Test 2
An infant is diagnosed with a congenital cataract. What would the nurse expect to assess? A. Absent red reflex B. Rapid irregular eye movement C. Misalignment of the eye D. Enlarged eye appearance
A
An infant is diagnosed with infantile glaucoma. When developing the plan of care for the infant, for what would the nurse expect to prepare the infant and family? A. Goniotomy B. Antibiotic therapy C. Contact lenses D. Patching of affected eye
A
The nurse is assessing heart rate for children on the pediatric ward. What is a normal finding based on developmental age? A. An infants rate is 90 bpm B. A toddlers rate is 150 bpm C. A preschoolers rate is 130 bpm D. A school-age child's rate is 50 bpm
A
The nurse is assessing the pain of a postoperative newborn. The nurse measures the infant's facial expression, body movement, sleep, verbal or vocal ability, consolability, and response to movements and touch. Which behavioral assessment tool is being used by the nurse? A. Riley infant pain scale B. Pain observation scale for young children C. CRIES scale for neonatal postoperative pain assessment D. FLACC behavioral scale for postoperative pain in young children
A
The nurse is caring for a 10 year old with allergic conjunctivitis. The nurse would be alert to the child's increased risk for what issue? A. Atopic dermatitis B. Insect bite sensitivity C. Acute otitis media D. Frequent sore throats
A
The nurse is caring for a child who is recovering from an appendectomy. What is the appropriate term for the pain this child is experiencing? A. Nociceptive pain B. Neuropathic pain C. Chronic pain D. Superficial somatic pain
A
The nurse is developing a plan of care for a 5 year old child with a severe hearing impairment focusing on psychosocial interventions based on assessment findings. Which behavior would the nurse have most likely assessed? A. Immature emotional behavior B. Self-stimulatory actions C. Inattention and vacant stare D. Head tilt or forward thrust
A
The nurse is preparing to administer a topical anesthetic for a 10 year old girl with a chin laceration. The nurse would expect to apply what as ordered in preparation for sutures? A. TAC (tetracaine, epinephrine, cocaine) B. Iontophoretic lidocaine C. EMLA D. Vapocoolant spray
A
The nurse performing a health history on a child asked the parents if their child has experienced increased appetite or thirst. What body system is the nurse assessing with this question? A. Endocrine B. Genitourinary C. Hematologic D. Neurologic
A
Which would be least effective in gaining the cooperation of a toddler during a physical examination? A. Tell the child that another child the same age was not afraid B. Allow the child to touch and hold the equipment when possible C. Permit the child to sit on the parents lap during the examination D. Offer immediate praise for holding still or doing what was asked
A
A group of students are preparing for a class exam on skin disorders. As part of their preparation, they are reviewing information about acne vulgaris and its association with increased sebum production. The students demonstrate understanding of the information when they identify which areas as having the highest sebaceous gland activity? Select all that apply A. Face B. Upper chest C. Neck D. Back E. Shoulders
A, B, D
The nurse is questioning the parents of a two-year-old child to obtain a functional history. Which topics might the nurse include? Select all answers that apply. A. The Childs toileting habits B. Use of car seats and other safety measures C. Problems with growth and development D. Prenatal and perinatal history E. The child's race and ethnicity F. Use of supplements and vitamins
A, B, F
The nurse is preparing a hospitalized seven year old girl for a lumbar puncture. Which actions would help her reduce stress related to the procedure? Select all that apply A. Pretend to perform the procedure on her doll B. Explain the procedure to her in medical terms C. Do not allow her to see or touch the equipment D. Teach her the steps of the procedure E. Tell her not to pay attention to any sounds she might hear F. Introduce her to the healthcare personnel
A, D, F
A child is diagnosed with bacterial conjunctivitis and is prescribed topical antibiotic therapy. The child's mother asks when he can return to school. Which response by the nurse would be most appropriate? A. You need to wait until you finish the entire prescription of antibiotics B. Once the drainage is gone, he can go back to school C. You can send him to school this afternoon after his first dose of antibiotic D. He needs to be symptom-free for at least 72 hours
B
A nurse is reviewing the medical record of a child with hearing loss and notes that the child's hearing loss is in the range of 40 to 60 dB. The nurse interpret this as indicating what level of hearing loss? A. Mild loss B. Moderate loss C. Severe loss D. Profound loss
B
An instructor is developing a plan for a class of nursing students on various skin disorders. When describing urticaria, what would the instructor include? A. It is a type IV hypersensitivity reaction B. Histamine release leads to vasodilation C. Wheals appear first followed by erythema D. The nonpruritic rash blanches with pressure
B
And adolescent is scheduled for outpatient arthroscopic surgery on his knee next week. As part of preparing him for the procedure, which action would be most appropriate? A. Discussing the events with the adolescent and his mother upon arrival the morning of the procedure B. Providing detailed explanations of the procedure at least a week in advance of the procedure C. Encouraging the parent to stay with the adolescent as much as possible before the procedure D. Answering the adolescent's questions with simple answers, encouraging him to ask the surgeon
B
Assignment of a child leads the nurse to suspect viral conjunctivitis based on what finding? A. Mild pain B. Photophobia C. Itching D. Watery discharge
B
For which children would the nurse conduct an immediate comprehensive health history? A. A child who is brought to the emergency room with labored breathing B. A child who is a new client in a pediatrics office C. A child who is a routine client and presents with signs of a sinus infection D. A child whose condition is improving
B
The nurse Is caring for a 7 year old boy who needs his left leg immobilized. What is the priority nursing intervention? A. Enlist the assistance of a child life specialist B. Explain to the boy that he must keep his leg very still C. Apply a clove-hitch restraint to the boy's left leg D. Explain that a restraint will be applied if he cannot hold still
B
The nurse is assessing the temperature of a diaphoretic toddler who is crying and being uncooperative. What would be the best method to assess the temperature in this child? A. Oral thermometer B. Axillary method C. Temporal scanning D. Rectal route
B
The nurse is caring for a 10-year-old boy who is in traction. The boy has a nursing diagnosis of deficient diversional activity related to confinement in bed that is evidenced by verbalization of boredom and lack of participation in play, reading, and schoolwork. What would be the best intervention? A. Offer the child reading materials B. Enlist the aid of a child life specialist C. Encourage the child to complete his homework D. Ask for the parents' assistance
B
The nurse is caring for a 10-year-old girl who is in an isolation room. Which intervention would be a priority intervention for this child? A. Reduce noise as much as possible B. Provide age-appropriate toys and games C. Discourage visits from family members D. Put on mask prior to entering room
B
The nurse is caring for a 15 year old boy who has sustained burn injuries. The nurse observes the burn developing a purple color with discharge and a foul odor. The nurse suspects which infection? A. Burn wound cellulitis B. Invasive burn cellulitis C. Burn impetigo D. Staphylococcal scalded skin syndrome
B
The nurse is caring for a 3 month old with nasolacrimal duct obstruction. Which intervention would be most appropriate for the nurse to implement? A. Being careful to prevent spread of infection B. Teaching the parents how to gently massage the duct C. Applying hot, moist compresses to the affected eye D. Referring the child to an ophthalmologist
B
The nurse is caring for an 11-year-old girl preparing to undergo an MRI scan. Which statement would best help prepare the girl for the test and decrease anxiety? A. You won't hear a sound if you wear your headphones B. The machine makes a very loud rattle; however, headphones will help C. There are a variety of loud sounds you will hear D. The MRI scanner sounds like a machine gun
B
The nurse is conducting a health history for a nine-year-old child with stomach pains. What is a recommended guideline when approaching the child for information? A. Wear a white examination coat when conducting an interview B. Allow the child to control the pace and order of the health history C. Use quick deliberate gestures to get your point across D. Do not make physical contact with the child during interview
B
The nurse is conducting a physical examination of a 9 month old baby with a flat, discolored area on the skin. The nurse documents this as a: A. Papule B. Macule C. Vesicle D. Scale
B
The nurse is examining a 3 year old boy with acute otitis media who has a mild earache and a temperature of 38.5 C. Which action would be taken? A. Obtain a culture of the middle ear fluid B. Instruct the parent to watch for worsening symptoms C. Administer antibiotics D. Administer antivirals
B
The nurse is explaining the effects of heat application for pain relief. Which effect would the nurse be likely to include? A. Decreased blood flow to the area B. Increased pressure on nociceptive fibers C. Possible release of endogenous opioids D. Altered capillary permeability
B
The nurse is measuring the blood pressure of a 12-year-old boy with an oscillometric device. The boy's reading is greater than the 90th percentile for gender and height. What is the appropriate nursing action? A. Repeat the reading with the oscillometric device B. Repeat the blood pressure reading using auscultation C. Measure the blood pressure in all four extremities D. Measure the blood pressure with a Doppler
B
The nurse is preparing to take a tympanic temperature reading of a four year old. In order to get an accurate reading, what does the nurse need to do? A. Pull the earlobe back and down B. Direct the infrared sensor at the Tympanic membrane C. Pull the earlobe down and forward D. Remove any visible cerumen from inside ear canal
B
The nurse is teaching the mother of a toddler about burn prevention. Which response by the mother indicates a need for further teaching? A. We will leave fireworks displays to the professionals B. I will set our water heater at 130 degrees C. All sleepwear should be flame retardant D. The handles of pots on the stove should face inward
B
When preparing to apply a restraint to a child, what would be most important for the nurse to do? A. Expect to keep the restraint on for at least 8 hours B. Explain that safety, not punishment, is the reason for the restraint C. Plan to use a square knot to secure the restraint to the side rails D. Use a limb restraint rather than a jacket restraint for most issues
B
Which statement accurately describes a recommended guideline for setting the tone of the examination for a school age child? A. Keep up a running dialogue with the caregiver, explaining each step as you do it B. Include the child in all parts of the examination; speak to the caregiver before and after the examination C. Speak to the child using mature language and appeal to his or her desire for self care D. Address the child by name; speak to the caregiver and do the most invasive parts last
B
While auscultating the heart of a five-year-old child, the nurse notes a murmur that is soft and quiet and heard each time the heart is auscultated. The nurse document this finding as what grade? A. Grade 1 B. Grade 2 C. Grade 3 D. Grade 4
B
A nurse is preparing a class for parents of infants about managing diaper dermatitis. What advice would the nurse include in the preparation? Select all that apply A. Applying topical nystatin to the diaper area B. Using a blow dryer on warm to dry the diaper area C. Refraining from using rubber pants over diapers D. Using scented diaper wipes to clean the area E. Washing the diaper area with an antibacterial soap
B, C
The nurse is preparing a nursing care plan for a child hospitalized for cardiac surgery. Which are examples of interventions that nurses perform in the "building a trusting relationship" stage? Select all that apply A. Gathering information about the child using the child's own toys B. Preparing the child for a procedure by playing games C. Explaining in simple terms what will happen during surgery D. Allowing the child to devise an exercise plan following surgery E. Praising the child for how well he is doing following instructions F. Giving the child a favorite toy to cuddle following a painful procedure
B, C
The nurse is performing an admission of a 10 year old boy. Which actions will help the nurse establish a trusting and caring relationship with the child and his family? Select all that apply A. The nurse should not minimize the child's fears by smiling B. The nurse should initiate introductions C. The nurse should not use formal titles at the introduction D. The nurse should maintain eye contact at the appropriate level E. The nurse should start communication with the child first and then move on to the family F. The nurse should use age appropriate communication with the child
B, D, F
A 4 year old is brought to the emergency room with a burn. What would alert the nurse to the possibility of child abuse? A. Burn assessment correlates with mother's report of contact with a portable heater B. Parents state that the injury occurred approximately 15 to 20 minutes ago C. Clear delineations are noted between burned and nonburned skin areas D. The burn appears asymmetric and nonuniform
C
A mother brings her three-year-old daughter to the emergency department because the child has been vomiting and having diarrhea for the past 36 hours. When assessing this child's temperature, which method would be least appropriate? A. Oral B. Tympanic C. Rectal D. Axillary
C
A nurse is caring for a 5 year old in Buck traction. When conducting a skin examination for signs of pressure ulcers, the nurse pays particular attention to which area? A. Sacral area B. Hip area C. Occiput D. Upper arm
C
After teaching a group of students about visual disorders, the instructor determines that the teaching was successful when the students identify what is the most common cause of visual difficulties in children? A. Astigmatism B. Strabismus C. Refractive errors D. Nystagmus
C
The nurse has applied EMLA cream as ordered. How does the nurse assess that the cream has achieved its purpose? A. Assess the skin for redness B. Note any blanching of skin C. Lightly tap the area where the cream is D. Gently poke the child with a needle
C
The nurse is assessing the neck of an eight-year-old child with down syndrome. Which finding with the nurse expect during the examination? A. Webbing B. Excessive neck skin C. Lax neck skin D. Shortened neck
C
The nurse is caring for a child who is experiencing pain related to chemotherapy treatment. What is a behavioral factor that might affect the child's pain experience? A. Knowledge of the therapy B. Fear about the outcome of therapy C. Participation in normal routine activities D. Ability to identify pain triggers
C
The nurse is caring for a four-year-old girl who has been hospitalized for over a week with severe burns. Which would be a priority intervention to help satisfy this preschool child's basic needs? A. Encourage friends to visit as often as possible B. Suggest that a family member be present with her 24 hours a day C. Explain necessary procedures and simple language that she will understand D. Allow her to make choices about her meals and activities as much as permitted
C
The nurse is collecting information from the parents of a three-year-old child about her sleeping patterns. Which question by the nurse will best elicit information from the parents? A. How are things going at home? B. Is your child sleeping well at night? C. How many hours does your child sleep at night? D. What time does your child go to bed at night?
C
The nurse is conducting a physical examination of a child following a comprehensive health history. What should be the focus of the physical exam? A. The child B. The parents C. Chief complaint D. Developmental age
C
The nurse is examining a 7 year old boy with blepharitis. What would the nurse least likely expect to assess? A. Redness B. Scaling C. Pain D. Edema
C
The nurse is examining the posture of a male toddler and notes lordosis. What would be the appropriate reaction of the nurse for this finding? A. Explain that the child will need a back brace B. Refer the toddler to a physical therapist C. Do nothing; this is a normal condition for toddlers D. Notify the primary care physician about the condition
C
The nurse is preparing a child for a lumbar puncture. How far ahead of the procedure should the nurse apply the EMLA cream? A. 30 minutes B. 1 hour C. 3 hours D. 4 hours
C
The nurse working in the emergency room monitors the admission of children. Statistically, for which disorder with children younger than five years most commonly be admitted? A. Mental health problems B. Injuries C. Respiratory disorders D. Gastrointestinal disorders
C
The parents of a five-year-old bring their son to the emergency department because of significant island edema. The mother states "he scratched himself near his eye a couple of days ago while playing outside in the yard". The nurse suspects preorbital cellulitis based on which finding? A. Evidence of discharge B. Reddened conjunctiva C. Purplish discoloration of eyelid D. Altered visual acuity
C
When developing the plan of care for a child with burns requiring fluid replacement therapy, what information would the nurse expect to include? A. Administration of colloid initially followed by crystalloid B. Determination of fluid replacement based on the type of burn C. Administration of most of the volume during the first 8 hours D. Monitoring of hourly urine output to achieve less than 1 mL/kg/hour
C
When speaking to a group of parents at a local elementary school, the nurse describes school nursing as a specialized practice of nursing based on the fact that a healthy child has a better chance to succeed in school. What best describes the strategy school nurses use to achieve student success? A. They coordinate all school health programs B. They link community health services C. They work to minimize health-related barriers to learning D. They promote student health and safety
C
The nurse is providing developmentally appropriate care for a toddler hospitalized for observation following a fall down the steps. Which measures might the nurse consider when caring for this child? Select all that apply A. Use the en face position when holding the toddler B. Use a bed for toddlers who have an adult present C. Avoid leaving small objects that can be swallowed in the bed D. Explain activities in concrete, simple terms E. Allow the child to select meals and activities F. Encourage parents to stay to prevent separation anxiety
C, F
A nurse is assessing the fontanels of a crying newborn and notes that the fontanel pulsates and briefly bulges. What do these findings indicate? A. Increased intracranial pressure B. Over hydration C. Dehydration D. These are normal findings
D
A nurse is examining a child who has sustained blunt trauma to the eye area. The nurse suspects a simple contusion based on what finding? A. Pain in the eye B. Impaired visual acuity C. Blurred vision D. Intact extraoccular movement
D
The nurse is assessing the heart rate of a healthy school age child. The nurse expects that the child's heart rate will be in what ranges? A. 80-150 bpm B. 70-120 bpm C. 65-110 bpm D. 60-100 bpm
D
The nurse is caring for a 3 year old boy with amblyopia. Which intervention would be most appropriate to include in the child's plan of care? A. Rinsing the eye with cool water B. Educating the family about the disease C. Encouraging frequent hand washing D. Promoting eye safety
D
The nurse is caring for an Eight-year-old girl who requires numerous venipunctures and injections daily. The nurse understands that the child is exhibiting signs of sensory overload and enlists the assistance of the child life specialist. What should the therapeutic play involve to best deal with the child's stressors? A. Puppets and dolls B. Drawing paper and crayons C. Wooden hammer and pegs D. Sewing puppets with needles
D
The nurse is caring for an eight year old boy hospitalized for a bone marrow transplant. His parents are in and out of the room throughout the day. Which behaviors of the child would alert the nurse that he is in the second stage of separation anxiety? A. He ignores his parents when they return to his room B. He cries uncontrollably whenever they leave C. He forms superficial relationships with his caregivers D. He sits quietly and is not interested in playing and eating
D
The nurse is conducting an assessment of a high school track athlete. The client tells the nurse he is experiencing pain along his outer thigh. He describes it as tight, achy, and tender, particularly after he runs. The nurse understands that he is most likely experiencing what kind of pain? A. Cutaneous B. Neuropathic C. Visceral D. Deep somatic
D
The nurse is instructing the parents of a school-age child with an eye disorder how to care for her eye. Which condition would the nurse explain as resolving by itself without the use of antibiotics? A. Blepharitis B. Hordeolum C. Corneal abrasion D. Chalazion
D
The nurse is performing a health history on a six year old boy who is having trouble adjusting to school. Which question would be most likely to elicit valuable information? A. Do you like your new school? B. Are you happy with your teacher? C. Do you enjoy reading a book? D. What are your new classmates like?
D
The nurse is performing a physical examination on a sleeping newborn. Which body system should the nurse examine last? A. Heart B. Abdomen C. Lungs D. Throat
D
The nurse is providing discharge planning for a 12 year old boy with multiple medical conditions. What would be the best teaching method for this child and his family? A. Demonstrate the care and ask for a return demonstration B. Provide and review educational booklets and materials C. Provide a written schedule for the child's care D. Provide a trial period of home care
D
The nurse is providing instructions to a mother on how to use thought stopping to help her child deal with anxiety and fear associated with frequent painful injections. Which statement indicates the mother understands the technique? A. We will imagine we are on the beach in Florida B. We can talk about our favorite funny movie and laugh C. She can let her body parts go limp, working from head to toe D. We'll repeat ''quick stick, feel better, go home soon" several times
D
The nurse is teaching a student nurse about abnormal findings when assessing the breasts of children. What may be associated with renal disorders? A. Swollen nipples upon inspection of a newborn's breasts B. Tender nodule palpated under the nipple of a 10-year-old C. Observation of enlarged breast tissue in a male adolescent D. Observation of a supernumerary nipple along the mammary ridge
D
The nurse is transporting a 6 month old with a suspected blood disorder to the nursery. What is the most appropriate method of transporting the child by the nurse? A. A wagon with rails B. Cradle hold C. Football hold D. Over-the-shoulder
D
The nurse is using pulse oximetry to measure oxygen saturation in a three year old girl. The nurse understands that falsely high readings may be associated with which situation or condition? A. A nonsecure connection B. Cold extremities C. Hypovolemia D. Anemia
D
The nurse working with children in a hospital setting notes that they are being discharged earlier and earlier. Which is a primary reason for this trend? A. Nursing shortages B. Increased funding for home care C. National health care initiatives D. Cost containment
D
The nurse is teaching the student nurse the sequence for performing the assessment techniques during a physical examination. What is the appropriate order?
Inspect, Palpate, Percuss, Auscultate
