CLO 3

Question 1

The nurse is assisting with the physical exam on a 2-year-old child. The nurse
predicts the order of the exam will be in which sequence?

-Eyes, ears, nose, mouth, back, and extremities; then the head and neck

-Back and extremities; head and neck; then the eyes, ears, nose, and mouth

-Back and extremities; eyes, ears, nose, mouth; then the head and neck

-Head and neck; eyes; ears; nose, mouth; then the back and extremities

Answer 1

Back and extremities; head and neck; then the eyes, ears, nose, and mouth

Question 2

The mother of 2-year-old triplets is anxious and worried because one of the trio
does not seem to be developing at the same rate as the other two. Which
assessment finding would lead the nurse to question the need for further diagnostic testing for this child?

-She speaks loudly when asked a question.

-The tops of her ears are below the corners of her eyes.

-She blows her nose frequently.

-The fontanelles on her head are closed.

Answer 2

The tops of her ears are below the corners of her eyes

Question 3

The nursing student is preparing to explain the appropriate steps for assessing an
infant. The instructor determines the student’s presentation is successful after
illustrating which location as appropriate for obtaining an apical pulse?

-Between the sternum and the left nipple

-Below the ribs about one half of an inch

-Above the sternum, slightly to the right

-Above the clavicle on the left side

Answer 3

Between the sternum and the left nipple

Question 4

A 5-yr-old child is scheduled for a dressing change that will produce moderate pain.
What pre-procedural intervention should the nurse prioritize?

-Inform the child that pain medication will be available if needed after the procedure.

-Inform the child that he can play a video game if he remains still during the procedure.

-Administer pain medication prior to the procedure.

-Inform the child that pain medication will be available if needed during the procedure.

Answer 4

Administer pain medication prior to the procedure

Question 5

What assessment tools should the nurse prioritize to measure pain in children?
Select all that apply.

-The color scale
-PCA scale
-The numeric scale
-The Roman Numeral scale
-The faces scale

Answer 5

-The numeric scale
-The faces scale

Question 6

The nurse is administering an intramuscular injection of an antibiotic to a 3-month-
old child. Which would be the best site for the nurse to give this medication?

-Abdomen
-Buttocks
-Thigh
-Upper arm

Answer 6

Thigh

Question 7

A nurse is preparing to administer an intramuscular (IM) injection to a child. Which of
the following muscle groups is contraindicated?

-Deltoid
-Ventrogluteal
-Dorsogluteal
-Vastus lateralis

Answer 7

Dorsogluteal

Question 8

If the child is following a normal development process, visual acuity gradually
increases from birth. What is most accurate regarding the age children develop
20/20 vision?

-A few children develop 20/20 vision by 4 years
of age.

-Most children develop 20/20 vision by 2 years of age.

-Most children do not develop 20/20 vision until about 18 years of age.

-Children usually develop 20/20 vision by 5 years of age.

Answer 8

Children usually develop 20/20 vision by 5 years of age

Question 9

A symptom often seen in the child diagnosed with Haemophilus influenzae
meningitis occurs when the child has a stiff neck. This symptom is referred to as
which of the following?

-Opisthotonos
-Nuchal rigidity
-Encephalopathy
-Purpuric rash

Answer 9

Nuchal rigidity

Question 10

The nurse is collecting data on an 18-month-old child admitted with a diagnosis of
possible seizures. When interviewing the caregivers, which questions would be most
important for the nurse to ask?

-“Is your child up to date on his immunizations?”

-“What type of activities was your child doing today?”

-“Have you checked your child’s temperature?”

-“Has anyone in your family been sick recently

Answer 10

Have you checked your child’s temperature

Question 11

The caregivers of a 2-year-old who has had a common cold for 4 days calls the nurse
in the emergency department at 2 AM on a cold winter night to say that the child
has awakened with a barking cough and an elevated temperature; she seems blue
around her mouth. The nurse would most appropriately recommend what action to
the caregiver?

-“Put a cool mist humidifier or vaporizer in the room to see if that relieves the cough. Call back if there’s no relief in an hour.”

-“Bundle the child up and take her out into the cold for a few minutes. Call back if the exposure to the cold air does not provide relief.

-“Turn on all of the hot water taps in the bathroom and close the door. Take the
child into the steam-filled room for 15 minutes. If there is no relief, bring the
child to the emergency room.”

-“Bring the child to the emergency room immediately.”

Answer 11

Bring the child the emergency room immediately

Question 12

In caring for the child with asthma, the nurse recognizes that bronchodilator
medications are administered to children with asthma for which reason?

-To stabilize the cell membranes
-Management of chronic pain
-Relief of acute symptoms
-Prevention of mild symptoms

Answer 12

Relief of acute sx

Question 13

The nurse is teaching the caregivers of a child with cystic fibrosis. What is most
important for the nurse to teach this family?

-Be sure the child exercises daily.
-Encourage everyone in the family to use good hand-washing techniques.
-Watch for signs that the family unit is stressed.
-Avoid overprotecting the child.

Answer 13

Encourage everyone in the family to use good hand-washing techniques

Question 14

The nurse is caring for a child with congestive heart failure and is administering the
drug digoxin. At the beginning of this drug therapy, the process of digitalization is
done for which reason?

-To establish a maintenance dose of the drug
-To build the blood levels to a therapeutic level
-To decrease the pain to a tolerable level
-To increase the heart rate

Answer 14

To build the blood levels to a therapeutic level

Question 15

The care provider has ordered the drug furosemide to treat a child diagnosed with
congestive heart failure. The nurse knows that this drug will be used to:

-eliminate excess fluids.
-slow the heart rate.
-increase vasodilation.
-strengthen the heart’s contractility.

Answer 15

Eliminate excess fluids

Question 16

In developing a plan of care for the child diagnosed with rheumatic fever, the nursing
intervention that takes highest priority for this child is to:

-provide age-appropriate diversional activities.
-position the child to relieve joint pain.
-promote rest periods and bed rest.
-monitor the C-reactive protein and SR levels.

Answer 16

Promote rest period and bed rest

Question 17

The nurse is caring for a child with leukemia. Which nursing intervention would be
the highest priority for this child?

-Encouraging the child to share feelings
-Providing age-appropriate activities
-Following guidelines for protective isolation
-Grouping nursing care

Answer 17

Following guidelines for protective isolation

Question 18

The nurse has admitted a child with a diagnosis of severe gastroenteritis. To help
prevent the risk of transmitting infection to other clients, the nurse should:

-wear a mask when handling articles contaminated with feces.

-sterilize thermometers between clients.

-follow standard precautions.

-discourage anyone from visiting.

Answer 18

Follow standard precautions

Question 19

A nurse stops at her friend’s house one evening to visit. Her friend isn’t home but a
teenager watching TV says she is babysitting for the family’s three children. The
nurse notices that one of the children is chewing several pieces of something white.
He is also drooling and crying. A container that looks like an empty pill bottle is on
the floor. The first action by the nurse would be to:

-call 911 for emergency help.
-give the child syrup of ipecac to induce vomiting.
-remove the substance from the child’s mouth.
-ask the poison control center about an antidote

Answer 19

Remove the substance from the child’s mouth

Question 20

The nurse is caring for a child admitted to the emergency center in diabetic
ketoacidosis. Which clinical manifestations would the nurse most likely note in this
child?

-Slow pulse and elevated blood pressure
-Pale and moist skin
-Hyperactive and restless behavior
-Drowsiness and fruity odor to breath

Answer 20

Drowsiness and fruity odor to breath?

Question 21

The nurse is caring for a child diagnosed with a urinary tract infection. The caregiver
asks the nurse why it is so important for the child to have so much fluid. The nurse
tells the caregiver that the most important reason the child needs increased fluids is
to:

-fill the bladder so a specimen can be obtained.
-dilute the urine and flush the bladder.
-decrease the pain of urination.
-prevent the child from developing a fever.

Answer 21

Dilute the urine and flush the bladder?

Question 22

The nurse is caring for a child who is being evaluated for a possible nephroblastoma.
Which nursing intervention would be important for this child?

-Protect the child from having the abdomen palpated.

-Measure the child’s intake and output every hour.

-Monitor for protein in the urine at each voiding.

-Check blood pressure every 2 hours.

Answer 22

Protect the child from having the abdomen palpated

Question 23

The caregiver of a 2-year-old who has a polyurethane resin cast on her arm calls the
clinic to report that her child is crying and says that the cast has sand in it. The
caregiver states that she has had casts herself and knows how badly they can itch.
She says she always used a hanger to scratch but is worried that it will be too sharp
for the child. Which statement would be appropriate for the nurse to make to this
caregiver?

-“You could give the child an extra dose of acetaminophen and see if that helps.”

-“A plastic ruler is less likely than a hanger to cut the child’s skin.’

-“Nothing should be put into the cast. You can blow cool air into it with a hair
dryer.”

-“Since the child’s cast is synthetic, she could soak it with cool water.”

Answer 23

-“Nothing should be put into the cast. You can blow cool air into it with a hair
dryer.”

Question 24

The nurse is caring for a child admitted with juvenile idiopathic arthritis (JIA). Which
of the clinical manifestation would likely have been noted in the child with this
diagnosis?

-Difficulty standing and walking
-Poor posture and malformed vertebrae
-Pain in the groin and a limp
-Inflammation of the joints

Answer 24

Inflammation of the joints

Question 25

In discussing the treatment for children with scoliosis, a group of pediatric nurses
makes the following statements. Which statement is most accurate related to the
treatment of scoliosis?

-“The only successful treatment for scoliosis is surgery within 2 weeks of the diagnosis.

-“Children with severe scoliosis are treated using electrical stimulation.”

-“The treatment for children with scoliosis usually lasts 3 to 4 months.”

-“Children treated for scoliosis by using braces have to wear the brace almost all
the time

Answer 25

-“Children treated for scoliosis by using braces have to wear the brace almost all
the time?

Question 26

The caregiver of a fifth-grade boy calls the pediatrician’s office and reports that her
son has been scratching at his groin for a week or so. Despite his need for privacy,
he’s finally allowed the caregiver to look at the groin area. The caregiver describes
the area to the nurse saying, “It looks like black pin dots that seem to have dark tails.”
The nurse suspects that the child may have which of the following

-Scabies
-Ringworm
-Lice
-Prickly heat

Answer 26

Scabies

Question 27

A school-aged child is brought to the office of the camp nurse with a small,
superficial burn. Which action by the nurse would be the most appropriate action for
the nurse to do first?

-Apply cold compresses to the area.
-Apply a topical anesthetic ointment.
-Cover the area with a sterile bandage.
-Administer acetaminophen.

Answer 27

Apply cold compresses to the area

Question 28

The nurse is discussing medications to be given to a child who has been diagnosed
with candidiasis. Which of the following medications would most likely be prescribed
for the child?

-Aspirin
-Ampicillin
-Nystatin
-Acetaminophen

Answer 28

Nystatin?

Question 29

The nurse is caring for an infant who has impetigo and is hospitalized. Which nursing
intervention is the highest priority for this child?

-The nurse follows contact precautions.
-The nurse soaks the skin with warm water.
-The nurse applies topical antibiotics to the lesions.
-The nurse applies elbow restraints to the infant.

Answer 29

The nurse follows contact precautions.?

Question 30

What are some signs of abuse or neglect that may be assessed on a child? Select all
that apply.

-Attending school in shorts and t-shirt in -January while its snowing
-The child is suffering from malnutrition
-The child has perfect attendance in school
-The child is cleaned and well groomed
-The child has a spinal fracture

Answer 30

-Attending school in shorts and t-shirt-in January while its snowing
-The child is suffering from malnutrition
-The child has a spinal fracture

Question 31

The nurse is assisting with a physical exam on a child who has been admitted with a
diagnosis of possible child abuse. Which finding might alert the nurse to this
possibility that the child may have been abused?

-The child has bruises on the knees and elbows.
-The child is hyperactive and angry.
-The child has a fractured bone.
-The child has a burn that has not been treated.

Answer 31

-The child has a burn that has not been treated.?

Question 32

The nurse is collecting data on an 18-month-old old child with a diagnosis of autism
spectrum disorder (ASD). What clinical manifestation would likely have been noted in
the child with this diagnosis?

-The child smiles when the caregiver shows her a stuffed animal.

-The child cries and runs to the door when the caregiver leaves the room.

-The child sits quietly in the caregiver’s lap during the interview.

-The child does not make eye contact.

Answer 32

The child does not make eye contact.?

Question 33

The nurse in the well-child clinic observes that a 5-year-old child in the waiting room
is having trouble using a crayon to color. During the visit, the same child climbs off
the table several times even after the nurse has asked him to stay on the table. Each
time the nurse reminds him he says, “Oh, yeah” and happily climbs back up. The
nurse suspects that the child has:

-attention deficit hyperactive disorder (ADHD).
-an addicted caregiver.
-failure to thrive.
-autism spectrum disorder.

Answer 33

Attention deficit hyperactive disorder (ADHD)