Chapter 35

Question 1

Which is the priority nursing action when performing a physical assessment on a toddler?

1. Leaving intrusive procedures such as eye and ear examinations until the end
2. Explaining each part of the examination to the child before performing it
3. Performing the assessment from head to toe
4. Asking the mother to tell the child not to be afraid

Answer 1

1

Question 2

At which age will the nurse begin to calculate body mass index (BMI) as a part of the nursing assessment process?

1. 12 months
2. 18 months
3. 2 years
4. 4 years

Answer 2

3

Question 3

During a well-child visit with a 4-year-old girl the nurse notes that the parents speaks harshly to the child and used negative remarks when speaking with the nurse. Which statement by the nurse would be beneficial in this situation?

1. “Perhaps you should leave the room so that I can speak with your child privately.”
2. “I am going to refer you for counseling since your interactions with your child seem so negative.”
3. Addressing the child, the nurse says, “Are you unhappy when mommy talks to you like this?”
4. “Let’s talk privately. We should discuss the way you speak with your child and possible ways to be more positive.”

Answer 3

4

Question 4

Which action by the nurse is appropriate when teaching the parents of a 2-year-old child during a scheduled health maintenance visit?

1. Encouraging the parents to allow the child to pour liquids using a pitcher
2. Being sure that all major foods group have been introduced to the child
3. Teaching the parents that it is appropriate to switch from whole to 2% milk
4. Educating the child about food groups

Answer 4

3

Question 5

The visiting nurse is evaluating the home environments of several preschool-age children as they relate to child safety. The nurse visits the home of each child and gathers the following data. Which activity noted during the visit places a child at the greatest risk for bodily harm?

1. The parents are in a methadone program.
2. The parents consume alcohol on a daily basis.
3. The child watches television for 2 hours each day.
4. The child is permitted to swim in the family pool unsupervised.

Answer 5

4

Question 6

The parents of a 2-year-old girl inquire about information to help their child transition to bed each night. Which response by the nurse is appropriate?

1. Let the child cry self to sleep a few nights to adjust to the transition.
2. Play a favorite video at bedtime on a television in the child’s room to enhance relaxation.
3. Read a book to the child just before bedtime each night.
4. Let the child fall asleep while playing and then put the child in bed.

Answer 6

3

Question 7

Parents of a preschool-age child report that they find it necessary to spank the child at least once a day. Which response by the nurse is appropriate based on this information?

1. “Can you try spanking the child only every other day for 1 week and see how that affects your child’s behavior?”
2. “Spanking is one form of discipline; however, you want to be sure that you do not leave any marks on the child.”
3. “I think you are not parenting properly, so let’s talk about ways to improve your parenting skills.”
4. “Let’s talk about other forms of discipline that have a more positive effect on the child.”

Answer 7

4

Question 8

Which parental statement during a scheduled health maintenance assessment for a preschool-age child would cause the nurse concern?

1. “We have dinner together as a family each evening.”
2. “We are so proud that our child is able to recognize letters of the alphabet.”
3. “Our child wakes up each night screaming because of nightmares.”
4. “Our child attends a daycare program 3 days per week.”

Answer 8

3

Question 9

Which immunization will the nurse provide parental education during the health maintenance visit for a 4-year-old child?

1. Hepatitis B #3
2. Haemophilus influenzae type B #2
3. Inactive poliovirus #3
4. Measles, mumps, and rubella #1

Answer 9

3

Question 10

The nurse is teaching the parents of a toddler-age child about injury prevention. Which statement by the parent indicates the need for further education?

1. “I will turn the handles of the pots outward while I am cooking dinner.”
2. “We will make sure that our child always wears a life vest when we are out in the boat.”
3. “I will keep all our medications out of reach and ensure child-resistant containers.”
4. “We will provide safe climbing toys for our child.”

Answer 10

1

Question 11

Which assessment finding for a toddler-age child indicates an increased risk for an unhealthy self-concept?

1. A parent who praises the child for his or her accomplishments
2. A parent who is attempting potty training but who understands that accidents will happen
3. A parent who is observed spanking a child for taking a toy from another child in the waiting room
4. A parent who reads a book to the toddler-age child each night before bed to encourage cooperation

Answer 11

3

Question 12

The nurse is teaching the parents of a toddler-age child information regarding toy and playground safety. Which parental statement indicates the need for further education?

1. “I allow my child to play with the packaging material for new toys.”
2. “I will avoid buying my child toys that are battery operated.”
3. “I allow my child to play with age-appropriate toys as indicated on the packaging.”
4. “I don’t let my child play on the playground without supervision.”

Answer 12

1

Question 13

The nurse is planning health promotion activities for a toddler-age child during a scheduled health maintenance visit. Which action by the nurse is appropriate during this visit?

1. Connecting developmental skills with risks for injury
2. Recognizing that childcare attendance increases the risk for communicable disease
3. Planning education for treatment of common disease processes
4. Illustrating developmental progression on a screening tool

Answer 13

4

Question 14

Which action should the nurse include when providing education regarding methods to enhance health promotion during a scheduled health maintenance visit for a 4-year-old child?

1. Recognizing that food jags are common
2. Involving the child in snack selection and preparation
3. Encouraging the use of a highchair with a safety strap
4. Recommending the child consumes high-fat foods

Answer 14

2

Question 15

The nurse is conducting a physical assessment for a preschool-age child. When plotting the child’s body mass index (BMI) the nurse notes that the child’s is at the 90th percentile. Which action by the nurse is appropriate?

1. Referring the child to a nutritionist
2. Conducting a developmental assessment
3. Assessing the child’s level of activity
4. Checking a blood glucose level

Answer 15

3

Question 16

Which will the nurse assess in the family of a 3-year-old child during a pediatric clinic visit scheduled due to regressive behavior? Select all that apply.

1. Change in parental marital status
2. Level of education for each parent
3. Health of child’s siblings
4. Maternal depression
5. Child’s exposure to communicable diseases

Answer 16

1,3,4

Question 17

Which assessment questions are appropriate when the nurse is assessing the mental health of a preschool-age client? Select all that apply.

1. “Is your child experiencing nightmares?”
2. “Does your child ask questions about the genitalia?”
3. “How do you implement punishment for your child when a rule is broken?”
4. “Is your child up-to-date on recommended immunizations?”
5. “Does your child wear safety equipment when riding a bicycle?”

Answer 17

1,2,3

Question 18

Which nursing actions are appropriate when conducting a mental health assessment for a toddler-age child? Select all that apply.

1. Observing the child’s interaction with family members
2. Asking the caregiver to describe the child’s typical day
3. Giving the child a crayon to assess ability to use
4. Determining the number of hours the child sleeps each night
5. Inquiring about recent exposure to communicable diseases

Answer 18

1,2,3,4

Question 19

Which interventions will the nurse recommend for a toddler-age client who is biting other children at daycare? Select all that apply.

1. Using a time-out as a form of discipline for the child’s behavior
2. Separating the child from the situation
3. Telling the child it is not okay to hurt another person
4. Inquiring whether the child is getting enough sleep
5. Implementing distraction to avert the behavior

Answer 19

1,2,3,4

Question 20

Which recommendations will the nurse make to the parents of a preschool-age child who is experiencing frequent nightmares? Select all that apply.

1. Reassure the child by back rubbing.
2. Repeat a nighttime routine, such a reading a story.
3. Bring the child to the parental bed.
4. Allow the child time to settle back into sleep.
5. Place a television in the child’s room for distraction.

Answer 20

1,2,4