Milena Milo Flashcards
Midterm (177 cards)
1
Q
The nurse is assessing the temperature of a diaphoretic toddler who is crying and being uncooperative. What would be the best method to assess temperature in this child?
A) Oral thermometer
B) Axillary method
C) Temporal scanning
D) Rectal route
A
B) Axillary method
2
Q
A nurse is providing teaching to the parents of a child who has had a shunt inserted as treatment for hydrocephalus. The parents demonstrate understanding of the teaching when they make what statement?
A) “Having the shunt put in decreases his risk for developmental problems.”
B) “If he doesn’t get an infection in the first week, the risk is greatly reduced.”
C) “He will need more surgeries to replace the shunt as he grows.”
D) “The shunt will help to prevent any further complications from his disease.”
A
C) “He will need more surgeries to replace the shunt as he grows.”
3
Q
As a result of seizure activity, a computed tomography (CT) scan was performed and showed that an 18-month-old child has intracranial arteriovenous malformation. When developing the child’s plan of care, what would the nurse expect to implement actions to prevent?
A) Drug interactions
B) Developmental disabilities
C) Hemorrhagic stroke
D) Respiratory paralysis
A
C) Hemorrhagic stroke
4
Q
A mother brings her 3-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
A
C) Rectal
5
Q
The nurse uses family-centered care to care for children in a pediatric office. Upon what concept is family-centered care based?
A) The family is the constant in the child’s life and the primary source of strength.
B) The care provider is the constant in the child’s life and the primary source of strength.
C) The child must be prepared to be his or her own source of strength during times of crisis.
D) The wishes of the family should direct the nursing care plan for the child.
A
A) The family is the constant in the child’s life and the primary source of strength.
6
Q
The nurse is caring for a 13-year-old girl hospitalized for complications from type 1 diabetes. The girl has a nursing diagnosis of powerlessness related to lack of control of multiple demands associated with hospitalization, procedures, treatments, and changes in usual routine. How can the nurse help promote control?
A) Ask the child to identify her areas of concern.
B) Encourage participation of parents in care activities.
C) Offer the girl as many choices as possible.
D) Enlist the family’s assistance in creating a time schedule.
A
C) Offer the girl as many choices as possible.
7
Q
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
A
d) Deep somatic
Feedback: Deep somatic pain typically involves the muscles, tendons, joints, fasciae, and bones. It can be localized or diffuse and is usually described as dull, aching, or cramping with tenderness. It can also be due to overuse injuries commonly experienced by athletes. Cutaneous pain usually involves the skin and is described as sharp or burning. Neuropathic pain is due to a malfunctioning of the peripheral nervous system and is described as burning or tingling. Visceral pain is pain that develops within organs
8
Q
The nurse is teaching the parents of a 2-year-old toddler methods of dealing with their child’s ‘negativism.’ Based on Erickson’s theory of development, what would be an appropriate intervention for this child?
A) Discourage solitary play; encourage playing with other children.
B) Encourage the child to pick out his own clothes.
C) Use ‘time-outs’ whenever the child says ‘no’ inappropriately.
D) Encourage the child to take turns when playing games.
A
B) Encourage the child to pick out his own clothes.
9
Q
The nurse is preparing a plan of care for a 5-year-old boy with chickenpox. Which nursing intervention should be questioned?
A) Administer antipyretics as ordered.
B) Keep the child’s fingernails short.
C) Monitor fluid intake and output.
D) Provide alcohol baths as needed.
A
D) Provide alcohol baths as needed.
10
Q
A mother confides to the nurse that she is thinking of divorce. Which suggestion by the nurse would help minimize the effects on the child?
a) “Tell the child together using appropriate terms.”
b) “Reassure him that no one loves him more than you.”
c) “Do special things with him to make up for the divorce.”
d) “Share your feelings with the child.”
A
a) “Tell the child together using appropriate terms.”
11
Q
The nurse is teaching an 8-year-old child and his family how to manage cancer pain using nonpharmacologic methods. Which parent statement signifies successful child teaching?
A) ‘I will avoid using descriptive words like pinching, pulling, or heat.’
B) ‘I will not use positive reinforcement until the technique is perfected.’
C) ‘I will begin using the technique before he experiences pain.’
D) ‘I will be honest and tell him that the procedure will hurt a lot.’
A
C) ‘I will begin using the technique before he experiences pain.’
12
Q
A 3-year-old child is scheduled for a hearing screening. The nurse would prepare the child for screening by which method?
A) Auditory brain stem response
B) Evoked otoacoustic emissions
C) Visual reinforcement audiometry
D) Conditioned play audiometry
A
D) Conditioned play audiometry
13
Q
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.
A
D) Provide a trial period of home care.
14
Q
Hydrocephalus is suspected in a 4-month-old infant. Which would the nurse expect to assess?
A) Sunken fontanels
B) Diminished reflexes
C) Lower extremity spasticity
D) Skull symmetry
A
C) Lower extremity spasticity
Feedback: Hydrocephalus is manifested by spasticity of lower extremities, bulging fontanels, brisk reflexes, and skull asymmetry.
15
Q
An important consideration when using the FACES Pain Rating Scale with children is:
A
The scale can be used with most children as yourng as 3 years of age.
16
Q
The nurse is providing home care for a 1-year-old girl who is technologically dependent. Which intervention will best support the family process?
A) Finding an integrated health program for the family
B) Teaching modifications of the medical regimen for vacation
C) Assessing family expectations for the special needs child
D) Creating schedules for therapies and interventions
A
D) Creating schedules for therapies and interventions
17
Q
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 the room.
A
B) Provide age-appropriate toys and games.
18
Q
Based on Erikson’s developmental theory, what is the major developmental task of the adolescent?
A) Gaining independence
B) Finding an identity
C) Coordinating information
D) Mastering motor skills
A
B) Finding an identity
19
Q
When the nurse is assessing a child’s pain, which is most important?
A) Obtaining a pain rating from the child with each assessment
B) Using the same tool to assess the child’s pain each time
C) Documenting the child’s pain assessment
D) Asking the parents about the child’s pain tolerance
A
B) Using the same tool to assess the child’s pain each time
20
Q
The nurse is caring for a special needs infant. Which intervention will be most important in helping the child reach her maximum developmental potential?
A) Directing her parents to an early intervention program
B) Monitoring her progress in elementary school
C) Serving on an individualized education program committee
D) Preparing a plan for her to transition to college
A
A) Directing her parents to an early intervention program
21
Q
The physician has ordered rectal diazepam for a 2-year-old boy with status epilepticus. Which instruction is essential for the nurse to teach the parents?
A) Monitor their child’s level of sedation.
B) Watch for fever indicating infection.
C) Gradually reduce the dosage as seizures stop.
D) Monitor for an allergic reaction to the medication.
A
A) Monitor their child’s level of sedation.
22
Q
A group of nursing students are reviewing information related to seizures that occur in infants and children. The students demonstrate a need for additional review when they identify which type as common in neonates?
A) Tonic
B) Focal clonic
C) Multifocal clonic
D) Myoclonic
A
D) Myoclonic
Feedback: Five major types of seizures have been recognized in the neonatal period: subtle, tonic, focal clonic, multifocal clonic, and myoclonic. Of these, myoclonic seizures rarely occur during the neonatal period. Subtle seizures affect preterm and full-term neonates. Tonic seizures primarily occur in preterm neonates. Focal clonic and multifocal clonic are more common in full-term neonates.
23
Q
The nurse is assessing heart rate for children on the pediatric ward. What is a normal finding based on developmental age?
A) An infant’s rate is 90 bpm.
B) A toddler’s rate is 150 bpm.
C) A preschooler’s rate is 130 bpm.
D) A school-age child’s rate is 50 bpm.
A
An infant’s rate is 90 bpm.
24
Q
When describing the various changes that occur in organ systems during adolescence, what would the nurse include?
A) Significant increase in brain size
B) Ossification completed later in girls
C) Decrease in heart rate
D) Decrease in activity of sebaceous glands
A
C) Decrease in heart rate
25
The nurse is caring for a child who is scheduled to begin chemotherapy. When planning education for the parents, what action by the nurse is most correct?
A) Obtain a large classroom to allow the nurse to stand at the front and present information.
B) Obtain a small conference room and arrange the chairs in a circle for both the nurse and family members to sit.
C) Provide written information to the family and allow them to review it, with instructions to contact the nurse if there are additional questions.
D) Provide a video of information to the family, with instructions to contact the nurse if there are additional questions.
B) Obtain a small conference room and arrange the chairs in a circle for both the nurse and family members to sit.
26
The nurse is testing the sensory development of a toddler brought to the clinic for a well visit. What might alert the nurse to a potential problem with the child's sensory development?
A) The toddler places the nurse's stethoscope in his mouth.
B) The toddler's vision tests at 20/50 in both eyes.
C) The toddler does not respond to commands whispered in his ear.
D) The toddler's taste discrimination is not at adult levels yet.
C) The toddler does not respond to commands whispered in his ear.
27
When providing anticipatory guidance to a group of parents with school-aged children, what would the nurse describe as the most important aspect of social interaction?
A) School
B) Peer relationships
C) Family
D) Temperament
B) Peer relationships
28
The nurse is performing a cognitive assessment of a 2-year-old. Which behavior would alert the nurse to a developmental delay in this area?
A) The child cannot say name, age, and gender.
B) The child cannot follow a series of two independent commands.
C) The child has a vocabulary of 40 to 50 words.
D) The child does not point to named body parts.
D) The child does not point to named body parts.
29
The leading cause of death from unintentional injuries in children is:
Motor vehicle-related fatalities.
30
A 4-year-old boy has a febrile seizure during a well-child visit. What action would be a priority?
A) Hyperextending the child's head while placing him on his side
B) Using a tongue blade to pry open the child's jaw
C) Loosening the child's clothing to ensure a patent airway
D) Protecting the child from harm during the seizure
D) Protecting the child from harm during the seizure
31
A group of nursing students are reviewing the six links in the chain of infection and the nursing implications for each. The students demonstrate understanding of the information when they identify which precaution as helping to break the chain of infection to the susceptible host?
a) Keeping linens dry and clean
b) Maintaining skin integrity
c) Washing hands frequently
d) Coughing into a handkerchief
b) Maintaining skin integrity
32
The nurse is using verbal skills to explain the nursing care plan to parents of a 10-year-old child with cancer. What describes a guideline the nurse should follow to provide appropriate verbal communication?
A) Use closed-ended questions that do not restrict the child's or parent's answers.
B) Allow the focus to change without redirecting the conversation.
C) Restate the child's and parent's comments in your own words.
D) Paraphrase the child's or parent's feelings to demonstrate empathy.
D) Paraphrase the child's or parent's feelings to demonstrate empathy.
33
The major cause of death for children older than 1 year is:
Unintentional injuries.
34
After teaching the parents of a child with varicella zoster, the nurse determines that the parents have understood the teaching when they state that their child can return to school at which time?
a) After day 5 of the rash
b) When the rash is completely healed
c) Once the rash appears
d) After the lesions have crusted
d) After the lesions have crusted
35
During a well-child visit, the nurse assesses an infant's ability to suck on a pacifier. The nurse is assessing which cranial nerve?
A) Olfactory (I)
B) Trigeminal (V)
C) Facial (VII)
D) Accessory (XI)
B) Trigeminal (V)
Feedback: To test the trigeminal nerve, the nurse would note the strength of the infant's suck on a pacifier, thumb, or bottle. The olfactory nerve is not assessed in infants and young children. The facial nerve is assessed by noting the symmetry of facial expressions. For the infant, this would be assessed during spontaneous crying or smiling. The accessory nerve is assessed when the infant is in the sitting position and symmetry of the head position is noted.
36
What finding would lead the nurse to suspect that a child is beginning to develop increased intracranial pressure?
A) Bradycardia
B)Cheyne-Stokes respirations
C) Fixed, dilated pupils
D) Projectile vomiting
D) Projectile vomiting
Feedback: Projectile vomiting is an early sign of increased intracranial pressure. Bradycardia, Cheyne-Stokes respirations, and fixed dilated pupils are late signs of increased intracranial pressure.
37
A mother and her 4-week-old infant have arrived for a health maintenance visit. Which activity will the nurse perform?
A) Assess the child for an upper respiratory infection
B) Take a health history for a minor injury
C) Administer a varicella injection
D) Plot the child's head circumference on a growth chart
D) Plot the child's head circumference on a growth chart
38
The nurse is administering pain medication for a child with continuous pain from internal injuries. Which method would be ordered to dispense the medication?
A) Administer the medication PRN (as needed).
B) Administer the mediation when pain has peaked.
C) Administer the medication around the clock at timed intervals.
D) Administer the medication when the child complains of pain.
C) Administer the medication around the clock at timed intervals.
39
The nurse is teaching an 8-year-old child and his family how to manage cancer pain using nonpharmacologic methods. Which parent statement signifies successful child teaching?
A) 'I will avoid using descriptive words like pinching, pulling, or heat.'
B) 'I will not use positive reinforcement until the technique is perfected.'
C) 'I will begin using the technique before he experiences pain.'
D) 'I will be honest and tell him that the procedure will hurt a lot.'
C) 'I will begin using the technique before he experiences pain.'
40
For which child would nonopioid analgesics be recommended?
A) A child with juvenile arthritis
B) A child with end-stage cancer
C) A child with a broken arm
D) A child with severe postoperative pain
A) A child with juvenile arthritis
Feedback: Nonopioid analgesics may be used to treat mild to moderate pain, often for conditions such as arthritis; joint, bone, and muscle pain; headache; dental pain; and menstrual pain. Opioid analgesics are typically used for moderate to severe pain as can occur with cancer, broken bones, and postoperative healing.
41
The nurse is conducting a pain assessment of a 10-year-old boy who has been taking acetaminophen for chronic knee pain. The assessment indicates that the recommended dose is no longer providing adequate relief. What is the appropriate nursing action?
a) Increase the dosage of the acetaminophen.
b) Tell the child he is experiencing the ceiling effect.
c) Use guided imagery to help his pain.
d) Obtain an order for a different medication.
d) Obtain an order for a different medication.
42
The nurse of a preschool child is helping parents develop a healthy meal plan for their child. What nutritional requirements for this age group should the nurse consider?
A) The 3- to 5-year-old requires 300 to 500 mg calcium and 10 mg iron daily.
B) The 3-year-old should consume 10 mg dietary fiber daily.
C) The 4- to 8-year-old requires 15 mg dietary fiber per day.
D) The typical preschooler requires about 85 kcal/kg of body weight.
D) The typical preschooler requires about 85 kcal/kg of body weight.
43
A nurse is talking with the parents of a child who has had a febrile seizure. The nurse would integrate an understanding of what information into the discussion?
A) The child's risk for cognitive problems is greatly increased.
B) Structural damage occurs with febrile seizure.
C) The child's risk for epilepsy is now increased.
D) Febrile seizures are benign in nature.
D) Febrile seizures are benign in nature.
44
The nurse is performing risk assessments on adolescents in the school setting. Which teen should the nurse screen for hypertension?
A) An Asian female
B) A white male
C) An African American male
D) A Jewish male
C) An African American male
45
Johnny a 5 year old is in your clinic for initial well check. You note he has not received any immunizations. Which of the following is not necessary at this age?
A) MMR
B) DTaP
C) Hib
D) Varicella
C) Hib
46
The nurse knows that effective communication with children and their parents is critical to providing atraumatic quality nursing care. Which statement accurately describes the communication patterns of children?
A) Communication patterns are similar from one child to the next.
B) Children often use more words than adults to describe their fears.
C) Children rely more on nonverbal communication and silence.
D) Parents more often require affective communication rather than neutral communication.
C) Children rely more on nonverbal communication and silence.
47
The nurse is caring for a child involved in an automobile accident whose family has been informed that the child is brain dead. What teaching might the nurse provide the family regarding organ donation?
A) The nurse should ask about organ donation when the family is informed of their child's condition.
B) The nurse should explain that written consent is necessary for the organ donation.
C) The nurse should make sure the parents know that procurement of organs may mar their child's appearance.
D) The nurse should make sure the parents know that they will be responsible for expenses related to organ procurement.
B) The nurse should explain that written consent is necessary for the organ donation.
48
After teaching the mother about follow-up immunizations for her daughter, who received the varicella vaccine at age 14 months, the nurse determines that the teaching was successful when the mother states that a follow-up dose should be given at which time?
A) When the child is 20 to 36 months of age
B) When the child is 4 to 6 years of age
C) When the child is 11 to 12 years of age
D) When the child is 13 to 15 years of age
B) When the child is 4 to 6 years of age
49
The nurse is examining a 15-month-old child who was able to walk at the last visit and now can no longer walk. What would be the nurse's best intervention in this case?
A) Schedule a full evaluation since this may indicate a neurologic disorder.
B) Note the regression in the child's chart and recheck in another month.
C) Document the findings as a developmental delay since this is a normal occurrence.
D) Ask the parents if they have changed the child's schedule to a less active one.
A) Schedule a full evaluation since this may indicate a neurologic disorder.
50
A child is brought to the emergency department after sustaining a concussion. The child is to be discharged home with his parents. What would the nurse include in the child's discharge instructions?
A) "Expect his headache to get worse initially and then disappear."
B) "Wake him every 2 hours to check his movement and responses."
C) "Call your medical provider if he vomits more than five times."
D) "Any watery fluid draining from his ears is normal."
B) "Wake him every 2 hours to check his movement and responses."
51
When providing care to a newborn infant who was born at 29 weeks' gestation, the nurse integrates knowledge of potential complications, being alert for signs and symptoms of what condition?
A) Neonatal conjunctivitis
B) Facial deformities
C) Intracranial hemorrhage
D) Incomplete myelinization
C) Intracranial hemorrhage
Feedback: Premature infants have more fragile capillaries in the periventricular area than term infants, which puts them at greater risk for intracranial hemorrhage. Neonatal conjunctivitis can occur in any newborn during birth and is caused by viruses, bacteria, or chemicals. Facial deformities are typical of babies of alcoholic mothers. Incomplete myelinization is present in all newborns.
52
The nurse is teaching discipline strategies to the parents of a 4-year-old boy. Which response from the parents indicates a need for more teaching?
a) "We should remove temptations that lead to bad behavior."
b) "We must explain how we expect him to behave."
c) "We should let him know he makes us angry with bad behavior."
d) "We must praise him for good behavior."
c) "We should let him know he makes us angry with bad behavior."
53
The nurse is conducting a well-child examination of a 5-year-old girl, who was 40 inches tall at her last examination at age 4. Which height measurement would be within the normal range of growth expected for a preschooler?
A) 41 inches
B) 43 inches
C) 45 inches
D) 47 inches
B) 43 inches
54
The parents of a 5-year-old boy tell the nurse that their son is having frequent episodes of night terrors. Which of the following statements would indicate that the boy is having nightmares instead of night terrors?
A) "It usually happens about an hour after he falls asleep."
B) "He will tell us about what happened in his dream."
C) "He is completely unaware that we are there."
D) "When we try to comfort him, he screams even more."
B) "He will tell us about what happened in his dream."
55
The nurse is performing a physical examination of an 8-year-old girl who was bitten by her kitten. Which assessment would lead the nurse to suspect cat-scratch disease?
A) Swollen lymph nodes
B) Strawberry tongue
C) Infected tonsils
D) Swollen neck
A) Swollen lymph nodes
56
The nurse is developing a teaching plan for the mother of a 4-year-old girl with cold and fever. What would the nurse include in this teaching plan?
A) Keeping the child covered and warm
B) Calling the doctor if the child's fever lasts more than 36 hours
C) Ensuring fluid intake to prevent dehydration
D) Observing for changes in alertness resulting from brain damage
C) Ensuring fluid intake to prevent dehydration
57
The nurse is interviewing a 3-year-old girl who tells the nurse: 'Want go potty.' The parents tell the nurse that their daughter often speaks in this type of broken speech. What would be the nurse's appropriate response to this concern?
A) 'This is a normal, common speech pattern in the 3-year-old and is called telegraphic speech.'
B) 'This is considered a developmental delay in the 3-year-old and we should consult a speech therapist.'
C) 'This is a condition known as echolalia and can be corrected if you work with your daughter on language skills.'
D) 'This is a condition known as stuttering and it is a normal pattern of speech development in the toddler.'
A) 'This is a normal, common speech pattern in the 3-year-old and is called telegraphic speech.'
58
A 2-week-old child responds to a bell during an initial health supervision examination. The child's records do not show that a newborn hearing screening was done. Which is the best action for the nurse to take?
A) Do nothing because responding to the bell proves he does not have a hearing deficit.
B) Immediately schedule the infant for a newborn hearing screening.
C) Ask the mother to observe for signs that the infant is not hearing well.
D) Screen again with the bell at the 2-month-old health supervision visit.
B) Immediately schedule the infant for a newborn hearing screening.
59
In addition to injuries, the leading causes of death in adolescents ages 15 to 19 years are:
Suicide, homicide
60
The nurse is preparing to take a tympanic temperature reading of a 4-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 the ear canal
B) Direct the infrared sensor at the tympanic membrane
61
The nurse is promoting a healthy diet to guide a mother when feeding her 2-week-old girl. Which is the most effective anticipatory guidance?
A) Substituting cow's milk if breast milk is not available
B) Advocating iron supplements with bottle-feeding
C) Advising fluid intake per feeding of 5 or 6 ounces
D) Discouraging the addition of fruit juice to the diet
D) Discouraging the addition of fruit juice to the diet
62
The nurse is teaching the student nurse the sequence for performing the assessment techniques during a physical examination. What is the appropriate order?
A) Inspection, palpation, percussion, auscultation
B) Inspection, percussion, palpation, auscultation
C) Palpation, percussion, inspection, auscultation
D) Inspection, auscultation, palpation, percussion
A) Inspection, palpation, percussion, auscultation
63
After teaching a group of parents about language development in toddlers, what if stated by a member of the group indicates successful teaching?
A) "When my 3-year-old asks 'why?' all the time, this is completely normal."
B) "A 15-month-old should be able to point to his eyes when asked to do so."
C) "At age 2 years, my son should be able to understand things like under or on."
D) "An 18-month-old would most likely use words and gestures to communicate."
A) "When my 3-year-old asks 'why?' all the time, this is completely normal."
64
The nurse is conducting a physical examination of a child following a comprehensive health history. What should be the focus of the physical examination?
A) The child
B) The parents
C) Chief complaint
D) Developmental age
C) Chief complaint
65
The nurse is discussing vaccination for Haemophilus influenzae type B (Hib) with the mother of a 6-month-old child. Which comment provides the most compelling reason to get the vaccination?
A) "These bacteria live in every human."
B) "Young children are especially susceptible to these bacteria."
C) "You have a choice of two excellent vaccines."
D) "Your child needs this final dose for protection."
B) "Young children are especially susceptible to these bacteria."
66
The nurse is teaching a new mother about the drastic growth and developmental changes her infant will experience in the first year of life. Which statement describes a developmental milestone occurring in infancy?
A) By 6 months of age the infant's brain weighs half that of the adult brain; at age 12 months, the brain weighs 2.5 times what it did at birth.
B) Most infants triple their birthweight by 4 to 6 months of age and quadruple their birthweight by the time they are 1 year old.
C) The head circumference increases rapidly during the first 6 months: the average increase is about 1 inch per month.
D) The heart triples in size over the first year of life; the average pulse rate decreases from 120 to 140 in the newborn to about 100 in the 1-year-old.
A) By 6 months of age the infant's brain weighs half that of the adult brain; at age 12 months, the brain weighs 2.5 times what it did at birth.
67
The nurse is caring for a neonate who is suspected of having sepsis. Which assessment findings would the nurse interpret as most indicative of sepsis?
A) Rash on face
B) Edematous neck
C) Hypothermia
D) Coughing
C) Hypothermia
68
The nurse is teaching a new mother about the development of sensory skills in her newborn. What would alert the mother to a sensory deficit in her child?
A) The newborn's eyes wander and occasionally are crossed.
B) The newborn does not respond to a loud noise.
C) The newborn's eyes focus on near objects.
D) The newborn becomes more alert with stroking when drowsy.
B) The newborn does not respond to a loud noise.
69
The most consistent indicator of pain in infants is:
Facial expression of discomfort
70
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) Lightly tap the area where the cream is.
71
The nurse is caring for a child hospitalized with Reye syndrome who is in the acute stage of the illness. The nurse would assess the child most carefully for what finding?
A) Indications of increased intracranial pressure
B) An increase in the blood glucose level
C) A decrease in the liver enzymes
D) A presence of protein in the urine
A) Indications of increased intracranial pressure
Feedback: Reye syndrome is characterized by brain swelling, liver failure, and death in hours if treatment is not initiated. Therefore, increased intracranial pressure could occur. Liver enzyme levels typically increase. Blood glucose levels and protein in the urine are not characteristic of this illness.
72
The nurse is providing anticipatory guidance for parents of a school-age child on teaching the dangers of drugs and alcohol. What advice might be helpful for these parents?
A) School-age children are not ready to absorb information that deals with drugs and alcohol.
B) School-age children can think critically to interpret messages seen in advertising, media, and sports.
C) Parents must prevent their child from being exposed to messages that are in conflict with their values.
D) Discussions with children need to be based on facts and focused on the past and future.
B) School-age children can think critically to interpret messages seen in advertising, media, and sports.
73
The nurse knows that the school-age child is in Erikson's stage of industry versus inferiority. Which best examplifies a school-ager working toward accomplishing this developmental task?
A) The child signs up for after-school activities.
B) The child performs his bedtime preparations autonomously.
C) The child becomes aware of the opposite sex.
D) The child is developing a conscience.
A) The child signs up for after-school activities.
74
When the nurse is assessing a child's pain, which is most important?
A) Obtaining a pain rating from the child with each assessment
B) Using the same tool to assess the child's pain each time
C) Documenting the child's pain assessment
D) Asking the parents about the child's pain tolerance
B) Using the same tool to assess the child's pain each time
75
The nurse is observing a 24-month-old boy in a day care center. Which finding suggests delayed motor development?
A) The child has trouble undressing himself.
B) The child is unable to push a toy lawnmower.
C) The child is unable to unscrew a jar lid.
D) The child falls when he bends over.
B) The child is unable to push a toy lawnmower.
76
The nurse is developing a nursing care plan for a hospitalized 6-year-old. Which behavior would warrant nursing intervention?
A) The child pretends he is talking to an imaginary friend when the nurse addresses the child.
B) The child states that her fairy godmother is going to come and take her home.
C) The child starts talking about his grandmother and then quickly changes the subject to a new toy he received.
D) The child does not want to play games with other children on the hospital ward.
D) The child does not want to play games with other children on the hospital ward.
77
The nurse contacts a child life specialist (CLS) to work with children on a pediatric ward. What is the primary goal of the CLS?
A) Decrease anxiety and fear during hospitalization and painful procedure.
B) Keep children who are hospitalized distracted from pain.
C) Perform medical procedures using atraumatic principles.
D) Act as a liaison between the nurse and the child.
A) Decrease anxiety and fear during hospitalization and painful procedure.
78
A mother brings her 8-year-old son for evaluation because of a rash on his lower leg. Which finding would support the suspicion that the child has Lyme disease?
A) Playing in the woods about a week ago
B) Rash is papular and vesicular
C) High fever occurring about 4 days before the rash
D) Complaints of extreme pruritus with visible nits
A) Playing in the woods about a week ago
79
The nurse uses the FLACC behavioral scale to assess a 6-year-old's level of postoperative pain and obtains a score of 9. The nurse interprets this to indicate that the child is experiencing:
A) little to no pain.
B) mild pain.
C) moderate pain.
D) severe pain.
D) severe pain.
80
The nurse caring for young children in a hospice setting is aware of the following statistics related to the occurrence of death in children. Which statement accurately reflects one of these statistics?
A) Each year, about 50,000 children die in the United States; of those, about 15,000 are infants.
B) It is unusual for a child's chronic illness to progress to the point of becoming a terminal illness.
C) Despite strides made, diabetes remains the leading cause of death from disease in all children older than the age of 1 year.
D) Congenital defects and traumatic injuries are the more common causes of diseases leading to death.
D) Congenital defects and traumatic injuries are the more common causes of diseases leading to death.
81
The nurse teaching safety to teens knows that which of these is the leading cause of death among adolescents?
A) Drowning
B) Poisoning
C) Diseases
D) Unintentional injuries
D) Unintentional injuries
82
The leading cause of death in infants younger than 1 year is/ are:
Congenital anomalies.
83
The nurse is choosing foods for a toddler's diet that are high in vitamin A. What foods could be added to the menu? Select all that apply.
```
A) Applesauce
B) Avocados
C) Broccoli
D) Sweet potatoes
E) Spinach
F) Carrots
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D) Sweet potatoes
E) Spinach
F) Carrots
84
Prior to administering morphine to a 10-year-old child, the nurse reviews the adverse effects of the drug. Which system is primarily affected by the drug, causing most of the adverse effects?
A) Central nervous system
B) Peripheral nervous system
C) Digestive system
D) Musculoskeletal system
A) Central nervous system
85
The child life specialist (CLS) is preparing a 6-year-old child for a magnetic resonance imaging (MRI) scan. Which statement reflects the use of atraumatic principles when explaining the procedure?
A) 'You will be taken to a magnetic resonance imaging machine for an x-ray of your liver.'
B) ’You may hear some loud noises when you are lying in the machine, but they won't hurt you.'
C) ‘You have nothing to worry about; the MRI machine is safe and will not cause you any pain.'
D) 'Let's just get you to the x-ray department for your test and you'll see how simple it is.'
B) ’You may hear some loud noises when you are lying in the machine, but they won't hurt you.
86
When describing organ donation to the family of a dying child, what would the nurse include in the discussion?
A) Telling them that further harm may occur to the child through the process
B) Tell them that their cultural and religious beliefs will be considered
C) Including this topic in the discussion of impending death
D) Informing the family that organ donation will delay the funeral
B) Tell them that their cultural and religious beliefs will be considered
87
The nurse is caring for infants having the condition failure to thrive (FTT). Which infants would be at risk for this condition? Select all that apply.
A) A newborn baby with tetralogy of Fallot
B) An infant with a cleft palate
C) An infant born to a diabetic mother
D) An infant born to an impoverished mother
E) An infant with bronchopulmonary dysplasia
F) An infant born to a teenage mother
A) A newborn baby with tetralogy of Fallot
B) An infant with a cleft palate
D) An infant born to an impoverished mother
E) An infant with bronchopulmonary dysplasia
88
The nurse is explaining a discharge plan to the parents of an infant being discharged from the hospital. Which characteristic regarding adult learning should the nurse incorporate into her plan?
A) Adults are dependent learners.
B) Adults are problem focused.
C) Adults are future focused.
D) Adults do not value past learning.
B) Adults are problem focused.
89
A school-aged child with an infectious disease is placed on transmission-based precautions. Which nursing diagnosis would be the priority?
A) Impaired skin integrity related to trauma secondary to pruritus and scratching
B) Fluid volume deficit related to increased metabolic demands and insensible losses
C) Social isolation related to infectivity and inability to go to the playroom
D) Deficient knowledge related to how infection is transmitted
C) Social isolation related to infectivity and inability to go to the playroom
90
The mother of a 12-year-old boy is talking with the school nurse about her son's clumsiness. She reports that he seems to fall a lot, his writing is horrible, and as much as he practices he can't play his guitar very well. How should the nurse respond to the mother?
A) "Boys tend to take a bit longer than girls to mature."
B) "Have you spoken with your pediatrician about your observations?"
C) "Boys tend to refine their fine motor skills by this age."
D) "I will make a note of your observations and talk to his teachers."
B) "Have you spoken with your pediatrician about your observations?"
91
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 to 150 bpm
B) 70 to 120 bpm
C) 65 to 110 bpm
D) 60 to 100 bpm
D) 60 to 100 bpm
92
A child with increased intracranial pressure is being treated with hyperventilation. The nurse understands the need for this treatment is based on what?
A) PaCO2 levels decrease, causing vasoconstriction.
B) Drainage of cerebrospinal fluid occurs.
C) Activity is controlled via a stimulator.
D) Hyperexcitability of the nerves is reduced.
A) PaCO2 levels decrease, causing vasoconstriction.
Feedback: Hyperventilation decreases PaCO2, which results in vasoconstriction and therefore decreases intracranial pressure. A shunt would allow for drainage of cerebrospinal fluid. A vagal nerve stimulator is used to provide an appropriate dose of stimulation to manage seizure activity. Anticonvulsants decrease the hyperexcitability of nerves.
93
The nurse assesses a child's level of consciousness, noting that the child falls asleep unless he is stimulated. The nurse documents this finding as:
A) Confusion
B) Obtunded
C) Stupor
D) Coma
B) Obtunded
Feedback: Obtunded is a state in which the child has limited responses to the environment and falls asleep unless stimulation is provided. Confusion involves disorientation; the child may be alert but responds inappropriately to questions. Stupor exists when the child responds only to vigorous stimulation. Coma is a state in which the child cannot be aroused even with painful stimuli.
94
A 10-year-old girl is living with a foster family. Which intervention is the priority for the child in this family structure?
a) Determining if the child is being bullied at school
b) Dealing with mixed expectations of parents
c) Establishing who is the child's actual caretaker
d) Performing a comprehensive health assessment
d) Performing a comprehensive health assessment
95
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) Riley Infant Pain Scale
Feedback: The Riley Infant Pain Scale measures six parameters: facial expression, body movement, sleep, verbal or vocal ability, consolability, and response to movements and touch. The Pain Observation Scale for Young Children (POCIS) measures seven parameters: facial expression, cry, breathing, torso, arms and fingers, legs and toes, and state of arousal. The CRIES tool assesses five parameters: cry, oxygen required for saturation levels less than 95%, increased vital signs, facial expression, and sleeplessness. The FLACC tool measures five parameters: facial expression, legs, activity, cry, and consolability.
96
The nurse is teaching the student nurse how to perform a physical assessment based on the child's developmental stage. Which statements 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) Include the child in all parts of the examination; speak to the caregiver before and after the examination.
97
The nurse is assessing the respiratory system of a newborn. Which anatomic differences place the infant at risk for respiratory compromise? Select all that apply.
A) The nasal passages are narrower.
B) The trachea and chest wall are less compliant.
C) The bronchi and bronchioles are shorter and wider.
D) The larynx is more funnel shaped.
E) The tongue is smaller.
F) There are significantly fewer alveoli.
A) The nasal passages are narrower.
D) The larynx is more funnel shaped.
F) There are significantly fewer alveoli.
98
The parents of a 2-day-old girl are concerned because her feet and hands are slightly blue. How should the nurse respond?
A) "Your daughter has acrocyanosis; this is causing her blue hands and feet."
B) "Let's watch her carefully to make sure she does not have a circulatory problem."
C) "This is normal; her circulatory system will take a few days to adjust."
D) "This is a vasomotor response caused by cooling or warming."
C) "This is normal; her circulatory system will take a few days to adjust."
99
A child needs a consent form signed for a minor surgical procedure. Which statement accurately describes the responsibilities of the health care providers when obtaining the consent?
A)The physician is responsible for ensuring that the consent form is completed with signatures from the parents or legal guardians.
B)The physician is responsible for serving as a witness to the signature process.
C) The nurse is responsible for informing the child and family about the procedure and obtaining consent.
D) The nurse is responsible for determining that the parents or legal guardians understand what they are signing by asking them pertinent questions.
D) The nurse is responsible for determining that the parents or legal guardians understand what they are signing by asking them pertinent questions.
100
The nurse determines that it is necessary to implement airborne precautions for children with which infection?
a) Measles
b) Streptococcus group A
c) Rubella
d) Scarlet fever
a) Measles
Feedback: Airborne precautions are designed to reduce the risk of infectious agents transmitted by airborne droplet nuclei or dust particles such as for children with measles, varicella, or tuberculosis. Droplet precautions would be used for children with streptococcal group A infections, rubella, and scarlet fever.
101
The nurse is performing a physical examination on a 9-year-old boy who has experienced a tick bite on his lower leg and is suspected of having Lyme disease. Which assessment finding would the nurse expect to find?
a) Swelling in the neck
b) Confusion and anxiety
c) Ring-like rash on lower leg
d) Hypersalivation
c) Ring-like rash on lower leg
102
A nurse is providing teaching to the mother of an adolescent girl about how to manage menstrual pain nonpharmacologically. Which statements by the mother indicates a need for further teaching?
A) "I need to help her learn techniques to distract her; card games, for example."
B) "I need to be able to identify the subtle ways she shows pain."
C) "I need to follow these instructions exactly for them to work properly."
D) "I need to encourage her to practice and utilize these techniques."
C) "I need to follow these instructions exactly for them to work properly."
103
The nurse is caring for an 8-year-old boy who has chronic epilepsy. What would be most important to address when teaching the child and parents about living with this condition?
A) Multiple corrective surgeries to slowly remove diseased parts of his brain
B) Physical, occupational, and speech therapy to maximize his potential
C) Support for maintaining self-esteem because of his altered lifestyle
D) Hyperventilation therapy to counteract the periods of decreased oxygenation
C) Support for maintaining self-esteem because of his altered lifestyle
104
A group of nursing students are reviewing information about childhood infectious diseases. The students demonstrate understanding of this information when they identify which disease as a common childhood exanthema?
a) Mumps
b) Rabies
c) Rubella
d) West Nile virus
c) Rubella
Feedback: Rubella is a common childhood exanthema. Mumps is a viral infection. Rabies is a zoonotic infection. West Nile virus is a vector-borne disease.
105
The nurse is caring for a newborn infant who has Down syndrome. Which nursing action reflects the nurse's use of the ethical principle of nonmaleficence?
A) The nurse speaks truthfully to the parents regarding their child's prognosis.
B) The nurse provides safe, competent nursing care to avoid harming the infant.
C) The nurse involves the parents in making health care decisions for their child.
D) The nurse fairly allocates resources for caring for newborns in a facility.
B) The nurse provides safe, competent nursing care to avoid harming the infant.
Feedback: Ethics includes the basic principles of autonomy, beneficence, nonmaleficence, justice, veracity, and fidelity. Nonmaleficence means avoiding causing harm, intentionally or unintentionally. One example is providing safe, competent nursing care. Speaking truthfully to the parents is an example of veracity. Generally, parents have the autonomy to make health care decisions for their child. Justice refers to acting fairly, and also involves allocating resources fairly.
106
The pediatric nurse knows that the children she is treating are considered minors. Which statement accurately describes the regulations related to consent for medical treatment?
A) Children older than age 16 can provide their own consent for, or refusal of, medical procedures.
B) A guardian ad litem may be appointed by the parents to serve to protect the child's best interests.
C) Parents ultimately are the decision makers regarding medical treatment for their children younger than the age of 18.
D) When divorce occurs, the parent with whom the child is living on a daily basis will be granted custody of the child.
C) Parents ultimately are the decision makers regarding medical treatment for their children younger than the age of 18.
Feedback: Parents ultimately are the decision makers for their children. Generally, only persons over the age of majority (18 years of age) can legally provide consent for health care. Minors (children younger than 18 years of age) generally require adult guardians to act on their behalf. Biological or adoptive parents are usually considered to be the child's legal guardian. When divorce occurs, one or both parents may be granted custody of the child. In certain cases (such as child abuse or neglect, or during foster care), a guardian ad litem may be appointed by the courts. This person generally serves to protect the child's best interests.
107
The nurse is caring for a 12-year-old child hospitalized for internal injuries following a motor vehicle accident. For which medical treatment would the nurse ensure that an informed consent is completed beyond the one signed at admission?
A) Diagnostic imaging
B) Cardiac monitoring
C) Blood testing
D) Spinal tap
D) Spinal tap
Feedback: Most care given in a health care setting is covered by the initial consent for treatment signed when the child becomes a patient at that office or clinic or by the consent to treatment signed upon admission to the hospital or other inpatient facility. Certain procedures, however, require a specific process of informed consent, including major and minor surgery; invasive procedures such as lumbar puncture or bone marrow aspiration; treatments placing the child at higher risk, such as chemotherapy or radiation therapy; procedures or treatments involving research; photography involving children; and applying restraints to children.
108
The nurse is caring for a child brought to the emergency department by a babysitter. The child needs an emergency appendectomy and the parents cannot be contacted. What would be the nurse's best response to this situation?
A) Have the babysitter sign the consent form even if she does not have signed papers to do so.
B) Have the primary care physician for the child sign the consent form.
C) Document failed attempts to obtain consent to allow emergency care.
D) Delay medical care until the child's next of kin can be contacted.
C) Document failed attempts to obtain consent to allow emergency care.
Feedback: Health care providers can provide emergency treatment to a child without consent if they have made reasonable attempts to contact the child's parent or legal guardian . If the parent is not available, then the person in charge may give consent for emergency treatment if that person has a signed form from the parent or legal guardian allowing him or her to do so. During an emergency situation, a verbal consent via the telephone may be obtained. In urgent or emergent situations, appropriate medical care never should be delayed or withheld due to an inability to obtain consent.
109
The nurse in charge of the quality department is reviewing cases regarding HIPAA compliance. In which cases does the nurse correctly determine that HIPAA standards were followed? Select all that apply.
A) A child is diagnosed with an inner ear infection and follow-up care instructions are given to the child's aunt, who provides a medical consent form from the parents, who are on vacation.
B) The emergency department nurse manager reports the suspicion of abuse to the child welfare department for a child admitted with suspicious injuries.
C) The grandparents of a child ask the nurse on the medical floor when their grandchild will be released home to the parents.
D) The physician reports the diagnosis of hepatitis C of a 14-year-old, who is abusing injectable drugs, to the health department.
E) The nurse manager tells the superintendent of schools that a high school student is infected with HIV so that proper precautions can be implemented in the school.
A) A child is diagnosed with an inner ear infection and follow-up care instructions are given to the child's aunt, who provides a medical consent form from the parents, who are on vacation.
B) The emergency department nurse manager reports the suspicion of abuse to the child welfare department for a child admitted with suspicious injuries.
D) The physician reports the diagnosis of hepatitis C of a 14-year-old, who is abusing injectable drugs, to the health department.
110
The mother of a 4-year-old is discussing discipline methods with the nurse. She states that she has never tried using "time-outs" with her child and wonders how and if this method works. Which responses from the nurse are appropriate? Select all that apply.
A) "I think time-outs are the best method of discipline for this age of child."
B) "Time-out is a way of removing positive reinforcement of an unwanted or inappropriate behavior."
C) "If you decide to try this method, be sure to use time-out in a nonthreatening, safe area where no interaction occurs with you."
D) "Time-out is a method that is recognized by many pediatricians and experts in pediatrics."
E) "I never found time-outs to work with my children, regardless of their age."
B) "Time-out is a way of removing positive reinforcement of an unwanted or inappropriate behavior."
C) "If you decide to try this method, be sure to use time-out in a nonthreatening, safe area where no interaction occurs with you."
D) "Time-out is a method that is recognized by many pediatricians and experts in pediatrics."
Feedback: Time-out is an extinction discipline method that is most effective with toddlers, preschoolers, and early school-aged children. Providing information so that the mother can make the decision about this method of discipline is appropriate. Giving the mother advice and personal evaluation is not appropriate.
111
The nurse is teaching parents of a 2-year-old about the extinction method of discipline. What is an example of this method of discipline?
A) Praising the child for good behavior
B) Reprimanding the child
C) Spanking the child
D) Enforcing a 'time-out'
D) Enforcing a 'time-out'
Feedback: Extinction focuses on reducing or eliminating the positive reinforcement for inappropriate behavior. Examples are ignoring the temper tantrums of a toddler, withholding or removing privileges, and requiring "time-out." Praising the child for good behavior is a form of positive reinforcement and reprimanding and spanking the child are forms of punishment.
112
The nurse is teaching discipline strategies to the parents of a 14-year-old girl. Which topic is an example of positive reinforcement discipline?
A) Unplugging the DVD player for the weekend
B) Taking a chore away from her for a week
C) Having her clean up the kitchen for a week
D) Ignoring her request if she doesn't say "please"
B) Taking a chore away from her for a week
Feedback: Taking a chore away from the child for a week is an excellent way to reward her for positive behavior. Unplugging the DVD player, assigning an extra chore, and ignoring her until she uses good manners are not examples of positive reinforcement.
113
The nurse is caring for a premature baby in the NICU. The mother reports that the infant's normally happy and outgoing 5-year-old sister is acting sad and withdrawn. The nurse understands that due to her developmental stage, the girl is at risk of what happening?
A) Viewing her baby sister's illness as her fault
B) Harming the baby
C) Experiencing clinical depression
D) Creating an imaginary friend to cope with the situation
A) Viewing her baby sister's illness as her fault
Feedback: Since the preschool child is facing the psychosocial task of initiative versus guilt, it is natural for the child to experience guilt when something goes wrong. The child may have a strong belief that if someone is ill or dying, he or she may be at fault and the illness or death is punishment. The child may create an imaginary friend to cope with the illness, but would not withdraw or express sadness as a result of the imaginary friend.
114
The nurse is assessing the developmental milestones of an infant. The infant was born 8 weeks ago and was 4 weeks premature. The nurse anticipates that the infant will be meeting milestones for what age of child? Record your answer in weeks
Ans: 4
Feedback: To determine adjusted age, subtract the number of weeks that the infant was premature (4 weeks) from the infant's chronological age (8 weeks).
115
The nurse observes an infant interacting with his parents. What are normal social behavioral developments for this age group? Select all that apply.
A) Around 5 months the infant may develop stranger anxiety.
B) Around 2 months the infant exhibits a first real smile.
C) Around 3 months the infant smiles widely and gurgles when interacting with the caregiver.
D) Around 3 months the infant will mimic the parent's facial movements, such as sticking out the tongue.
E) Around 3 to 6 months of age the infant may enjoy socially interactive games such as patty-cake and peek-a-boo.
F) Separation anxiety may also start in the last few months of infancy.
B) Around 2 months the infant exhibits a first real smile.
C) Around 3 months the infant smiles widely and gurgles when interacting with the caregiver.
D) Around 3 months the infant will mimic the parent's
F) Separation anxiety may also start in the last few months of infancy.
Feedback: The infant exhibits a first real smile at age 2 months. By about 3 months of age the infant will start an interaction with a caregiver by smiling widely and possibly gurgling. The 3- to 4-month-old will also mimic the parent's facial movements, such as widening the eyes and sticking out the tongue. Separation anxiety may also start in the last few months of infancy. Around the age of 8 months the infant may develop stranger anxiety. At 6 to 8 months of age the infant may enjoy socially interactive games such as patty-cake and peek-a-boo.
116
The parents of a child with a developmental disability tell the nurse that they feel guilty because they sometimes find themselves feeling sad and wondering how their child would be without the disability. Which response by the nurse best shows empathy and encourages the parents to vent their feelings?
A) "I'm sure it must be difficult to have a child developmentally delayed."
B) "There are lots of parents that are experiencing the difficulty and feelings of hopelessness and grief you're having. Maybe if you talk to someone it might help you both."
C) "I can only imagine how hard it is for you. You should know that it is common for parents to have these feelings when having a child with special needs."
D) "It's important to focus on the positives that can come from the experience of being the parents of a child that has these issues."
C) "I can only imagine how hard it is for you. You should know that it is common for parents to have these feelings when having a child with special needs."
Feedback: Showing empathy by stating, "I can only imagine how hard it is for you" is important when developing rapport and supporting the parents, and letting them know that they are not alone in the feelings they are experiencing allows them to feel less guilty. Just stating, "I'm sure it must be difficult to have a child developmentally delayed" may convey empathy but it does not allow for open conversation. "There are lots of parents that are experiencing the difficulty and feelings of hopelessness and grief you're having. Maybe if you talk to someone it might help you both" doesn't convey empathy. "It's important to focus on the positives that can come from the experience of being the parents of a child that has these issues" does not address the parents' feelings.
117
The parents of a child with physical and developmental special needs state, "We wish our child could get some kind of educational experience." How should the nurse respond?
A) "This must be difficult for you. Let's talk with the social worker to see what programs are available for your child."
B) "I am sure it must be difficult to know that your child will never be able to go to school like other children."
C) "Since all children can attend school regardless of their special need, I suggest you talk with your local school about enrolling your child."
D) "It would be very difficult for your child to attend school with all of their disabilities. It's unfortunate, but it is reality."
A) "This must be difficult for you. Let's talk with the social worker to see what programs are available for your child."
Feedback: Education is federally mandated. Contacting the social worker gives the parents the support they need to find and choose the appropriate school. Telling them to contact their local school is not supportive of the parent's needs.
118
The nurse is teaching a group of parents with premature infants about the various medical and developmental problems that may occur. The nurse determines that additional teaching is needed when the group identifies what as a problem?
A) Sudden infant death syndrome
B) Hydrocephalus
C) Peptic ulcer
D) Bronchopulmonary dysplasia
C) Peptic ulcer
Feedback: Gastroesophageal reflux disease, not peptic ulcer, is a medical problem that commonly affects premature infants. Myriad problems may occur, including sudden infant death syndrome, hydrocephalus, bronchopulmonary dysplasia, cardiac changes, growth retardation, nutrient deficiencies, bradycardia, rickets, inguinal or umbilical hernias, visual problems, hearing
119
The nurse is caring for a toddler with special needs. Which developmental tasks related to toddlerhood might be delayed in the child with special needs?
A) Developing body image
B) Developing peer relationships
C) Developing language and motor skills
D) Learning through sensorimotor exploration
C) Developing language and motor skills
Feedback: In special needs children, developmental delays may occur in all stages. In particular, motor and language skill development may be delayed if the toddler is not given adequate opportunities to test his or her limits and abilities. Development of body image may be hindered in the preschooler due to painful exposures and anxiety. Development of peer relationships may be delayed in the school-age and adolescent child. The infant's ability to learn through sensorimotor exploration may be impaired due to lack of appropriate stimulation, confinement to a crib, or increased contact with painful experiences.
120
The nurse working in the emergency room monitors the admission of children. Statistically, for which disorder would children younger than 5 years most commonly be admitted?
A) Mental health problems
B) Injuries
C) Respiratory disorders
D) Gastrointestinal disorders
C) Respiratory disorders
Feedback: According to Child Health USA 2010, diseases of the respiratory system, such as asthma and pneumonia, account for the majority of hospitalizations in children younger than 5 years of age, while diseases of the respiratory system, mental health problems, injuries, and gastrointestinal disorders lead to more hospitalizations in older children.
121
The nurse is providing teaching about accidental poisoning to the family of a 3-year-old. The nurse understands that a child of this age is at increased risk of accidental ingestion due to which sensory alteration?
A) A less discriminating sense of taste
B) A lack of fully developed hearing
C) Visual acuity that has not fully developed
D) A less discriminating sense of touch
A) A less discriminating sense of taste
122
The nurse is caring for an 8-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) Sewing puppets with needles
Feedback: The nurse understands that the child may benefit from supervised needle play to assist the child undergoing frequent blood work, injections, or intravenous procedures. The child life specialist can determine what form of therapeutic play is best, but the nurse can recommend interventions based on his or her knowledge of the specific child.
123
The nurse observing toddlers in a day care center notes that they may be happy and pleasant one moment and overreact to limit setting the next minute by throwing a tantrum. What is the focus of the toddler's developmental task that is driving this behavior?
A) The need for separation and control
B) The need for love and belonging
C) The need for safety and security
D) The need for peer approval
A) The need for separation and control
Feedback: Emotional development in the toddler years is focused on separation and individuation. The focus in infancy is on love and belonging, and the need for peer approval occurs in the adolescent. Safety and security are concerns in all levels of development, but not the primary focus.
124
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 in 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) Avoid leaving small objects that can be swallowed in the bed.
F) Encourage parents to stay to prevent separation anxiety.
Feedback: For a toddler, the nurse would avoid leaving small objects that can be swallowed in the bed and encourage parents to stay to prevent separation anxiety. The nurse would use the en face position when holding an infant and use a bed only for the older toddler who has an adult present in the room at all times. The nurse would explain activities in concrete, simple terms for a preschooler and allow a school-age child to select meals and activities.
125
The nurse is implementing care for a hospitalized toddler. What communication technique would the nurse use with the child to reflect the child's developmental level?
A) Allow the child extra time to complete thoughts.
B) Communicate solely through play.
C) Provide simple but honest and straightforward responses.
D) Remain nonjudgmental to avoid alienation.
A) Allow the child extra time to complete thoughts.
Feedback: When working with toddlers and preschoolers, the nurse should allow them time to complete their thoughts. Though language acquisition at this age is exponential, it often takes longer for the young child to find the right words, particularly in response to a query. Infants communicate nonverbally and often through play. School-age children need simple but honest and straightforward responses, and nurses should be nonjudgmental with adolescents to avoid alienating them and to keep lines of communication open.
126
The nurse is conducting a well-child assessment for a 5-year-old boy in preparation for kindergarten. The boy's grandmother is his primary caregiver because the boy's mother has suffered from depression and substance abuse issues. The nurse understands that the child is at increased risk for which developmental problem?
A) Lack of social and emotional readiness for school
B) Stuttering
C) Speech and language delays
D) Fine motor skills delay
A) Lack of social and emotional readiness for school
Feedback: Risk factors for lack of social and emotional readiness for school include insecure attachment in the early years, maternal depression, parental substance abuse, and low socioeconomic status.
127
The nurse is designing a nursing care plan for a toddler with lymphoma, who is hospitalized for treatment. What is a priority intervention that the nurse should include in this child's nursing plan?
A) Limiting visitors to scheduled visiting hours
B) Planning physical therapy for the child
C) Introducing the toddler to other toddlers in the unit
D) Monitoring the toddler for developmental delays
D) Monitoring the toddler for developmental delays
Feedback: When the toddler is hospitalized, growth and development may be altered. The toddler's primary task is establishing autonomy, and the toddler's focus is mobility and language development. The nurse caring for the hospitalized toddler must use knowledge of normal growth and development to be successful in interactions with the toddler, promote continued development, and recognize delays. Parents should be encouraged to stay with the toddler to avoid separation anxiety. Planning activities and socialization of the toddler is important, but the priority intervention is monitoring for, and addressing, developmental delays that may occur in the hospital.
128
The nurse is assessing a 2-year-old boy who has missed some developmental milestones. Which finding will point to the cause of motor skill delays?
A) The mother is suffering from depression.
B) The child is homeless and has no toys.
C) The mother describes an inadequate diet.
D) The child is unperturbed by a loud noise.
B) The child is homeless and has no toys.
Feedback: Children develop through play, so a child without any toys may have trouble developing the motor skills appropriate to his age. Maternal depression is a risk factor for poor cognitive development. Inadequate diet will cause growth deficiencies. A child who does not respond to a loud noise probably has hearing loss, which will lead to a language deficit.
129
The nurse is assessing a 4-month-old boy during a scheduled visit. Which findings might suggest a developmental problem?
A) The child does not babble.
B) The child does not vocally respond to voices.
C) The child never squeals or yells.
D) The child does not say dada or mama.
B) The child does not vocally respond to voices.
Feedback: The fact that the child does not vocally respond to voices might suggest a developmental problem. At 4 to 5 months of age most children are making simple vowel sounds, laughing aloud, doing raspberries, and vocalizing in response to voices. The child is too young to babble, squeal, yell, or say dada or mama.
130
The nurse is performing developmental surveillance for children at a medical home. Which infants are most at risk for developmental delays? Select all that apply.
A) A child whose birthweight was 1,600 g
B) A child whose parent has a mental illness
C) A child raised by a single parent
D) A child with a lead level above 10 mg/dL
E) A child with hypertonia or hypotonia
F) A child with gestational age more than 33 weeks
B) A child whose parent has a mental illness
C) A child raised by a single parent
D) A child with a lead level above 10 mg/dL
E) A child with hypertonia or hypotonia
Feedback: Risk factors for developmental delays include having a single parent, a parent with developmental disability or mental illness, hypertonia or hypotonia, birthweight less than 1,500 g, lead level above 5 mg/dL, and gestational age less than 33 weeks.
131
The nurse is caring for a 7-year-old girl hospitalized in isolation. The nurse notices that she has begun sucking her thumb and changing her speech patterns to those of a toddler. What condition is the girl manifesting?
A) Regression
B) Suppression
C) Repression
D) Denial
A) Regression
Feedback: Sucking the thumb and changing of speech pattern (such as to baby talk) are signs of regression, a defense mechanism used by children to deal with unpleasant experiences by returning to a previous stage that may be more comfortable to the child. Suppression is a conscious inhibition of an idea or desire. Repression is an unconscious inhibition of an idea or desire. Denial would be exhibited by expressions of resignation instead of true contentment, not thumb sucking or baby talk.
132
The nurse is teaching the parents of a 9-year-old girl about the socialization that is occurring in their child through school contacts. Which information would the nurse include in her teaching plan?
A) Teachers are the most influential people in the development of the school-age child's social network.
B) Continuous peer relationships provide the most important social interaction for school-age children.
C) Parents should establish norms and standards that signify acceptance or rejection.
D) A characteristic of school-age children is their formation of groups with no rules and values involved.
B) Continuous peer relationships provide the most important social interaction for school-age children.
Feedback: Continuous peer relationships provide the most important social interaction for school-age children. Peer and peer-group identification are most essential to the socialization of the school-age child. Peer groups establish norms and standards that signify acceptance or rejection. Valuable lessons are learned from interactions with children their own age. A characteristic of school-age children is their formation of groups with rules and values.
133
The nurse is describing the maturation of various organ systems during toddlerhood to the parents. What would the nurse correctly include in this description?
A) Myelinization of the brain and spinal cord is complete at about 24 months.
B) Alveoli reach adult numbers by 3 years of age.
C) Urine output in a toddler typically averages approximately 30 mL/hour.
D) Toddlers typically have strong abdominal muscles by the age of 2.
A) Myelinization of the brain and spinal cord is complete at about 24 months.
Feedback: Myelinization of the brain and spinal cord continues to progress and is complete around 24 months of age. Alveoli reach adult numbers usually around the age of 7. Urine output in a toddler typically averages 1 mL/kg/hour. Abdominal musculature in a toddler is weak, resulting in a pot-bellied appearance.
134
While obtaining a health history from a male adolescent during a well check-up, the nurse assesses his sexual behavior and risk for sexually transmitted infections. Based on the information, the nurse plans to teach the adolescent about using a condom. What would the nurse include in the teaching plan?
A) "You can reuse a condom if it's within 3 hours."
B) "Store your condoms in your wallet so they are ready for use."
C) "Put the condom on before engaging in any genital contact."
D) "Use petroleum jelly with a latex condom for extra lubrication."
C) "Put the condom on before engaging in any genital contact."
Feedback: When teaching an adolescent about condom use, the nurse should tell the adolescent to put the condom on before any genital contact. A new condom should be used with each act of sexual intercourse; a condom should never be reused. Condoms should be stored in a cool, dry place away from direct sunlight and never stored in wallets, automobiles, or anywhere they could be exposed to extreme temperatures. Only water-soluble lubricants should be used with latex condoms. Oil-based or petroleum-based lubricants such as Vaseline can weaken latex condoms.
135
An adolescent is diagnosed with gonorrhea. When developing the plan of care for this adolescent, the nurse would expect that she would also receive treatment for what?
A) Chlamydia
B) Syphilis
C) Genital herpes
D) Trichomoniasis
A) Chlamydia
Feedback: Patients with gonorrhea usually receive treatment for chlamydia as well because patients often are coinfected. Coinfection with syphilis, genital herpes, or trichomoniasis is uncommon.
136
A nurse suspects that an adolescent may have community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA). What would the nurse expect to assess? Select all that apply.
```
A) Participation in contact sport
B) Recent cut on the lower leg
C) History of a recent sore throat
D) Raised fluctuant lesions
E) Erythematous rash over the trunk and face
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A) Participation in contact sport
B) Recent cut on the lower leg
D) Raised fluctuant lesions
Feedback: With CAMRSA, skin and tissue infections are common, often appearing as a bump or skin area that is red, swollen, painful, and warm to the touch. There also may be fluctuance and purulent drainage. Participation in contact sports, openings in the skin such as abrasions and cuts, contact with contaminated items and surfaces, poor hygiene, and crowded living conditions are risk factors for CAMRSA. Recent sore throat and an erythematous rash on the trunk, face, and possibly the extremities are associated with scarlet fever.
137
The school nurse is teaching parents risk factors for suicide in adolescents. What would the nurse discuss? Select all that apply.
```
A) Mental health changes
B) History of previous suicide attempt
C) Higher socioeconomic status
D) Greatly improved school performance
E) Family disorganization
F) Substance abuse
```
A) Mental health changes
B) History of previous suicide attempt
E) Family disorganization
F) Substance abuse
Feedback: Suicide is the third leading cause of death in adolescents 15 to 19 years of age. Risk factors for suicide include mental health changes, history of previous suicide attempt, family disorganization, and substance abuse. Other risk factors include poor school performance, crowded conditions/housing, low socioeconomic status, limited parental supervision, single-parent families/both parents in workforce, access to guns or cars, drug or alcohol use, low self-esteem, racism, peer or gang pressure, and aggression.
138
The nurse is consulting with a child life specialist (CLS) to help minimize the stress of hospitalization for a child. Which services would the CLS provide? Select all answers that apply.
A) Medical preparation for tests, surgeries, and other medical procedures
B) Support before and after, but not during, medical procedures
C) Activities to support normal growth and development
D) Grief and bereavement support
E) Emergency room interventions for children and families
F) Only inpatient consultations with families
C) Activities to support normal growth and development
D) Grief and bereavement support
E) Emergency room interventions for children and families
Feedback: The CLS would provide activities to support normal growth and development, grief and bereavement support, and emergency room interventions for children and families. The CLS would also provide nonmedical preparation for tests, surgeries, and other medical procedures; support during medical procedures; and outpatient consultation with families.
139
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) Enlist the aid of a child life specialist.
Feedback: The nurse should enlist the aid of a child life specialist to provide suggestions for appropriate activities. Offering the child reading materials or encouraging him to complete his homework would most likely be met with resistance as he has already verbalized his boredom and disinterest in play, reading, and schoolwork. The parents could offer the child life specialist ideas about the boy's likes and dislikes; however, the child life specialist could offer expertise in assisting hospitalized children.
140
The school nurse is conducting a seminar for parents of adolescents on how to communicate with teenagers. Which guidelines might the nurse recommend? Select all that apply.
A) Talk face to face and be aware of body language.
B) Ask questions to see why he or she feels that way.
C) Do not give praise unless the adolescent deserves it.
D) Speak to your child as an authority figure, not an equal.
E) Don't admit that you make mistakes.
F) Don't pretend you know all the answers.
A) Talk face to face and be aware of body language.
B) Ask questions to see why he or she feels that way.
F) Don't pretend you know all the answers
Feedback: In order to improve communication with teenagers, the parents should talk face to face and be aware of body language, ask questions to see why the teenager feels that way, not pretend they know all the answers, give praise and approval to the teenager often, speak to him or her as an equal (not talk down to him or her), and admit that they do make mistakes.
141
The nurse is providing anticipatory guidance for parents of a preschooler regarding sex education. What is a recommended guideline when dealing with this issue?
A) Be prepared to thoroughly cover a topic before the child asks about it.
B) Before answering questions, find out what the child thinks about the subject.
C) Expand upon the topic when answering questions to prevent further confusion.
D) Provide a less than honest response to shelter the child from knowledge that is too advanced.
B) Before answering questions, find out what the child thinks about the subject.
Feedback: Preschoolers are very inquisitive and want to learn about everything around them; therefore, they are very likely to ask questions about sex and where babies come from. Before attempting to answer questions, parents should try to find out first what the child is really asking and what the child already thinks about that subject. Then they should provide a simple, direct, and honest answer. The child needs only the information that he or she is requesting.
142
The nurse is explaining to parents that the preschooler's developmental task is focused on the development of initiative rather than guilt. What is a priority intervention the nurse might recommend for parents of preschoolers to stimulate initiative?
A) Reward the child for initiative in order to build self-esteem.
B) Change the routine of the preschooler often to stimulate initiative.
C) Do not set limits on the preschooler's behavior as this results in low self-esteem.
D) As a parent, decide how and with whom the child will play.
A) Reward the child for initiative in order to build self-esteem.
Feedback: The building of self-esteem continues throughout the preschool period. It is of particular importance during these years, as the preschooler's developmental task is focused on the development of initiative rather than guilt. A sense of guilt will contribute to low self-esteem, whereas a child who is rewarded for his or her initiative will have increased self-confidence. Routine and ritual continue to be important throughout the preschool years, as they help the child to develop a sense of time as well as provide the structure for the child to feel safe and secure. Also, consistent limits provide the preschooler with expectation and guidance. Giving children opportunities to decide how and with whom they want to play also helps them develop initiative.
143
The nurse is caring for an infant who had hyperbilirubinemia requiring exchange transfusion. Based on this information, this infant is at risk for what type of disorder?
A) Vision loss
B) Hearing loss
C) Hypertension
D) Hyperlipidemia
B) Hearing loss
Feedback: There are many conditions that place an infant at risk for hearing loss, including an exchange transfusion with hyperbilirubinemia. A risk factor for vision loss is history of ocular structural abnormalities. Risk factors for systemic hypertension include preterm birth, very low birthweight, renal disease, organ transplant, congenital heart disease, or other illnesses associated with hypertension. A risk factor for hyperlipidemia is family history.
144
The mother of a 15-month-old child is questioning the nurse about the need for the hepatitis B vaccination. Which comment provides the most compelling reason for the vaccine?
A) "The most common side effect is injection site soreness."
B) "This is a recombinant or genetically engineered vaccine."
C) "Immunizations are needed to protect the general population."
D) "This protects your child from infection that can cause liver disease."
D) "This protects your child from infection that can cause liver disease."
Feedback: Up to 90% of neonates infected with hepatitis B develop chronic carrier status and will be predisposed to cirrhosis and hepatic cancer. The mother is not questioning side effects, safety, or disease prevention in general. Therefore, it is best to speak to her concerns.
145
The school nurse is performing a physical examination on a 13-year-old boy who is on the soccer team. What is a physical quality that develops during these early adolescent years?
A) Coordination
B) Endurance
C) Speed
D) Accuracy
B) Endurance
Feedback: It is usually during early adolescence that teenagers begin to develop endurance. Their concentration has increased so they can follow complicated instructions. Coordination can be a problem because of the uneven growth spurts. During middle adolescence, speed and accuracy increase while coordination also improves.
146
The nurse is performing a physical assessment of a 10-year-old boy. The nurse notes that during last year's check-up the child weighed 80 pounds. According to average growth for this age group, what would be his expected current weight?
A) 81 pounds
B) 85 pounds
C) 87 pounds
D) 89 pounds
C) 87 pounds
Feedback: From 6 to 12 years of age, an increase of 7 pounds (3 to 3.5 kg) per year in weight is expected.
147
The nurse is performing a physical examination of an 11-year-old girl. What observations would be expected?
A) The child has not gained weight since last year.
B) The child has grown 2.5 inches since last year.
C) The child breathes abdominally.
D) The child's third molars are about to erupt.
B) The child has grown 2.5 inches since last year.
Feedback: From 6 to 12 years of age, children grow an average of 2.5 inches (6 to 7 cm) per year, increasing their height by at least 1 foot. An increase of 7 pounds (3 to 3.5 kg) per year in weight is expected. Abdominal breathing is typical of a preschooler and would have disappeared several years earlier. The third molars do not erupt until late adolescence.
148
During a physical assessment of a 5-month-old child, the nurse observes the first tooth has just erupted and uses the opportunity to advise the mother to schedule a dental examination for her baby. When is the correct time for the dentist visit?
A) By the first birthday
B) By the second birthday
C) By entry into kindergarten
D) By entry into first grade
A) By the first birthday
Feedback: The American Academy of Pediatric Dentistry recommends that a dentist examine the infant by his or her first birthday. Besides assessing routine oral health care, establishing a dental contact by the first birthday provides a resource for emergency dental care if it is needed.
149
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) Throat
Feedback: If the infant is asleep, the nurse should auscultate the heart, lungs, and abdomen first while the baby is quiet. The nurse performs the assessment in a head-to-toe manner, leaving the most traumatic procedures, such as examination of the ears, nose, mouth, and throat, until last.
150
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 wasn't afraid.
B) Allow the child to touch and hold the equipment when possible.
C) Permit the child to sit on the parent's lap during the examination.
D) Offer immediate praise for holding still or doing what was asked.
A) Tell the child that another child the same age wasn't afraid.
Feedback: Toddlers are egocentric, and telling the toddler how well another child behaved or cooperated probably will not help gain this child's cooperation. Allowing the child to touch and hold the equipment, permitting the child to sit on the parent's lap during the exam, and offering praise immediately for cooperating would foster cooperation.
151
The nurse is preparing to take a tympanic temperature reading of a 4-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 the ear canal
B) Direct the infrared sensor at the tympanic membrane
Feedback: The accuracy of tympanic temperature reading is dependent upon appropriate technique. The nurse needs to be sure to direct the infrared sensor at the tympanic membrane. Since the child is older than age 3, the earlobe does not need to be pulled back and down. The nurse would not remove earwax from inside the ear canal.
152
A nursing instructor is teaching a group of students about the action of antipyretic agents in children. The instructor determines that the teaching has been successful when the students identify which action as the primary action?
A) Cause vasodilation to promote heat loss
B) Decrease the temperature set point
C) Block release of histamine
D) Promote prostaglandin production
B) Decrease the temperature set point
Feedback: Antipyretics act to decrease the temperature set point in children with elevated temperatures by inhibiting the production of prostaglandins, which leads to heat loss through vasodilation and sweating. Antihistamines block the release of histamine.
153
The nurse is assessing the tympanic temperature of several children. The nurse documents that the child with which temperature reading has a fever?
A) 98.2° F (36.8° C)
B) 99.2° F (37.3° C)
C) 100° F (37.8° C)
D) 100.8° F (38.2° C)
D) 100.8° F (38.2° C)
Feedback: A tympanic temperature greater than 100.4° F (greater than 38° C) is defined as fever. An oral temperature of 100° F (greater than 37.8° C) would identify a fever. An axillary temperature of 99° F (greater than 37.2° C) would identify a fever.
154
The parents of a 7-month-old child with an infection ask the nurse about how to treat their child's fever. After providing teaching, the parents voice understanding with which statements? Select all that apply.
A) "Unless my child develops a fever over 102.2°F , I don't need to make an appointment with the physician."
B) "Having a temperature over 38°C puts my child at risk for the infection spreading to the bloodstream."
C) "I can use acetaminophen to help with the symptoms of the infection but it won't get rid of the infection."
D) "Even though people get frightened, fevers are not a bad thing during an infection unless it gets too high."
E) "Any fever is dangerous and can cause serious damage to brain cells if it goes on too long."
A) "Unless my child develops a fever over 102.2°F , I don't need to make an appointment with the physician."
C) "I can use acetaminophen to help with the symptoms of the infection but it won't get rid of the infection."
D) "Even though people get frightened, fevers are not a bad thing during an infection unless it gets too high."
Feedback: In infants older than 3 months of age, fever less than 39°C (102.2°F) usually does not require treatment by a physician. Antipyretics, such as acetaminophen, provide symptomatic relief but do not change the course of the infection. A fever can actually enhance various components of the immune response. Infants younger than 3 months of age with a rectal temperature greater than 38°C should be seen by a physician or nurse practitioner because of increased risk of sepsis.
155
The nurse has completed diabetic education regarding insulin administration to a 14-year-old child newly diagnosed with diabetes and his family. The nurses knows the teaching was effective if the client and family:
A) can list appropriate sites for insulin administration.
B) have demonstrated correct insulin administration over the past several days.
C) indicate that they understand proper nutrition for a person with diabetes.
D) state that they understand hypoglycemic reaction signs and symptoms.
B) have demonstrated correct insulin administration over the past several days.
Feedback: Demonstration is the best way to determine if teaching was effective in any situation. Listing, identifying, and stating understanding of a concept are desirable, but these behaviors are not the best way to determine understanding.
156
The nurse is managing children who have chronic diseases in a neighborhood clinic. What are some examples of chronic conditions? Select all that apply.
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A) Diabetes mellitus
B) Myocardial infarction
C) Rheumatoid arthritis
D) Compound fracture
E) Acute asthma
F) Bronchopneumonia
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A) Diabetes mellitus
C) Rheumatoid arthritis
E) Acute asthma
Feedback: Chronic pain is defined as pain that continues past the expected point of healing for injured tissue. Diabetes, arthritis, and asthma are examples of chronic pain. Acute pain is defined as pain that is associated with a rapid onset of varying intensity. It usually indicates tissue damage and resolves with healing of the injury. Examples include heart attack, fractures, and bronchopneumonia.
157
The nurse is caring for a 14-year-old girl with multiple health problems. Which of the following activities would best reflect evidence-based practice by the nurse?
A) Following blood pressure monitoring recommendations
B) Determining how often the vital signs are monitored
C) Using hospital protocol for ordering diagnostic tests
D) Deciding the prescribed medication dose
A) Following blood pressure monitoring recommendations
Feedback: Using hospital protocol for ordering a diagnostic test, determining how often the vital signs are monitored, and deciding the medication dose ordered would be the physician's responsibility. However, following blood pressure monitoring recommendations would be part of evidence-based practice reflected in the nursing care delivered.
158
The client has a heavily draining wound for which there is an order to change the dressing every 4 hours. The nurse becomes busy and does not change the dressing as ordered. Which link in the chain of infection has the nurse allowed to flourish?
A) Susceptible host
B) Portal of exit
C) Reservoir
D) Mode of transmission
C) Reservoir
Feedback: The reservoir is the area where a pathogen grows and reproduces. Leaving the dressing unchanged allows for a dark, warm, nutrient rich, and moist environment where many organisms will thrive. A susceptible host is a person who cannot fight off an infection. The portal of exit is the way a pathogen exits the host. The mode of transmission is the way the pathogen travels.
159
The nurse is counseling the parents of a 9-year-old boy who is receiving morphine for postoperative pain. Which statement from the nurse accurately reflects the pain experience in children?
A) 'You can expect that your child will tell you when he is experiencing pain.'
B) 'Your child will learn to adapt to the pain he is experiencing.'
C) 'Your child will experience more adverse effects to narcotics than adults.'
D) 'It is very rare that children become addicted to narcotics.'
D) 'It is very rare that children become addicted to narcotics.'
Feedback: Addiction to narcotics when used in children is very rare. Often children deny pain to avoid a painful situation or procedure, embarrassment, or loss of control. Repeated exposure to pain or painful procedures can result in an increase in behavioral manifestations. The risk of adverse effects of narcotic analgesics is the same for children as for adults.
160
The nurse is monitoring a child who has received epidural analgesia with morphine. The nurse is careful to monitor for which adverse effect of the medication?
A) Epidural hematoma
B) Arachnoiditis
C) Spinal headache
D) Respiratory depression
D) Respiratory depression
Feedback: The nurse needs to monitor for signs of respiratory depression, a potential adverse effect of the opioid medication. Epidural hematoma, arachnoiditis, and spinal headache are potential adverse effects of the insertion of the epidural catheter.
161
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) 3 hours
Feedback: For a deeper procedure such as a lumbar puncture, the nurse needs to apply the cream 2 to 3 hours before the procedure. For a superficial procedure, the EMLA cream should be applied at least 1 hour before the procedure.
162
The nurse caring for infants in the neonatal intensive care unit (NICU) relies on the use of behavioral and physiologic indicators for determining pain. Which examples are behavioral indicators? Select all that apply.
A) The infant grimaces.
B) The infant's heart rate is elevated.
C) The infant flails his arms and legs.
D) The infant's respiratory rate is elevated.
E) The infant is crying uncontrollably.
F) The infant's oxygen saturation is low.
A) The infant grimaces.
C) The infant flails his arms and legs.
E) The infant is crying uncontrollably.
Feedback: In preterm and term newborns, behavioral and physiologic indicators are used for determining pain. Behavioral indicators include facial expression, body movements, and crying. Physiologic indicators include changes in heart rate, respiratory rate, blood pressure, oxygen saturation levels, vagal tone, palmar sweating, and plasma cortisol or catecholamine levels.
163
The nurse is administering a number of therapeutic interventions for neonates, infants, and children on the pediatric unit. Which intervention contributes to an increase in chronic illness seen in early childhood?
A) Administering antibiotics to prevent lethal infections
B) Vaccinating children to prevent childhood diseases
C) Using mechanical ventilation for premature infants
D) Using corticosteroids as a treatment for asthma
C) Using mechanical ventilation for premature infants
Feedback: Using mechanical ventilation and medications to foster lung development in premature infants increases their survival rate. Yet the infants who survive are often faced with myriad chronic illnesses. Administering antibiotics to prevent lethal infections, vaccinating children to prevent childhood diseases, and using corticosteroids as a treatment for asthma may cause side effects, but do not contribute to chronic illness in children.
164
A child is diagnosed with scarlet fever. The nurse is reviewing the child's medical record, expecting which medication to be prescribed for this child?
A) Ibuprofen
B) Acyclovir
C) Penicillin V
D) Doxycycline
C) Penicillin V
Feedback: Penicillin V is the antibiotic of choice for the treatment of scarlet fever. Ibuprofen is used to treat fever. Acyclovir is used to treat viral infections. Doxycycline, a tetracycline, is the drug of choice for treating Rocky Mountain spotted fever.
165
The nurse is caring for a 4-year-old girl of Mexican descent who is recovering in the hospital following a diagnosis of epileptic seizures. The child's mother insists on a visit from her curandera to provide healing powers to her daughter. What would be the best intervention of the nurse in this situation?
A) Explain to the mother that hospital policy does not allow visits from unlicensed practitioners.
B) Encourage the mother to arrange a visit with her curandera when her daughter is released from the hospital.
C) Discuss the situation with the child's physician and arrange for a visit from the curandera at the hospital if appropriate.
D) Distract the child's mother from her demands by focusing on child and family teaching related to her daughter's condition.
C) Discuss the situation with the child's physician and arrange for a visit from the curandera at the hospital if appropriate.
166
A 10-month-old is brought to the emergency department by her parents after they found her face down in the bathtub. The mother said, "I just left the bathroom to answer the phone. When I came back, I found her." Which assessment would be the priority?
A) Airway, breathing, and circulation
B) Level of consciousness
C) Vital signs
D) Pupillary response
A) Airway, breathing, and circulation
Feedback: With a submersion injury, hypoxia is the primary problem. Therefore, assessment of airway, breathing, and circulation are the priority assessments for which the nurse would institute resuscitative measures. Other assessments such as level of consciousness, vital signs, and papillary response would be done once the child's airway, breathing, and circulation are assessed and emergency interventions are instituted.
167
A 4-year-old boy has a history of seizures and has been started on a ketogenic diet. Which food selection would be most appropriate for his lunch?
A) Fried eggs, bacon, and iced tea
B) A hamburger on a bun, French fries, and milk
C) Spaghetti with meatballs, garlic bread, and a cola drink
D) A grilled cheese sandwich, potato chips, and a milkshake
A) Fried eggs, bacon, and iced tea
Feedback: The ketogenic diet involves a high intake of fats, adequate protein intake, and a very low intake of carbohydrates, resulting in a state of ketosis. The child is kept in a mild state of dehydration. Eggs and bacon are high in fat; the tea does not contain any carbohydrates. Therefore, this is the best choice. The hamburger is fat and protein, the bun is a carbohydrate, and the French fries and the milk both contain fat and protein, but both contain a lot of carbohydrates. The pasta and the sauce for the spaghetti are carbohydrates, the meatballs are protein, and the garlic bread is a carbohydrate, as is the cola drink. The grilled cheese sandwich has the fat and protein from the cheese, but the bread and chips are primarily carbohydrates, and the milkshake has fat, protein, and carbohydrates. Only the selection in A contains a ketogenic meal.
168
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) Increased pressure on nociceptive fibers
Feedback: Heat causes an increase in blood flow. This alters capillary permeability, leading to a reduction in swelling and pressure on nociceptive fibers. Heat also may trigger the release of endogenous opioids, which mediate the pain response.
169
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) Nociceptive pain
Feedback: Nociceptive pain reflects pain due to noxious stimuli that damages normal tissues or has the potential to do so if the pain is prolonged. Nociceptive pain ranges from sharp or burning; to dull, aching, or cramping; to deep aching or sharp stabbing. Examples of conditions that result in nociceptive pain include chemical burns, sunburn, cuts, appendicitis, and bladder distention. Neuropathic pain is pain due to malfunctioning of the peripheral or central nervous system. Chronic pain is defined as pain that continues past the expected point of healing for injured tissue. Superficial somatic pain, often called cutaneous pain, involves stimulation of nociceptors in the skin, subcutaneous tissue, or mucous membranes.
170
The nurse is caring for a child who reports chronic pain. What is the priority nursing assessment?
A) How the pain impacts the child's and family's stress level
B) The pain's history, onset, intensity, duration, and location
C) The child's and parents' feeling of anxiety and depression
D) The child's cognitive level and emotional response
B) The pain's history, onset, intensity, duration, and location
Feedback: Assessment of the child's pain is key; it is the priority assessment and is the only answer that focuses on the child's physiologic need. Assessment of how the pain impacts the child's and family's stress, feelings of anxiety, hopelessness, and depression, as well as the child's cognitive level and emotional response, are secondary after the pain is explored.
171
The nurse is researching behavioral-cognitive pain relief strategies to use on a 5-year-old child with unrelieved pain. Which methods might the nurse choose? Select all that apply.
a) Relaxation
b) Distraction
c) Thought stopping
d) Massage
e) Sucking
a) Relaxation
b) Distraction
c) Thought stopping
172
The nurse is administering a liquid medication to a 3-year-old using an oral syringe. Which action would be most appropriate?
a) Direct the liquid toward the anterior side of the mouth.
b) Keep the child's hand away from the oral syringe when squirting the medication.
c) Give all of the drug in the syringe at one time with one squirt.
d) Allow the child time to swallow the medication in between amounts.
d) Allow the child time to swallow the medication in between amounts.
173
The nurse is preparing to administer insulin to a diabetic child. Which would be the recommended route for this administration?
a) Subcutaneous
b) Intradermal
c) Intramuscular
d) Oral
a) Subcutaneous
174
The nurse is administering immunizations to children in a neighborhood clinic. What is the most frequent route of administration?
a) Oral
b) Intradermal
c) Intramuscular
d) Topical
c) Intramuscular
175
The mother of a 7-year-old boy with autism tearfully reports feeling as if she is not qualified to care for her child. Which initial action by the nurse is most appropriate?
a) Tell the child's mother that this is a common feeling when caring for a special needs child.
b) Encourage the child's mother to keep a journal to best identify areas needing improvement in the home routine.
c) Recognize the mother's positive accomplishments in caring for her child.
d) Recommend the child's mother seek counseling.
c) Recognize the mother's positive accomplishments in caring for her child.
176
The nurse is weighing an underweight infant diagnosed with failure to thrive (FTT) and notes that the baby does not make eye contact and is less active than the other infants. What would be a probable cause for the FTT related to the infant's body language?
a) Congenital heart defect
b) Cleft palate
c) Gastroesophageal reflux disease
d) Maternal abuse
d) Maternal abuse
177
The nurse is caring for families with vulnerable child syndrome. Which situation would be most likely to predispose the family to this condition?
a) Having a postterm infant
b) Having an infant who is reluctant to feed properly
c) Having a child diagnosed with impetigo at age 10
d) Having a child with juvenile diabetes
b) Having an infant who is reluctant to feed properly
