Unit 6 - Ch. 42, 44, 48, and 50
The nurse is caring for a 3-year-old girl with short bowel syndrome as a result of trauma to the small intestine. The girl's mother is extremely anxious and tells the nurse she is afraid she will never learn how to care for her daughter at home. How should the nurse respond? A) "I will help you become an expert on your daughter's care." B) "You must learn how to care for your daughter at home." C) "You really need the support of your husband." D) "There is a lot to learn and you need a positive attitude."
A) "I will help you become an expert on your daughter's care."
When developing the plan of care for a child with cerebral palsy, which treatment would the nurse expect as least likely? A) Skeletal traction B) Physical therapy C) Orthotics D) Occupational therapy
A) Skeletal traction
The nurse is assessing the neuromusculoskeletal system of a newborn. Which of the following would the nurse identify as an abnormal finding? A) Sluggish deep tendon reflexes B) Full range of motion in extremities C) Absence of hypotonia D) Lack of purposeful muscular control
A) Sluggish deep tendon reflexes
A child with diabetes insipidus is being treated with vasopressin. The nurse would assess the child closely for signs and symptoms of which of the following? A) Syndrome of inappropriate antidiuretic hormone (SIADH) B) Thyroid storm C) Cushing syndrome D) Vitamin D toxicity
A) Syndrome of inappropriate antidiuretic hormone (SIADH)
The nurse is caring for an 8-year-old boy with myasthenia gravis and is teaching his parents about the signs of cholinergic crisis. Which of the following responses by the parents indicates a need for further teaching? A) "Low blood pressure is a sign of crisis." B) "He might have difficulty swallowing." C) "He may start to sweat a lot." D) "More saliva in the mouth is a common sign."
B) "He might have difficulty swallowing."
A child with diabetes reports that he is feeling a little shaky. Further assessment reveals that the child is coherent but with some slight tremors and sweating. A fingerstick blood glucose level is 70 mg/dL. Which of the following would the nurse do next? A) Administer a sliding-scale dose of insulin B) Give 10 to 15 grams of a simple carbohydrate C) Offer a complex carbohydrate snack D) Administer glucagon intramuscularly
B) Give 10 to 15 grams of a simple carbohydrate
A nurse is preparing a presentation for a group of parents with children diagnosed with diabetes type 1. The children are all adolescents. Which of the following issues would the nurse need to address? Select all that apply. A) Self-monitoring of blood glucose levels B) Feelings of being different C) Deficient decision-making skills D) Body image conflicts E) Struggle for independence
C) Deficient decision-making skills D) Body image conflicts E) Struggle for independence
The nurse is caring for a 10-year-old boy with hyperpituitarism due to a tumor on the anterior pituitary gland. Which of the following would be a priority for this child? A) Promoting a healthy body image B) Encouraging effective family coping C) Providing pre- and postoperative care D) Promoting knowledge about treatment options
C) Providing pre- and postoperative care
A child with depression is prescribed fluoxetine. The nurse identifies this as belonging to which class of drugs? A) Atypical antidepressant B) Tricyclic antidepressant C) Selective serotonin reuptake inhibitor D) Psychostimulant
C) Selective serotonin reuptake inhibitor
A child with attention deficit/hyperactivity disorder is prescribed long-acting methylphenidate. Which of the following would the nurse include when teaching the child and his parents about this drug? A) "Give the drug three times a day: morning, midday, and after school." B) "This drug may cause drowsiness, so be careful when doing things." C) "Some increase in appetite may occur, so watch how much you eat." D) "Take this drug every day in the morning when you wake up."
D) "Take this drug every day in the morning when you wake up."
After teaching the parents of a 6-year-old how to administer an enema, the nurse determines that the teaching was successful when they state that they will give how much solution to their child? A) 100 to 200 mL B) 200 to 300 mL C) 250 to 500 mL D) 500 to 1,000 mL
D) 500 to 1,000 mL
Which of the following would the nurse expect to find initially in a child with Guillain-Barré syndrome? A) Symmetric flaccid weakness B) Ataxia C) Sensory disturbances D) Lower extremity pain
D) Lower extremity pain
A nurse is teaching the parents of an infant with congenital adrenal hyperplasia about the signs and symptoms of adrenal crisis. The nurse determines that the teaching was successful when the parents identify which of the following? A) Bradycardia B) Constipation C) Fluid overload D) Persistent vomiting
D) Persistent vomiting
Which of the following would the nurse expect to assess in a child with hypothyroidism? A) Nervousness B) Heat intolerance C) Smooth velvety skin D) Weight gain
D) Weight gain
The nurse is teaching the mother of a 5-year-old boy with a history of impaction how to administer enemas at home. Which of the following responses from the mother indicates a need for further teaching? A) "I should position him on his abdomen with knees bent." B) "He will require 250 to 500 mL of enema solution." C) "I should wash my hands and then wear gloves." D) "He should retain the solution for 5 to 10 minutes."
A) "I should position him on his abdomen with knees bent."
Which of the following would the nurse include in the preoperative plan of care for an infant with myelomeningocele? A) Positioning supine with a pillow under the buttocks B) Covering the sac with saline-soaked nonadhesive gauze C) Wrapping the infant snugly in a blanket D) Applying a diaper to prevent fecal soiling of the sac
B) Covering the sac with saline-soaked nonadhesive gauze
The nurse is assessing a newborn who was delivered after a prolonged labor due to an abnormal presentation. The newborn sustained a cranial nerve injury. The nurse would most likely expect to assess deficits related to which cranial nerve? A) Optic B) Facial C) Acoustic D) Trigeminal
B) Facial
The nurse is reviewing the laboratory test results of a child with Addison disease. Which of the following would the nurse expect to find? A) Hypernatremia B) Hyperkalemia C) Hyperglycemia D) Hypercalcemia
B) Hyperkalemia
The nurse is teaching a group of students about myelinization in a child. Which statement by the students indicates that the teaching was successful? A) Myelinization is completed by 4 years of age. B) The process occurs in a head-to-toe fashion. C) The speed of nerve impulses slows as myelinization occurs. D) Nerve impulses become less specific in focus with myelinization.
B) The process occurs in a head-to-toe fashion.
The nurse is caring for a 10-year-old with Duchenne muscular dystrophy. As part of the plan of care, the nurse focuses on maintaining his cardiopulmonary function. Which intervention would the nurse implement to best promote maximum chest expansion? A) Deep-breathing exercises B) Upright positioning C) Coughing D) Chest percussion
B) Upright positioning
When examining the abdomen of a child, which technique would the nurse use last? A) Auscultation B) Percussion C) Palpation D) Inspection
C) Palpation
The nurse is caring for a 4-year-old boy who has undergone an appendectomy. The child is unwilling to use the incentive spirometer. Which approach would be most appropriate to elicit the child's cooperation? A) "Can you cough for me please?" B) "You must blow in this or you might get pneumonia." C) "If you don't try, I will have to get the doctor." D) "Can you blow this cotton ball across the tray?"
D) "Can you blow this cotton ball across the tray?"
When reviewing the medical record of a child, which of the following would the nurse interpret as the most sensitive indicator of intellectual disability? A) History of seizures B) Preterm birth C) Vision deficit D) Language delay
D) Language delay
A nursing instructor is developing a class presentation about the medications used to treat peptic ulcer disease. Which drug class would the instructor be least likely to include in the presentation? A) Antibiotics B) Proton pump inhibitors C) Histamine antagonists D) Prokinetics
D) Prokinetics
The nurse is taking a health history of an 11-year-old girl with recurrent abdominal pain. Which of the following responses would lead the nurse to suspect irritable bowel syndrome? A) "I always feel better after I have a bowel movement." B) "I don't take any medicine right now." C) "The pain comes and goes." D) "The pain doesn't wake me up in the middle of the night."
A) "I always feel better after I have a bowel movement."
The nurse is caring for a child with a spinal cord injury and providing instruction to the parents on promoting skin integrity. Which response from the mother indicates a need for further teaching? A) "I need to monitor his skin at least twice a week." B) "I must monitor skin affected by his adaptive equipment." C) "He must change positions frequently." D) "We must avoid harsh cleaning products."
A) "I need to monitor his skin at least twice a week."
The nurse is providing postoperative care for a 14-month-old girl who has undergone a myelomeningocele repair. The girl's mother is extremely anxious and tells the nurse she is afraid she will never learn how to care for her daughter at home. Which response by the nurse would be most appropriate? A) "I will help you become comfortable in caring for your daughter." B) "You must learn how to care for your daughter at home." C) "You will need to learn to collaborate with all the caregivers." D) "There is a lot to learn, and you need a positive attitude."
A) "I will help you become comfortable in caring for your daughter."
A child is receiving therapy in which he is learning to replace automatic negative thought patterns with alternative ones. The nurse interprets this as which type of therapy? A) Cognitive therapy B) Behavioral therapy C) Milieu therapy D) Individual therapy
A) Cognitive therapy
A nurse is preparing a teaching session for a group of parents with children newly diagnosed with attention deficit/hyperactivity disorder (ADHD). When explaining this disorder to the parents, which of the following would the nurse include as being involved? Select all answers that apply. A) Impulsivity B) Inattention C) Distractibility D) Hyperactivity E) Defiance F) Anxiety
A) Impulsivity B) Inattention C) Distractibility D) Hyperactivity
The nurse identifies a nursing diagnosis of impaired social interaction related to altered social skills as evidenced by impulsivity and intrusive behavior. The nurse plans to identify factors that aggravate the child's behavior for which reason? A) Minimize stimuli that exacerbate the child's undesired behaviors B) Improve the child's ability to deal with external stressors C) Promote increased ability to follow through D) Encourage the child to adopt expectations into his routine
A) Minimize stimuli that exacerbate the child's undesired behaviors
A nurse is reviewing the medical record of an 11-year-old child with a conduct disorder. Which of the following would the nurse identify as characteristic of this disorder? Select all answers that apply. A) Easily annoyed B) Initiator of physical fights C) Temper tantrums D) Truancy E) Arrest for arson
B) Initiator of physical fights D) Truancy E) Arrest for arson
After teaching the parents of a child with attention deficit/hyperactivity disorder about ways to control the child's behavior, the nurse determines a need for additional teaching when the parents state which of the following? A) "If he starts to act out, we'll have him do a time-out to help him refocus." B) "We can use a reward system when he behaves appropriately." C) "If he misbehaves, we need to punish him instead of reward him." D) "We need to help him set realistic goals that he can achieve."
C) "If he misbehaves, we need to punish him instead of reward him."
A child with growth hormone deficiency is receiving growth hormone. Which of the following would the nurse interpret as indicating effectiveness of this therapy? A) Rapid weight gain B) Complaints of headaches C) Height increase of 4 inches D) Growth plate closure
C) Height increase of 4 inches
A nurse is preparing a program for a group of parents about injury prevention. Which of the following would the nurse include as an important contributing factor for cervical spine injury in a child? A) Exposure to teratogens while in utero B) Immaturity of the central nervous system C) Increased mobility of the spine D) Incomplete myelinization
C) Increased mobility of the spine
Which finding would lead the nurse to suspect that a child is experiencing moderate dehydration? A) Dusky extremities B) Tenting of skin C) Sunken fontanels D) Hypotension
C) Sunken fontanels
The nurse is assessing a 13-year-old boy with type 2 diabetes mellitus. Which of the following would the nurse correlate with disorder? A) The parents report that their child had "a cold or flu" recently. B) Blood pressure is decreased when checking vital signs. C) The parents report that their son "can't drink enough water." D) Auscultation reveals Kussmaul breathing.
C) The parents report that their son "can't drink enough water."
A child is prescribed trazodone. Which of the following would the nurse be least likely to include in the plan of care related to this drug? A) Monitoring blood pressure for orthostatic hypotension B) Assessing the child for sedation and drowsiness C) Administering the drug with a snack D) Monitoring for tardive dyskinesia
D) Monitoring for tardive dyskinesia
When assessing the adolescent with anorexia, which of the following would the nurse expect to find? A) Tachycardia B) Hypertension C) Fever D) Murmur
D) Murmur
The nurse has developed a plan of care for a 6-year-old with muscular dystrophy. He was recently injured when he fell out of bed at home. Which intervention would the nurse suggest to prevent further injury? A) Recommend the bed's side rails be raised throughout the day and night. B) Suggest a caregiver be present continuously to prevent falls from bed. C) Encourage a loose restraint to be used when he is in bed. D) Recommend raising the bed's side rails when a caregiver is not present.
D) Recommend raising the bed's side rails when a caregiver is not present.
The nurse is teaching the mother of a 12-year-old boy about the risk factors associated with drug and alcohol abuse. Which response by the mother indicates a need for further teaching? A) "A family history of alcoholism is a risk factor for substance abuse." B) "Just because his friends are experimenting does not mean that he will." C) "If my husband or I have a substance abuse problem it could increase his risk." D) "Negative life events are a potential risk factor."
B) "Just because his friends are experimenting does not mean that he will."
A group of students are reviewing information about neuromuscular disorders. The students demonstrate understanding of the information when they identify which of the following as examples of autoimmune neuromuscular disorders? Select all answers that apply. A) Cerebral palsy B) Guillain-Barré syndrome C) Myasthenia gravis D) Spinal muscular atrophy E) Dermatomyositis
B) Guillain-Barré syndrome C) Myasthenia gravis E) Dermatomyositis
The nurse is assessing a 9-year-old girl with a history of tuberculosis at age 6 years. She has been losing weight and has no appetite. The nurse suspects Addison disease based on which of the following assessment findings? A) Arrested height and increased weight B) Thin, fragile skin and multiple bruises C) Hyperpigmentation and hypotension D) Blurred vision and enuresis
C) Hyperpigmentation and hypotension
An 8-month-old infant is brought to the clinic for evaluation. The mother tells the nurse that she has noticed some white patches on the infant's tongue that look like curdled milk after breastfeeding. The nurse suspects oral candidiasis (thrush). Which question would the nurse use to help confirm this suspicion? A) "Are you having breast pain when you nurse the baby?" B) "Has he had any dairy problems recently?" C) "Is he experiencing any vomiting lately?" D) "How have his stools been this past week?"
A) "Are you having breast pain when you nurse the baby?"
The nurse is caring for a 13-year-old boy with a history of inappropriate behavior. Which statement by the mother would lead the nurse to suspect oppositional defiant disorder rather than conduct disorder? A) "He has frequent temper tantrums." B) "He was pulling the neighbor's dog around by his leash." C) "He is constantly lying to me." D) "He has stolen hundreds of dollars from my purse."
A) "He has frequent temper tantrums."
A child with Duchenne muscular dystrophy is to receive prednisone as part of his treatment plan. After teaching the child's parents about this drug, which statement by the parents indicates the need for additional teaching? A) "We should give this drug before he eats anything." B) "We need to keep a close eye for possible infection." C) "The drug should not be stopped suddenly." D) "He might gain some weight with this drug."
A) "We should give this drug before he eats anything."
The nurse is caring for a child with bipolar disorder. The child is taking lithium as ordered. The parents inquire about the potential side effects. Which response by the nurse would be most appropriate? A) "You might see excessive urination and thirst, tremor, nausea, weight gain, and diarrhea." B) "He might experience a significant decrease in his appetite and difficulty sleeping." C) "You need to watch for dry mouth, urinary retention, and constipation." D) "This medication can cause seizures, agitation, headache, and nausea."
A) "You might see excessive urination and thirst, tremor, nausea, weight gain, and diarrhea."
A school nurse is working with the parents of an 8-year-old who has Tourette syndrome on how best to accommodate the child. Which of the following would be most helpful? Select all answers that apply. A) Allowing for breaks when tics occur B) Providing for "time-outs" during the day C) Using a tape recorder to take notes D) Ensuring a specified amount of time for test taking E) Implementing a reward system for behavior
A) Allowing for breaks when tics occur C) Using a tape recorder to take notes
A group of students are reviewing information about gallbladder disease in children. The students demonstrate a need for additional review when they identify which of the following? A) Cholesterol gallstones are more frequently found in males. B) Pigment stones are found primarily in the common bile duct. C) Pancreatitis is a common complication of cholecystitis in children. D) Cholecystitis is due to chemical irritation from obstructed bile flow.
A) Cholesterol gallstones are more frequently found in males.
The nurse is developing a plan of care for a 7-year-old boy with diabetes insipidus. Which of the following would the nurse most likely identify as the priority nursing diagnosis? A) Deficient fluid volume related to dehydration B) Excess fluid volume related to edema C) Deficient knowledge related to fluid intake regimen D) Imbalanced nutrition, more than body requirements related to excess weight
A) Deficient fluid volume related to dehydration
The nurse is preparing a teaching plan for the family and their 6-year-old son who has just been diagnosed with diabetes mellitus. Which of the following would the nurse identify as the initial goal for the teaching plan? A) Developing management and decision-making skills B) Educating the parents about diabetes mellitus type 1 C) Developing a nutritionally sound, 30-day meal plan D) Promoting independence with self-administration of insulin
A) Developing management and decision-making skills
A nurse is preparing a program for a parent group about various techniques that can be used to manage behavior. Which of the following would the nurse be least likely to include? A) Focus the child's attention on the negative behavior. B) Set limits with the child for responsible behavior. C) Ignore inappropriate behaviors. D) Provide positive feedback for self-control efforts.
A) Focus the child's attention on the negative behavior.
The nurse is providing care to a child with pancreatitis. When reviewing the child's laboratory test results, which of the following would the nurse expect to find? Select all answers that apply. A) Leukocytosis B) Decreased C-reactive protein C) Elevated serum amylase levels D) Positive stool culture E) Decreased serum lipase levels
A) Leukocytosis C) Elevated serum amylase levels
A school-age child diagnosed with depression is receiving antidepressant therapy. The nurse would instruct the parents to notify the physician immediately if the child demonstrates which of the following? A) Loss of interest B) Gastric upset C) Sedation D) Urinary retention
A) Loss of interest
The nurse is assessing a child who is suspected of having Guillain-Barré syndrome. Which assessment findings would the nurse correlate as supporting this diagnosis? Select all answers that apply. A) Recent cytomegalovirus infection B) Hyperactive deep tendon reflexes C) Numbness in the lower extremities D) Sustained clonus E) Difficulty swallowing
A) Recent cytomegalovirus infection C) Numbness in the lower extremities D) Sustained clonus
A nurse is caring for a 14-year-old girl scheduled for a barium swallow/upper gastrointestinal (GI) series. Before providing instructions, which of the following would be the priority? A) Screening the girl for pregnancy B) Reminding her to drink plenty of fluids after the procedure C) Ordering a bowel prep D) Reminding the girl about potential light-colored stools
A) Screening the girl for pregnancy
The nurse is caring for a 2-month-old with a cleft palate. The child will undergo corrective surgery at age 3 months. The mother would like to continue breastfeeding the baby after surgery and wonders if it is possible. How should the nurse respond? A) "There is a good chance that you will be able to breastfeed almost immediately." B) "Breastfeeding is likely to be possible, but check with the surgeon." C) "After the suture line heals, breastfeeding can resume." D) "We will have to wait and see what happens after the surgery."
B) "Breastfeeding is likely to be possible, but check with the surgeon."
A child with myasthenia gravis is brought to the emergency department by his parents. The parents have noticed a sudden increase in respiratory difficulty. The nurse suspects myasthenic crisis based on which statement by the parents? A) "We gave him an extra dose of his medication earlier today." B) "He was coughing and had a slight fever yesterday and today." C) "Things have been pretty stress-free lately." D) "He's been resting when he gets tired."
B) "He was coughing and had a slight fever yesterday and today."
The mother of a 3-week-old infant old brings her daughter in for an evaluation. During the visit, the mother tells the nurse that her baby is spitting up after feedings. Which response by the nurse would be most appropriate? A) "We need to tell the doctor about this." B) "Infants this age commonly spit up." C) "Your daughter might have an allergy." D) "Don't worry; you're just feeding her too much."
B) "Infants this age commonly spit up."
After teaching the parents of a daughter with central precocious puberty about medication therapy, which statement by the parents indicates successful teaching? A) "She needs to use the nasal spray once every day." B) "She'll start puberty again when the medication stops." C) "This medication will slow down the changes but not reverse them." D) "Once therapy is done, she'll need surgery."
B) "She'll start puberty again when the medication stops."
The school nurse is working with a 10-year-old girl with recurrent abdominal pain. The girl's teacher has been less than understanding about the frequent absences and trips to the nurse's office. How should the nurse respond? A) "Be patient; she is trying some new medication." B) "The pain she is having is real." C) "The family is working toward improvement." D) "Please do not add to this family's stress."
B) "The pain she is having is real."
The nurse is determining maintenance fluid requirements for a child who weighs 25 kg. How much fluid would the child need per day? A) 1,560 mL B) 1,600 mL C) 1,650 mL D) 1,700 mL
B) 1,600 mL
A 5-year-old child with type 1 diabetes is brought to the clinic by his mother for a follow-up visit after having his hemoglobin A1C level drawn. Which result would indicate to the nurse that the child is achieving long-term glucose control? A) 9.0% B) 8.2% C) 7.3% D) 6.9%
B) 8.2%
The nurse is caring for an infant with a temporary ileostomy. As part of the plan of care, the nurse monitors for skin breakdown around the stoma. If redness occurs, which of the following would be most appropriate to promote healing and prevent further skin breakdown? A) Clean the area well with a scented diaper wipe. B) Apply a barrier/healing cream or paste on the skin. C) Use a barrier wafer (such as Stomahesive) to attach the appliance. D) Sanitize the area with an alcohol wipe after each diaper change
B) Apply a barrier/healing cream or paste on the skin.
The nurse is caring for a 2-month-old with cerebral palsy. The infant is limp and flaccid with uncontrolled, slow, worm-like, writhing, and twisting movements. Which of the following would the nurse use when documenting these observations? A) Spastic B) Athetoid C) Ataxic D) Mixed
B) Athetoid
Which of the following would lead the nurse to suspect that an adolescent has bulimia? A) Body mass index less than 17 B) Calluses on back of knuckles C) Nail pitting D) Bradycardia
B) Calluses on back of knuckles
The nurse is caring for an adolescent girl with anorexia nervosa. Which of the following findings would indicate to the nurse that the girl requires hospitalization? A) Weight gain of one-half pound per week B) Food refusal C) Body mass index of 18 D) Soft, sparse body hair and dry, sallow skin
B) Food refusal
The parents of a 6-week-old boy come to the clinic for evaluation because the infant has been vomiting. The parents report that the vomiting has been increasing in frequency and forcefulness over the last week. The mother says, "Sometimes, it seems like it just bursts out of his mouth." A diagnosis of hypertrophic pyloric stenosis is suspected. When performing the physical examination, which of the following would the nurse most likely find? A) Sausage-shaped mass in the upper midabdomen B) Hard, moveable, olive-shaped mass in the right upper quadrant C) Tenderness over the McBurney point in the right lower quadrant D) Abdominal pain in the epigastric or umbilical region
B) Hard, moveable, olive-shaped mass in the right upper quadrant
The parents of a boy diagnosed with Hirschsprung disease are anxious and fearful of the upcoming surgery. The mother states, "I'm worried about having to care for our son's ostomy." Which intervention would be most helpful for the parents? A) Explaining to them about the diagnosis and surgery B) Having a wound, ostomy, and continence nurse meet with them C) Reinforcing that the ostomy will be temporary D) Teaching them about the medications used to slow stool output
B) Having a wound, ostomy, and continence nurse meet with them
A group of nursing students are reviewing the components of the endocrine system. The students demonstrate understanding of the review when they identify which of the following as the primary function of this system? A) Regulation of water balance B) Hormonal secretion C) Cellular metabolism D) Growth stimulation
B) Hormonal secretion
A nurse is conducting a screening program for autism in infants and children. Which of the following would the nurse identify as a warning sign? A) Lack of babbling by 6 months B) Inability to say a single word by 16 months C) Lack of gestures by 8 months D) Inability to use two words by 18 months
B) Inability to say a single word by 16 months
The nurse is caring for an 8-year-old girl with hyperpituitarism. Which of the following ordered treatments will the nurse expect to perform? A) Give desmopressin acetate intranasally B) Inject octreotide acetate C) Give 1 mg/kg/day of methimazole D) Administer glipizide orally
B) Inject octreotide acetate
A child is diagnosed with hyperthyroidism. Which agent would the nurse expect the physician to prescribe? A) Mineralocorticoid B) Methimazole C) Levothyroxine D) Dexamethasone
B) Methimazole
A group of nursing students are reviewing information about inflammatory bowel disease in preparation for a class discussion on the topic. The students demonstrate understanding of the material when they identify which of the following as characteristic of Crohn disease? Select all answers that apply. A) Distributed in a continuous fashion. B) Most common between the ages of 10 to 20 years C) Elevated erythrocyte sedimentation rate D) Low serum iron levels E) Tenesmus F) Loss of haustra within bowel
B) Most common between the ages of 10 to 20 years
A nurse is caring for a 14-year-old girl following myelography. Which of the following would be the priority nursing action? A) Monitoring for a decrease in spasticity B) Observing for signs of meningeal irritation C) Assessing motor function D) Observing for mental confusion or hallucinations
B) Observing for signs of meningeal irritation
After teaching the parents of a child diagnosed with celiac disease about nutrition, the nurse determines that the teaching was effective when the parents identify which foods as appropriate for their child? Select all answers that apply. A) Wheat germ B) Peanut butter C) Carbonated drinks D) Shellfish E) Jelly F) Flavored yogurt
B) Peanut butter C) Carbonated drinks D) Shellfish E) Jelly
The nurse is conducting a physical examination of a child with suspected Crohn disease. Which of the following findings would be the most highly suspicious of Crohn disease? A) Normal growth patterns B) Perianal skin tags or fissures C) Poor growth patterns D) Abdominal tenderness
B) Perianal skin tags or fissures
A nurse is caring for a 5-year-old girl with depression. The girl is having difficulty coping with her feelings of sadness and fear, which stem from her parents' separation and recent divorce. The girl has been prescribed antidepressant medication but the mother thinks the girl would benefit from therapy. The nurse anticipates a referral to a therapist specializing in which type of therapy? A) Individual therapy B) Play therapy C) Behavioral therapy D) Hypnosis
B) Play therapy
The nurse is caring for a 5-year-old. The child's mother reports that he is extremely sensitive to sounds that most people do not notice and that he prefers complete silence. She explains that the boy is resisting going to school due to the noise and commotion. Additionally, the mother states that he will only wear 100% cotton clothing with all of the tags cut out. The nurse interprets these findings as indicating which of the following? A) Anxiety disorder B) Sensory integration dysfunction C) Depression D) Obsessive-compulsive disorder
B) Sensory integration dysfunction
The nurse is caring for an 8-year-old girl with an endocrine disorder involving the posterior pituitary gland. Which of the following would the nurse expect to implement? A) Instructing the parents to report adverse reactions to the growth hormone treatment B) Teaching the parents how to administer the desmopressin acetate C) Informing the parents that treatment stops when puberty begins D) Educating the parents to report signs of acute adrenal crisis
B) Teaching the parents how to administer the desmopressin acetate
A nursing instructor is preparing for a class discussion on spinal muscular atrophy (SMA). When describing type 2 SMA, which of the following would the instructor include? Select all answers that apply. A) Onset before 6 months of age B) Weakness most severe in shoulders and hips C) Difficulty with swallowing D) Slowly progressing condition E) Genetic disease with autosomal recessive inheritance
B) Weakness most severe in shoulders and hips D) Slowly progressing condition E) Genetic disease with autosomal recessive inheritance
The nurse is teaching the mother of a 5-year-old boy with a myelomeningocele who has developed a sensitivity to latex. Which of the following responses from his mother indicates a need for further teaching? A) "He needs to get a medical alert identification." B) "I will need to discuss this with his caregivers." C) "A product's label indicates whether it is latex-free." D) "He must avoid all contact with latex."
C) "A product's label indicates whether it is latex-free."
The nurse is caring for a 3-year-old boy. The parents are concerned that he is exhibiting signs of cognitive delays. Which statement by the parents would lead the nurse to suspect autism spectrum disorder rather than possible learning disability? A) "He is not speaking in complete sentences." B) "We can understand a lot of what he says, but no one else can." C) "He seems to be speaking words less and less frequently." D) "He is unable to sit still for a short story."
C) "He seems to be speaking words less and less frequently."
A 6-year-old boy with cerebral palsy has been admitted to the hospital for some tests. His condition is stable. The boy's mother remains with her son, but she is obviously exhausted and stressed. Which response by the nurse would be most appropriate? A) "Would you like me to bring you a blanket and pillow?" B) "You are doing such a wonderful job with your son." C) "He's in good hands; consider going home to get some sleep." D) "Are you planning to spend the night or to go home?"
C) "He's in good hands; consider going home to get some sleep."
A child is scheduled for a lower endoscopy. Which of the following would the nurse include in the child's plan of care in preparation for this test? A) Explaining about the need to ingest barium B) Establishing an intravenous access for radionuclide administration C) Administering the prescribed bowel cleansing regimen D) Withholding prescribed proton pump inhibitors for 5 days before
C) Administering the prescribed bowel cleansing regimen
The nurse is caring for a 7-year-old with Tourette syndrome. The nurse would be alert for which of the following comorbid conditions? A) Depression B) Anxiety disorder C) Attention-deficit/hyperactivity disorder D) Asperger syndrome
C) Attention-deficit/hyperactivity disorder
The nurse is administering 10 units of NPH insulin to a child at 8 a.m. The nurse would expect this insulin to begin acting at which time? A) By 8:15 a.m. B) Between 8:30 and 9 a.m. C) Between 9 and 11 a.m. D) Around 12 noon
C) Between 9 and 11 a.m.
The nurse is providing care to a child with an intussusception. The child has a bowel movement and the nurse inspects the stool. The nurse would document the stool's appearance most likely as which of the following? A) Greasy B) Clay-colored C) Currant jelly-like D) Bloody
C) Currant jelly-like
The nurse suspects that a 4-year-old with type 1 diabetes is experiencing hypoglycemia based on which of the following? Select all that apply. A) Blurred vision B) Dry, flushed skin C) Diaphoresis D) Slurred speech E) Fruity breath odor F) Tachycardia
C) Diaphoresis D) Slurred speech F) Tachycardia
A nurse is caring for a 10-year-old boy with a nursing diagnosis of ineffective coping related to an inability to deal with stressors secondary to anxiety. Which of the following would be most important for the nurse to do first? A) Set clear limits on the child's behavior B) Teach the child problem-solving skills C) Encourage a discussion of the child's thoughts and feelings D) Role model appropriate social and conversation skills
C) Encourage a discussion of the child's thoughts and feelings
The nurse is preparing a teaching plan for a 10-year-old girl with hyperthyroidism. Which of the following would the nurse include in the plan? A) Describing surgery to remove an anterior pituitary tumor B) Teaching her parents to give injections of growth hormone C) Explaining about the radioactive iodine procedure D) Showing her parents how to give DDAVP intranasally
C) Explaining about the radioactive iodine procedure
A group of nursing students are reviewing information about the endocrine system in infants and children. The students demonstrate understanding of the information when they state which of the following? A) Endocrine glands begin developing in the third trimester of gestation. B) At birth, the endocrine glands are completely functional. C) Infants have difficulty balancing glucose and electrolytes. D) A child's endocrine system has little effect on growth and development
C) Infants have difficulty balancing glucose and electrolytes.
A child with spastic cerebral palsy is to receive botulin toxin. The nurse prepares the child for administration of this drug by which route? A) Oral B) Subcutaneous injection C) Intramuscular injection D) Intravenous infusion
C) Intramuscular injection
The nurse is reviewing the medical record of a child who has dyspraxia. The nurse understands that this child experiences difficulty with which of the following? A) Reading and writing B) Mathematics and computation C) Manual dexterity and coordination D) Composition and spelling
C) Manual dexterity and coordination
The nurse is caring for a 13-year-old girl with delayed puberty. Based on the nurse's knowledge of this condition, the nurse would include which nursing diagnosis in the child's plan of care? A) Disabled family coping related to the child's disorder B) Imbalanced nutrition, less than body requirements related to the child's short stature C) Noncompliance related to the need for lifelong hormone therapy D) Deficient knowledge related to the administration of estradiol
D) Deficient knowledge related to the administration of estradiol
A child with cerebral palsy has undergone surgery for placement of a baclofen pump. Which of the following would the nurse include when teaching the parents about caring for their child? A) Waiting 48 hours before allowing the child to take a tub bath B) Not allowing the child to sleep on his side for about 4 weeks C) Calling the physician if the child's temperature is over 100.5°F D) Discouraging the child from stretching or bending forward for 4 weeks
D) Discouraging the child from stretching or bending forward for 4 weeks
After teaching a class of nursing students about muscular dystrophy, the instructor determines that the teaching was successful when the students identify which type of muscular dystrophy as demonstrating an X-linked recessive pattern of inheritance? A) Limb-girdle B) Myotonic C) Distal D) Duchenne
D) Duchenne
The parents of a child diagnosed with celiac disease ask the nurse what types of food they can offer their child. Which of the following would the nurse include in the teaching plan? A) Frozen yogurt B) Rye bread C) Creamed spinach D) Fruit juice
D) Fruit juice
A group of students are reviewing information about the various types of insulin used to treat type 1 diabetes. The students demonstrate understanding of the information when they identify which insulin listed below as having the longest duration? A) Lispro B) Regular C) NPH D) Glargine
D) Glargine
The parents of a child with congenital adrenal hyperplasia bring the child to the emergency department for evaluation because the child has had persistent vomiting. Which of the following would lead the nurse to suspect that the child is experiencing an acute adrenal crisis? A) Hypernatremia B) Bradycardia C) Hypertension D) Hyperkalemia
D) Hyperkalemia
The nurse is obtaining a health history from parents whose 4-month-old boy has congenital hypothyroidism. Which of the following would the nurse most likely assess? A) The child has above-normal growth for his age. B) The child is active and playful. C) The skin is pink and healthy looking. D) It is difficult to keep the child awake.
D) It is difficult to keep the child awake.
The nurse has developed a plan of care for a 12-month-old hospitalized with dehydration as a result of rotavirus. Which intervention would the nurse include in the plan of care? A) Encouraging consumption of fruit juice B) Offering Kool-Aid or popsicles as tolerated C) Encouraging milk products to boost caloric intake D) Maintaining the intravenous fluid rate as ordered
D) Maintaining the intravenous fluid rate as ordered
The nurse is caring for an adolescent girl with a suspected anxiety disorder. The girl states that she is constantly double-checking that she has unplugged her curling iron and must make sure that everything is in perfect order in her room before she leaves the house. The nurse interprets these findings as indicating which of the following? A) Generalized anxiety disorder B) Posttraumatic stress disorder C) Social phobia D) Obsessive-compulsive disorder
D) Obsessive-compulsive disorder
A nurse is providing an in-service program on child abuse for a group of newly hired nurses. When evaluating the effectiveness of the teaching, the nurse determines a need for additional review when the group identifies which of the following as an indicator of possible child abuse? A) Consistent delays in seeking treatment for the child's injuries B) Frequent changes in history information with visits C) Injuries that are inconsistent with the reported traumatic event D) Sexual behavior that correlates with the child's developmental age
D) Sexual behavior that correlates with the child's developmental age
The nurse is developing a teaching plan for the parents of a child with a myelomeningocele who will require clean intermittent catheterization. Which of the following would the nurse include? A) Applying petroleum jelly to lubricate the catheter B) Cleaning the reusable catheter with peroxide after each use C) Storing the reusable cleaned catheter in a brown paper bag D) Soaking the catheter in a vinegar and water solution to sterilize
D) Soaking the catheter in a vinegar and water solution to sterilize
A group of students are reviewing information about fluid balance and losses in children in comparison to adults. The students demonstrate a need for additional review when they identify which of the following? A) Children have a proportionately greater amount of body water than do adults. B) Fever plays a greater role in insensible fluid losses in infants and children. C) A higher metabolic rate plays a major role in increased insensible fluid losses. D) The infant's immature kidneys have a tendency to overconcentrate urine more
D) The infant's immature kidneys have a tendency to overconcentrate urine more
