D. Seek out a preteen weight loss group for the child to participate in. E. Encourage increased activity such as walking the dog after school.
B, D, E
24. While administering a blood transfusion to a child with a hematologic disorder, the nurse notes the child develops urticaria and wheezing. Which collaborative interventions will the nurse begin? Select all that apply. A. Administer a diuretic. B. Give an antihistamine. C. Obtain a blood culture. D. Apply oxygen as needed. E. Discontinue the transfusion.
B, D, E
10. A woman who began breastfeeding develops sore nipples. The nurse bases her response on which of the following? A. She will have to discontinue breastfeeding. B. To prevent getting an infection, she will need an antibiotic prescribed. C. Exposing her nipples to air after each feeding should help. D. Allowing the infant to suck for longer periods during each feeding will toughen her nipples.
C
11. A 3-month-old infant is diagnosed with failure to thrive. For which cause should the nurse include interventions when planning care for this client? A. a reaction to severe stress B. limited calcium metabolism C. poor parent-child relationship D. interference with gastrointestinal absorption
C
11. A mother asks you how she can judge that her infant is receiving sufficient breast milk. What would be the most appropriate response? A. "You need to weigh the infant before and after each feeding." B. "The infant should sleep at least 3 hours between feedings." C. "The infant should gain weight and have six wet diapers daily." D. "The infant should not become constipated."
C
12. When assisting parents in a home care plan for a child with Legg-Calvé-Perthes disease (LCPD), the nurse would teach the parents that which is anticipated? A. Surgery with supporting rods B. Passive range-of-motion exercises 3x per day C. A non-weight-bearing period initially occurs. D. Exercise to increase muscle strength of the knee joint
C
13. An 18-month-old child is admitted with signs of increased intracranial pressure. What should the nurse observe when assessing this client? A. numbness of fingers and decreased temperature B. increased pulse rate and decreased blood pressure C. increased temperature and decreased respiratory rate D. decreased level of consciousness and increased respiratory rate
C
15. During a home visit, the nurse learns that a new mother is experiencing breast engorgement. What should the nurse recommend to help alleviate this problem? A. discontinuing breastfeeding for 24 hours B. having her apply lanolin cream to each breast C. encouraging her to wear a firm-fitting bra D. decreasing her fluid intake to below 500 ml per 24 hours
C
2. A 9-month-old infant with iron-deficiency anemia is given ferrous sulfate therapy. Which assessment would best help the nurse determine that the infant is actually taking it daily? A. The reticulocyte count will have decreased. B. The infant will develop diarrhea. C. The stools will appear black. D. The infant will be more irritable than at the last visit
C
20. The nurse visits the foster home of a newborn with failure to thrive syndrome. Which observation indicates a successful outcome for this child's care? A. Birth mother has stopped visiting the child. B. Birth father comes by the home to bring toys. C. Child eagerly takes a bottle and is gaining weight. D. Child is crying and has bruises over the lower legs.
C
21. The nurse is caring for a child who is having a seizure. What is the appropriate action by the nurse? A. Attempt to place oxygen on the child so they don't become cyanotic. B. Hold the child's arms and legs still so they aren't injured. C. Attempt to turn the child on their side to prevent aspiration. D. Place a bite block or oral airway into the child's mouth to prevent biting of the tongue.
C
3. On the fourth day postpartum, a woman develops breast engorgement. Which measure would be best to recommend to her as a means of alleviating this problem? A. discontinuing breastfeeding for 24 hours B. decreasing her fluid intake to below 500 ml per 24 hours C. encouraging her to continue regular breastfeeding D. having her apply lanolin cream to each breast
C
4. A parent tells the nurse that the 6-year-old child has been biting his fingernails since beginning first grade. After analysis, the cause is determined to be increased stress. What advice would the nurse give the parent regarding this behavior? A. Encourage the child to drink more milk for stronger nails. B. Distract the child by teaching a new skill, such as whistling. C. Allow some time every day for the child to talk about new experiences D. Allow the child to choose a reward for not biting the nails.
C
4. The parents of a child with a thoracic-level spinal injury are anxious to know what the long-term prognosis is for their son. They ask, "Will our son walk again?" What is your best response? A. "It is most unlikely that your son will ever walk again." B. "Damage usually progresses after the first week." C. "It will be several weeks before an answer to your question is possible." D. "What has the physician said about your son's recovery?"
C
5. Which statement by a parent of a 4-year-old child is most likely to suggest child abuse (child maltreatment)? A. "He is constantly on the go." B. "He has his father's eyes." C. "He doesn't ever help me clean house." D. "He doesn't seem to like strangers."
C
6. A 4-year-old has been sexually abused. As you watch her play with anatomically correct dolls, she inserts the male doll's penis into the female doll's mouth. What is your best response to this action? A. "Be careful; you'll hurt the doll that way." B. "Are you playing a game from television?" C. "What are the dolls doing?" D. "Nice dolls don't do that. Why are you playing that way?"
C
6. A school-aged child is admitted to the hospital with a vaso-occlusive sickle cell crisis. Which measure in the child's care plan should be given priority? A. Beginning active range-of-motion exercises B. Seeing that the child ingests a protein-rich diet C. Maintaining fluids through an intravenous line D. Encouraging the child to take deep breaths hourly
C
7. An important concept to teach preschoolers in an effort to prevent attacks of sexual abuse would be to first teach them: A. never to use a restroom at a public beach. B. that their life is their own and they have a right not to have others interfere with it. C. that their body belongs to them and they have the right to decide who can touch it or look at it. D. that they should try and dress modestly even in very warm weather.
C
9. The most important assessment of neurovascular status to make after spinal surgical instrumentation is: A. check the nailbeds of the fingers for capillary refill. B. determine the presence of brachial pulses. C. assess the legs for warmth. D. ask if the child has pain.
C
9. The responsibility of the nurse caring for a victim of child abuse (child maltreatment) in the emergency room would include which of the following? A. prohibiting parents from visiting until more facts are obtained B. prohibiting the babysitter from staying to offer support C. suggesting to the attending physician that the child be admitted for observation D. asking the child what was happening that led to the abuse
C
22. During a home visit, a new mother tells the nurse that her nipples are sore from breastfeeding. What should the nurse instruct the mother at this time? Select all that apply. A. Insert plastic liners into the nursing bra. B. Apply petroleum jelly to the nipples before feeding. C. Expose the nipples to air so the nipple dries. D. Position the baby differently for each feeding. E. Massage a few drops of breast milk to the areola.
C, D, E
10. While in a pediatric client's room, the nurse notes that the client is beginning to have a tonic-clonic seizure. Which nursing action is priority? A. Administer lorazepam rectally to the client. B. Refer the client to a neurologist. C. Discuss dietary therapy with the client's caregivers. D. Protect the child from hitting the arms against the bed.
D
14. It is determined that a preschooler developed anemia after exposure to an insecticide. What should the nurse teach the parents before the child is discharged from the hospital? A. Schedule weekly chelating treatments. B. Provide the child with a high-protein diet. C. Schedule hospital visits to desensitize the child to the insecticide. D. Ensure that the child has no further exposure to the insecticide.
D
15. During a visit, the parents of a school-age child diagnosed with pauciarticular juvenile idiopathic arthritis tell the nurse, "There are times when the joint pain is really severe, Is there anything that might help?" Which response by the nurse would be appropriate? A. "Have your child lie still for about 1/2 hour when the pain gets bad." B. "Let me show you how to do sotonic exercises until the pain is gone." C. "Give your child a dose of aspirin on an empty stomach immediately when the pain occurs." D. "Apply a warm moist compress or heating pad to the area for 20 minutes."
D
15. The nurse is caring for a preschool-age child recovering from a lumbar puncture. What should the nurse do to ensure the client does not develop a spinal headache? A. Measure temperature every hour. B. Restrict fluids for 2 hours after the procedure. C. Elevate the head of the bed to a 30-degree angle. D. Take the pillow away and have the client lie flat in bed.
D
15. The nurse is talking with a mother of a 6-year-old child who says, "I"m really concerned because my child seems really stressed and has been biting the fingernails since beginning the first grade.What can I do?" Which response by the nurse would be appropriate? A. "Encourage your child to drink more milk for stronger nails." B. "Allow your child to pick out a reward for not biting the nails." C. "Distract your child by teaching a new skill such as whistling." D. "Allow some time every day for your child to talk about things."
D
15. The nurse is visiting the home of a family with a previous history of physical neglect. Which observation indicates that interventions have not been successful? A. The mother feeds the children a total vegetarian diet. B. The father encourages male children to play high school football. C. The mother worries that immunizations will be painful for the children. D. The father allows the children to stay home from school whenever they desire.
D
16. A new mother is ambivalent about breastfeeding and agrees to do it for at least 3 months. What response should the nurse provide to the client at this time that would support the 2030 National Health Goals? A. Breastfeeding helps the mother return to prepregnancy weight faster. B. Three months is the recommended time frame for the baby's nutrition. C. Breast milk can be donated so that preterm infants can have additional nutrition. D. Six months to 1 year of age is the best time frame to support the baby's growth needs.
D
18. A pregnant client had decided to breastfeed the infant but, after delivery, tells the nurse that formula feeding would be the best choice for her now. What nursing diagnosis should the nurse use to plan this client's care? A. anxiety B. ineffective coping C. imbalanced nutrition D. risk for impaired parenting
D
19. Which client's physical assessment finding of a school-age child should the nurse question as a potential indication of child abuse (child maltreatment)? A. a thin, tall appearance B. a scald burn on the chest C. a maculopapular rash on the buttocks D. linear abrasions on his ankles and wrists
D
2. A 9-year-old is hospitalized for a long-term illness. The best project to give the to help achieve the child's developmental task would be: A. a scrapbook that will take 3 weeks to complete. B. a puppet show that will take 2 weeks to plan. C. watching her favorite program on television. D. sewing a purse that will take one afternoon.
D
2. On the first day postpartum, a new mother is concerned that her milk has not yet "come in." The nurse would explain to her that: A. most mothers do have milk by 1 day postpartum. B. she will not have breast milk until 7 days postpartum. C. her infant must not be sucking well or she would have milk by now. D. breast milk normally comes in on the third or fourth postpartum day.
D
2. The physician of a child with juvenile idiopathic arthritis asks the nurse to telephone the school to arrange a new activity program for her. A change the nurse would anticipate arranging for the child is to: A. be excused from all extracurricular activities. B. begin school earlier in the day than other children. C. be excused from all swimming classes. D. modify her physical exercise program.
D
2. Which of the following statements probably would be most therapeutic to an adolescent seen for rape? A. "Try not to think any more about what happened." B. "Rape is a terrible crime. I'm sorry this happened." C. "Tell me about what happened to you." D. "Don't feel guilty; you did not provoke the attack."
D
21. A new mother asks the nurse to explain the difference between breastfeeding and formula when feeding a newborn. What should the nurse respond as an advantage of breastfeeding for the infant? A. Breast milk leads to firmer stools, increasing bowel tone. B. It takes less effort for an infant to suck on a breast than from a bottle. C. Breast milk is more difficult to digest, so it makes the infant feel fuller longer. D. Breast milk contains antibodies and decreases the possibility of gastrointestinal illnesses.
D
21. The nurse receives a report from the admission department that a child with a slipped capital femoral epiphysis is in route to the care area. The nurse would likely have received which description of the child to plan care? A. tall, thin female B. preadolescent female C. active school-age male D. obese preadolescent male
D
22. The nurse is planning care for a school-aged child recovering from being hit by a motor vehicle while riding a bicycle. For what will the nurse assess to determine the onset of disseminated intravascular coagulation in this child? A. Blurred vision B. Nausea and vomiting C. Sudden onset of knee pain D. Bleeding from intravenous sites
D
3. A 16-year-old has suffered a thoracic-level spinal injury from a diving accident. To initiate CPR at the poolside, which measure would be most important? A. Hyperextend the neck to clear the airway prior to mouth-to-mouth resuscitation. B. Administer cardiopulmonary resuscitation in a prone position. C. Do not administer CPR after a head injury. D. Elevate the mandible to assess airway with the head in a neutral position.
D
5. The nurse assists with the application of a full-body plaster cast to a child. The child immediately becomes diaphoretic and reports feeling hot. Which nursing intervention would be indicated? A. Observe the child for infection. B. Suggest removal of the cast to the orthopedist. C. Moisten the cast with cool water. D. Advise the child that this is to be expected.
D
6. On the third week of hospitalization following a spinal cord injury, an adolescent reports that his face is bright red, and he is sweating profusely. Which nursing action is completed first? A. Obtain a stat electrocardiogram. B. Lower his head to increase cerebral circulation. C. Massage his lower extremities to cause vasodilation. D. Assess if his retention catheter is blocked.
D
7. An 8-month-old boy is diagnosed as having cerebral palsy. During physical assessment, the nurse notes which abnormal finding that is common in this disease process? A. He cries when held in a ventral suspension position. B. He holds his back very straight when in a sitting position. C. He bears weight on both feet when held upright. D. He has a strong Moro reflex when startled.
D