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Principles of Pediatric Nursing Caring for Children 6th Edition, Jane Test Bank

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Test Bank For Principles of Pediatric Nursing Caring for Children 6th Edition, Jane. Note: This is not a text book. Description: ISBN-13: 978-0133898064, ISBN-10: 0133898067.

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Test Bank Principles Pediatric Nursing Caring Children 6th Edition, Jane

CHAPTER 1

Question 1

Type: MCSA

Which nursing role is not directly involved when providing family-centered approach to the pediatric population?

  1. Advocacy
  2. Case management
  3. Patient education
  4. Researcher

Question 2

Type: MCMA

A nurse is working with pediatric clients in a research facility. The nurse recognizes that federal guidelines are in place that delineate which pediatrics clients must give assent for participation in research trials. Based upon the client’s age, the nurse would seek assent from which children?

Standard Text: Select all that apply.

  1. The precocious 4-year-old starting as a cystic fibrosis research-study participant.
  2. The 7-year-old leukemia client electing to receive a newly developed medication, now being researched.
  3. The 10-year-old starting in an investigative study for clients with precocious puberty.
  4. The 13-year-old client beginning participation in a research program for ADHD treatments.

Question 3

Type: MCSA

The nurse in a pediatric acute-care unit is assigned the following tasks. Which task is not appropriate for the registered to nurse complete?

  1. Diagnose an 8-year-old with acute otitis media and prescribe an antibiotic.
  2. Listen to the concerns of an adolescent about being out of school for a lengthy surgical recovery.
  3. Provide information to a mother of a newly diagnosed 4-year-old diabetic about local support-group options.
  4. Diagnose a 6-year-old with Diversional Activity Deficit related to placement in isolation.

Question 4

Type: MCSA

A 7-year-old child is admitted for acute appendicitis. The parents are questioning the nurse about expectations during the child’s recovery. Which information tool would be most useful in answering a parent’s questions about the timing of key events?

  1. Healthy People 2020
  2. Clinical pathways
  3. Child mortality statistics
  4. National clinical practice guidelines

Question 5

Type: MCSA

The nurse recognizes that the pediatric client is from a cultural background different from that of the hospital staff. Which goal is most appropriate for this client when planning nursing care?

  1. Overlook or minimize the differences that exist.
  2. Facilitate the family’s ability to comply with the care needed.
  3. Avoid inadvertently offending the family by imposing the nurse’s perspective.
  4. Encourage complementary beneficial cultural practices as primary therapies.

Question 6

Type: MCSA

The telephone triage nurse at a pediatric clinic knows each call is important. Which call would require extra attentiveness from the registered nurse because of an increased risk of mortality?

  1. A 3-week-old infant born at 35 weeks gestation with gastroenteritis
  2. A term 2-week-old infant of American Indian descent with an upper respiratory infection
  3. A post term 4-week-old infant non-Hispanic black descent with moderate emesis after feeding
  4. A 1-week-old infant born at 40 weeks gestation with symptoms of colic

Question 7

Type: MCSA

Despite the availability of Children’s Health Insurance Programs (CHIP), many eligible children are not enrolled. Which nursing intervention would be the most appropriate to help children become enrolled in CHIP?

  1. Assessment of the details of the family’s income and expenditures
  2. Case management to limit costly, unnecessary duplication of services
  3. To advocate for the child by encouraging the family to investigate its SCHIP eligibility
  4. To educate the family about the need for keeping regular well-child–visit appointments

Question 8

Type: MCSA

A supervisor is reviewing the documentation of the nurses in the unit. Which client documentation is the most accurate and contains all the required part for a narrative entry?

  1. “2/2/05 1630 Catheterized using an 8 French catheter, 45 mL clear yellow urine obtained, specimen sent to lab, squirmed and cried softly during insertion of catheter. Quiet in mother’s arms following catheter removal. M. May RN”
  2. “1/9/05 2 pm NG tube placement confirmed and irrigated with 30 ml sterile water. Suction set at low, intermittent. Oxygen via nasal canal at 2 L/min. Nares patent, pink, and nonirritated. K. Earnst RN”
  3. “4:00 Trach dressing removed with dime-size stain of dry serous exudate. Site cleansed with normal saline. Dried with sterile gauze. New sterile trach sponge and trach ties applied. Respirations regular and even throughout the procedure. F. Luck RN”
  4. “Feb. ’05 Port-A-Cath assessed with Huber needle. Blood return present. Flushed with NaCl sol., IV gamma globins hung and infusing at 30cc/hr. Child smiling and playful throughout the procedure. P. Potter, RN”

Question 9

Type: MCSA

A 12-year-old pediatric client is in need of surgery. Which member of the health care team is legally responsible for obtaining informed consent for an invasive procedure?

  1. Nurse
  2. Physician
  3. Unit secretary
  4. Social worker

Question 10

Type: MCSA

A child is being prepared for an invasive procedure. The mother of the child has legal custody but is not present. After details of the procedure are explained, who can provide legal consent on behalf of a minor child for treatment?

  1. The divorced parent without custody
  2. A cohabitating unmarried boyfriend of the child’s mother
  3. A grandparent who lives in the home with the child
  4. A babysitter with written proxy consent

CHAPTER 2

Question 1

Type: MCMA

The nurse is planning care for an adolescent client who will be hospitalized for several weeks following a traumatic brain injury. Which interventions will enhance family-centered care for this client and family?

Standard Text: Select all that apply.

  1. Making all ADL decisions for the adolescent and family
  2. Asking the adolescent what foods to include during meal time
  3. Allowing the family time to pray each day with the adolescent
  4. Encouraging the adolescent’s friends to visit during visiting hours
  5. Leaving all questions for the healthcare provider

Question 2

Type: MCSA

A new pediatric hospital will open soon. While planning nursing care, the hospital administration is considering two models of providing health care: family-focused care and family-centered care. Which action best implements family-centered care?

  1. Telling the family what must be done for the family’s health
  2. Assuming the role of an expert professional to direct the health care
  3. Intervening for the child and family as a unit
  4. Conferring with the family in deciding which healthcare option will be chosen

Question 3

Type: MCSA

A school-age client tells you that “Grandpa, Mommy, Daddy, and my brother live at my house.” Which type of family will the nurse identify in the medical record based on this description?

  1. Binuclear family
  2. Extended family
  3. Gay or lesbian family
  4. Traditional nuclear family

Question 4

Type: MCSA

The nurse is performing an assessment of a child’s biologic family history. Which situation would necessitate the nurse’s asking the mother for information should use the term “child’s father” instead of “your husband”?

  1. Traditional nuclear family
  2. Traditional extended family
  3. Two-income nuclear family
  4. Cohabitating informal stepfamily

Question 5

Type: MCSA

Several children arrived at the emergency department accompanied only by their fathers. Which father may legally sign emergency medical consent for treatment?

  1. The divorced one from the binuclear family
  2. The stepfather from the blended or reconstituted family
  3. The divorced one when the single-parent mother has custody
  4. The nonbiologic one from the heterosexual cohabitating family

Question 6

Type: MCSA

The community-health nurse is assessing several families for various strengths and needs in regard to after-school and backup child-care arrangements. Which family type will benefit the most from this assessment and subsequent interventions?

  1. The binuclear family
  2. The extended family
  3. The single-parent family
  4. The traditional nuclear family

Question 7

Type: MCSA

The nurse is working on parenting skills with a group of mothers. Which mother would need the fewest discipline-related suggestions?

  1. Authoritarian one
  2. Authoritative one
  3. Indifferent one
  4. Permissive one

Question 8

Type: MCSA

The nurse in the pediatric clinic observes a parental lack of warmth and interest toward the child. Which family style will the nurse most likely document in this situation?

  1. Authoritarian
  2. Authoritative
  3. Indifferent
  4. Permissive

Question 9

Type: MCSA

The nurse is working on parenting skills with a mother of three children. The nurse demonstrates a strategy that uses reward to increase positive behavior. Which strategy will the nurse document in the medical record based on this description?

  1. Time out
  2. Reasoning
  3. Behavior modification
  4. Experiencing consequences of misbehavior

Question 10

Type: MCSA

The nurse is assessing a family’s effective coping strategies and ineffective defensive strategies. Which family-social-system theory is the nurse using in this assessment of the family?

  1. Family-stress theory
  2. Family-development theory
  3. Family-systems theory
  4. Family life-cycle theory

CHAPTER 3

Question 1

Type: MCSA

Personalized health care for health promotion and maintenance can be based on environmental factors and which other item?

  1. The genes a person inherited
  2. Common conditions with known treatment strategies
  3. Teaching strategies
  4. The health of the person

Question 2

Type: MCSA

A three-generation pedigree is constructed around the designated “index” patient. Based on this knowledge which explanation of the term proband is the most accurate?

  1. The “index” patient has the disorder of interest
  2. One parent of the “index” patient has the disorder of interest
  3. The “index” patient does not have the disorder of interest
  4. Siblings of the “index” patient do not have the disorder of interest

Question 3

Type: MCSA

When discussing inheritance with parents of a child with a genetic disorder, which statement by the parents indicates they understand inheritance risk?

  1. “This child has a genetic disorder, so future children will not have it.”
  2. “Each pregnancy carries the same percent risk of inheritance.”
  3. “I cannot have any more children, because they will all have the disorder.”
  4. “There is a good chance future children will be normal.”

Question 4

Type: MCSA

Parents of a child with a congenital heart defect ask what the chances are of recurrence in future pregnancies. Which response by the nurse is the most appropriate?

  1. “There is a 50% chance of recurrence in a future pregnancy.”
  2. “There is a very low chance of recurrence.”
  3. “It should not happen again with a future pregnancy.”
  4. “There is a strong chance of recurrence.”

Question 5

Type: MCSA

A family with a child who had a cleft lip and palate at birth are planning another pregnancy. What intervention should be recommended prior to conception?

  1. A genetic family history
  2. A family pedigree
  3. A genetic physical assessment
  4. A maternal health history

Question 6

Type: MCSA

A father is a known carrier of an X-linked condition, and asks when he will know whether his newborn son has the condition he carries. Which response by the nurse is the most appropriate?

  1. “Genetic studies have been ordered, and they will take about a week to determine the results.”
  2. “We plan to run additional tests this afternoon, and should have results by the end of the day.”
  3. “Your son cannot have the condition because the condition is X-linked and cannot be passed on to him.”
  4. “There is a 50% chance you passed it on, but further tests are not recommended until he is a month old.”

Question 7

Type: MCSA

A student nurse asks, “What is carrier testing?” Which response by the nurse educator is most appropriate to answer the student nurse’s question?

  1. “Carrier testing involves testing an asymptomatic individual for carrier status for a genetic condition.”
  2. “Carrier testing is used to establish a diagnosis of a genetic disorder in an individual who is symptomatic or has had a positive screening test.”
  3. “Carrier testing is testing to identify a fetus with a genetic disease or condition. Some prenatal testing is offered routinely; other testing may be initiated due to family history or maternal factors.”
  4. “Carrier testing follows in vitro fertilization (IVF) testing to identify embryos with a particular genetic condition.”

Question 8

Type: MCSA

Which genetic test would be best for the prospective father who recently had a positive screen for a genetic condition?

  1. Carrier testing
  2. Predictive testing
  3. Diagnostic testing
  4. Prenatal testing

Question 9

Type: MCSA

The nurse is preparing a three-generation family pedigree. A student asks the nurse the significance of the darkened circles. Which response by the nurse is the most appropriate?

  1. Males unaffected by the disease.”
  2. Males affected by the disease.”
  3. Females unaffected by the disease.”
  4. Females affected by the disease.”

Question 10

Type: MCSA

A family desires genetic testing for their adolescent. What response by the clinic nurse is appropriate?

  1. “The child is a minor and cannot give consent.”
  2. “It is not advisable because insurance does not pay for this test.”
  3. “Let me discuss this with the adolescent and then we can discuss it more fully.”
  4. “There is a chance the adolescent might be discriminated against because of the test.”

CHAPTER 4

Question 1

Type: MCMA

While in the pediatrician’s office for their child’s 12-month well-child exam, the parents ask the nurse for advice on age-appropriate toys for their child. Based on the child’s developmental level, which types of toys would the nurse suggest?

Standard Text: Select all that apply.

  1. Soft toys that can be manipulated
  2. Small toys that can pop apart and go back together
  3. Jack-in-the-box toys
  4. Toys with black and white patterns
  5. Push-and-pull toys

Question 2

Type: MCSA

A mother of a school-age client who recently had surgery for the removal of tonsils and adenoids complains that the child has begun sucking his thumb again. Which coping mechanisms is the child using to cope with the surgery and hospitalization?

  1. Repression
  2. Rationalization
  3. Regression
  4. Fantasy

Question 3

Type: MCSA

While being comforted in the emergency department, a young school-age sibling of a pediatric trauma victim blurts out to the nurse, “It’s all my fault! When we were fighting yesterday, I told him I wished he was dead!” Which response is most appropriate by the nurse?

  1. Asking the child if she would like to sit down and drink some water
  2. Sitting the child down in an empty room with markers and paper so that she can draw a picture
  3. Calmly discussing the catheters, tubes, and equipment that the patient requires and explaining to the sibling why the patient needs them
  4. Reassuring the child that it is normal to get angry and say things that we do not mean but that we have no control over whether or not an accident happens

Question 4

Type: MCSA

While assessing the development of a 9-month-old infant, the nurse asks the mother if the child actively looks for toys when they are placed out of sight. Which developmental task is the nurse assessing this infant for?

  1. Object permanence
  2. Centration
  3. Transductive reasoning
  4. Conservation

Question 5

Type: MCSA

The nurse is counseling the parents of a 6-1/2-month-old infant. Which age-appropriate toy is most appropriate for the nurse to suggest to these parents?

  1. Soft, fluid-filled ring that can be chilled in the refrigerator
  2. Colorful rattle
  3. Jack-in-the-box toy
  4. Push-and-pull toy

Question 6

Type: MCSA

A nurse is assessing language development in all the infants presenting at the doctor’s office for well-child visits. At which age range would the nurse expect a child to verbalize the words “dada” and “mama”?

  1. 3 and 5 months
  2. 6 and 8 months
  3. 9 and 12 months
  4. 13 and 18 months

Question 7

Type: MCSA

The parents of an 8-year-old state that their son seems very interested in trying new activities. When the parents ask for suggested activities for this age child, the nurse recommends scouts as an activity that will foster growth and development. In which stage of Erikson’s “psychosocial stages of development” is this child?

  1. Trust versus mistrust
  2. Initiative versus guilt
  3. Industry versus inferiority
  4. Identity versus role confusion

Question 8

Type: MCSA

Two 3-year-olds are playing in a hospital playroom together. One is working on a puzzle while the other is stacking blocks. Which type of play are these children exhibiting?

  1. Cooperative play
  2. Associative play
  3. Parallel play
  4. Solitary play

Question 9

Type: MCSA

The nurse, talking with the parents of a toddler who is struggling with toilet training, reassures them that their child is demonstrating a typical developmental stage. According to Erikson, which developmental stage will the nurse document in the medical record for this toddler?

  1. Trust versus mistrust
  2. Autonomy versus shame and doubt
  3. Initiative versus guilt
  4. Industry versus inferiority

Question 10

Type: SEQ

A new parent group inquires about the stages through which their children will progress as they grow older. The nurse is discussing Piaget’s developmental stages. In what order would the nurse expect the child to progress through Piaget’s stages of development?

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Sensorimotor

Choice 2. Formal operational

Choice 3. Preoperational

Choice 4. Concrete operational

CHAPTER 5

Question 1

Type: MCSA

The nurse is taking a health history from a family of a 3-year-old child. Which statement by the nurse would most likely establish rapport and elicit an accurate response from the family?

  1. “Does any member of your family have a history of asthma, heart disease, or diabetes?”
  2. “Hello, I would like to talk with you and get some information on you and your child.”
  3. “Tell me about the concerns that brought you to the clinic today.”
  4. “You will need to fill out these forms; make sure that the information is as complete as possible.”

Question 2

Type: MCSA

When assessing the cognitive development, which technique would be appropriate to test the remote memory of a 5-year-old?

  1. Say the name of an object and after 5 minutes ask the child to tell you what you said the object was.
  2. Ask the child to repeat his address.
  3. Ask the child to say a poem and listen to the child’s speech articulation.
  4. Have the child point to various parts of the body as you name them.

Question 3

Type: SEQ

Place the nursing assessments of a toddler in the best order.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Examination of eyes, ears, and throat

Choice 2. Auscultation of chest

Choice 3. Palpation of abdomen

Choice 4. Developmental assessment

Question 4

Type: MCSA

While assessing a 10-month-old African American infant, the nurse notices that the sclerae have a yellowish tint. Which organ system should the nurse further evaluate to determine an ongoing disease process?

  1. Cardiac
  2. Respiratory
  3. Gastrointestinal
  4. Genitourinary

Question 5

Type: MCSA

A nurse caring for a school-age client notices some swelling in the child’s ankles. The nurse presses against the ankle bone for five seconds, then releases the pressure and notices a markedly slow disappearance of the indentation. Which priority nursing assessment is appropriate?

  1. Skin integrity, especially in the lower extremities
  2. Urine output
  3. Level of consciousness
  4. Range of motion and ankle mobility

Question 6

Type: MCSA

A new mother is worried about a “soft spot” on the top of her newborn infant’s head. The nurse informs her that this is a normal physical finding called the anterior fontanel. At what age will the nurse educate the mother that the soft spot will close?

  1. 2 to 3 months of age
  2. 6 to 9 months of age
  3. 12 to 18 months of age
  4. Approximately 2 years of age

Question 7

Type: MCSA

While inspecting a 5-year-old child’s ears, the nurse notes that the right pinna protrudes outward and that there is a mass behind the right ear. In light of these findings, which vital-sign parameter would the nurse assess on priority?

  1. Temperature
  2. Heart rate
  3. Respirations
  4. Blood pressure

Question 8

Type: MCMA

A 7-year-old child presents to the clinic with an exacerbation of asthma symptoms. On physical examination, the nurse would expect which assessment findings?

Standard Text: Select all that apply.

  1. Wheezing
  2. Increased tactile fremitus
  3. Decreased vocal resonance
  4. Decreased tactile fremitus
  5. Bronchophony

Question 9

Type: MCSA

The nurse is caring for a newly-admitted infant diagnosed with “failure to thrive.” The nurse begins to implement the healthcare provider prescribed orders by taking blood pressures in all four extremities. Which congenital cardiac defect does the nurse anticipate based on the prescribed order?

  1. Tetralogy of Fallot
  2. Pulmonary atresia
  3. Coarctation of the aorta
  4. Ventricular septal defect

Question 10

Type: MCSA

During an examination, a nurse asks a 5-year-old child to repeat his address. What is the nurse evaluating with this action?

  1. Recent memory
  2. Language development
  3. Remote memory
  4. Social-skill development

CHAPTER 6

Question 1

Type: MCSA

A nurse is helping the parents of 2-year-old twins cope with the daily demands of life in an active household. Which strategy is most appropriate for the nurse to use?

  1. Health maintenance
  2. Health promotion
  3. Health protection
  4. Health supervision

Question 2

Type: MCSA

A nurse in the outpatient pediatric clinic is reviewing the records of a preschool-age child and notes that because the parents often miss routine healthcare visits the child has not received the second measles, mumps, and rubella (MMR) vaccine. Which action by the nurse is most appropriate in this situation?

  1. Speak firmly with the parents about the importance of being compliant.
  2. Notify the physician that the child’s immunizations are no longer up to date.
  3. Call the parents and encourage them to bring the child for recommended care.
  4. Plan to discuss the principles of health supervision at the next scheduled visit.

Question 3

Type: MCSA

A mother brings a child to the pediatric office for a sick visit. Which action by the nurse is the most appropriate?

  1. Focus exclusively on the reported illness.
  2. Review health-promotion and health-maintenance activities.
  3. Ask the mother to leave the room after obtaining the history.
  4. Obtain a comprehensive history, including sociodemographic data.

Question 4

Type: MCSA

Which of these strategies would be most effective for a “teachable moment” during a routine office visit for the parents of a 6-year-old child?

  1. Select one topic and present a brief amount of information on the topic.
  2. Review all 6-year-old anticipatory guidelines with the parents.
  3. Review 7-year-old anticipatory guidelines with the parents.
  4. Discuss signs of malnutrition with the parents.

Question 5

Type: MCMA

The clinic administrator has asked each nurse to classify the nursing activities as a beginning step of clinic reorganization. Which of these strategies can be identified as health promotion and health maintenance?

Standard Text: Select all that apply.

  1. Administration of the flu vaccine for infants from 6 months to 23 months old.
  2. Daily feeding schedules for infants.
  3. Instruction to adolescents on how to use dental floss.
  4. Treatment for a child with a diagnosis of acute otitis media.

Question 6

Type: MCSA

A mother of a 2-year-old child becomes very anxious when the child has a temper tantrum in the medical office.  Which response by the nurse is the most appropriate?

  1. “What do you usually do or say during a temper tantrum?”
  2. “Let’s ignore this behavior; it will stop sooner or later.”
  3. “Pick up and cuddle your child now, please.”
  4. “This is definitely a temper tantrum; I know exactly what you are feeling right now.”

Question 7

Type: MCSA

A nurse says to the mother of a 6-month-old infant, “Does the baby sit without assistance, and is the baby crawling?” Which process is the nurse using in this interaction?

  1. Health promotion
  2. Health maintenance
  3. Disease surveillance
  4. Developmental surveillance

Question 8

Type: MCSA

A parent says to a nurse, “How do you know when my child needs these screening tests the doctor just mentioned?” Which response by the nurse is the most appropriate?

  1. “Screening tests are administered at the ages when a child is most likely to develop a condition.”
  2. “Screening tests are done in the newborn nursery and from these results, additional screening tests are ordered throughout the first two years of life.”
  3. “Screening tests are most often done when the doctor suspects something is wrong with the child.”
  4. “Screening tests are done at each office visit.”

Question 9

Type: MCMA

Which nursing assessment activities should be included for the child and family at each health-supervision visit?

Standard Text: Select all that apply.

  1. Interview to obtain an updated health history.
  2. Performing an age-appropriate development assessment.
  3. Monitoring parents’ ability to pay for services.
  4. Performing age-appropriate screening examinations.
  5. Physical assessment for genetic abnormalities.

Question 10

Type: MCSA

The nurse of an outpatient clinic is sitting with the parents while their adolescent goes for a test. The parents are complaining about their child’s behavior. Which statement by the nurse fosters family-centered communication?

  1. “I agree with you, discipline is an important part of parenting.”
  2. “I know just how you feel. I had the same experience with my children.”
  3. “You are so right. Adolescents function in the me-first mode all the time.”
  4. “Tell me what concerns you about your child’s behavior.”

CHAPTER 7

Question 1

Type: MCMA

A nursery nurse is planning care for the newborns currently in the newborn nursery. Which activities does the nurse plan for the first 48 hours of life?

Standard Text: Select all that apply.

  1. Monitor feeding behaviors.
  2. Perform a hearing screening.
  3. Perform a heel stick to obtain blood for the newborn screen.
  4. Monitor the mother as she performs the first newborn bath to remove blood and amniotic fluids.
  5. Administer folic-acid injection to the infant to prevent bleeding.

Question 2

Type: MCSA

The nurse is planning care for clients seen in a newborn clinic. Which is the priority for a newborn client during the first clinic visit?

  1. Providing pamphlets to reinforce information provided at the visit
  2. Assessing the newborn-and-family interactions
  3. Modeling infant-nurturing behaviors
  4. Informing the parents of the infant’s gains in height and weight

Question 3

Type: MCMA

The nurse in the newborn nursery is admitting a neonate. To determine the health and development of the newborn, what will the nurse include in the assessment?

Standard Text: Select all that apply.

  1. Head circumference
  2. Body length
  3. Weight
  4. Length of pregnancy
  5. Hearing screens

Question 4

Type: MCSA

An infant weighs 9 pounds, 3 ounces at birth. The nurse plans to make a home visit to the mother and infant when the infant is 7 days old. What is the lowest acceptable weight the infant should be at this age?

  1. 7 pounds, 12 ounces
  2. 8 pounds, 2 ounces
  3. 8 pounds, 12 ounces
  4. 9 pounds

Question 5

Type: MCSA

The nurse is teaching a new mother developmental expectations. Which activity should the nurse expect a newborn to do within the first month of life?

  1. Bring hands to eyes and mouth.
  2. Push up with hands, moving chest up.
  3. Keep hands in a relaxed position.
  4. Roll over from back to abdomen.

Question 6

Type: MCSA

The nurse is providing anticipatory guidance instructions to the parents of a newborn. Which instruction should the nurse give as a strategy for illness/disease prevention?

  1. Don’t allow visitors for the first month.
  2. Smoke outside only.
  3. Take the newborn to weekly child-stimulation classes.
  4. SIDS risk-reduction measures

Question 7

Type: MCSA

A nurse assesses the height and weight measurements on an infant and documents these measurements at the 75th percentile. The nurse notes that the previous measurements two months ago were at the 25th percentile. Which interpretation by the nurse is the most accurate?

  1. The infant is not gaining enough weight.
  2. The infant has gained a significant amount of weight.
  3. The previous measurements were most likely inaccurate.
  4. These measurements are most likely inaccurate.

Question 8

Type: MCSA

A nurse asks the mother of a 4-month-old infant to undress the infant. The nurse observes the mother taking off several layers of clothing and knows that the outdoor temperature is 70 degrees Fahrenheit. Which statement by the nurse is most appropriate in this situation?

  1. “My, you are dressing your infant warmly today.”
  2. “Did you think it was cold when you left your home this morning?”
  3. “I see that you have many layers of clothing on your baby. This may cause your baby’s temperature to rise. ”
  4. “When you leave the office, only put one layer of clothing on your baby.”

Question 9

Type: MCMA

The nurse working with a family has observed that the older children have a large number of dental caries and plans to provide the mother with information to prevent the development of dental caries in her new infant. Which interventions will prevent the development of dental caries in the infant?

Standard Text: Select all that apply.

  1. Avoiding nursing or giving the infant a bottle at bedtime
  2. Giving foods high in sugar only at breakfast time
  3. Using a soft moist gauze for cleaning
  4. Using a topical anesthetic daily beginning as soon as the first tooth begins to erupt

Question 10

Type: MCSA

A nurse is assessing an 11-month-old infant and notes that the infant’s height and weight are at the 5th percentile on the growth chart. Family history reveals that the infant’s two siblings are at the 50th percentile for height and at the 75th percentile for weight. Psychosocial history reveals that the parents are separated and are planning to divorce. Which of these nursing diagnoses takes priority?

  1. Alteration in Growth Pattern Related to Parental Anxiety
  2. Alteration in Growth Pattern Secondary to Familial Short Stature
  3. Nutritional Intake: Excessive Secondary to Maternal Feeding Patterns
  4. At Risk for Constitutional Growth Delay Related to Decreased Appetite

CHAPTER 8

Question 1

Type: MCMA

Which of these aspects of developmental health supervision should be included in each healthcare visit of young children?

Standard Text: Select all that apply.

  1. Assessment
  2. Discipline
  3. Education
  4. Intervention
  5. Toilet training

Question 2

Type: MCSA

A 27-month-old toddler who is in the pediatric office for a well-child visit begins to cry the moment he is placed on the examination table. The parent attempts to comfort the toddler; however, nothing is effective. Which of these actions by the nurse takes priority?

  1. Instruct the father to hold the toddler down tightly to complete the examination.
  2. Allow the toddler to sit on the parent’s lap and begin the assessment.
  3. Allow the toddler to stand on the floor until he stops crying.
  4. Ask another nurse in the office to hold the toddler, since the parent is not able to control the toddler’s behavior.

Question 3

Type: MCSA

At a routine healthcare visit, a nurse measures a toddler and plots the height and weight on the growth charts. The nurse documents that the toddler is above the 95th percentile for weight and is at the 5th percentile for height. How should the nurse interpret these data?

  1. The toddler is proportionate for the age.
  2. The toddler needs to eat more at each feeding.
  3. The height and weight are disproportionate, and the toddler needs further evaluation.
  4. The family is most likely short.

Question 4

Type: MCSA

A nurse is preparing to perform a physical assessment on a toddler. Which action is most appropriate for the nurse to take?

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

Question 5

Type: MCMA

Which of these developmental milestones should the nurse expect to find in children who are between 2 and 3 years old?

Standard Text: Select all that apply.

  1. Always feeds self
  2. Scribbles and draws on paper
  3. Kicks a ball
  4. Throws ball overhand
  5. Goes up and down stairs

Question 6

Type: MCSA

A nurse observes the parent/child interaction during the 4-year-old well-child checkup and notes that the parent speaks harshly to the child and uses negative remarks when speaking with the nurse. Which statement by the nurse would be most beneficial?

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

Question 7

Type: MCSA

A nurse who is the manager of an ambulatory pediatric healthcare center is planning protocols for the routine healthcare visits of the children. Children at this care center have a high incidence of obesity. At which age should the nurses at this clinic calculate the body mass index (BMI) for all pediatric clients?

  1. 12 months
  2. 24 months
  3. 36 months
  4. 4 years

Question 8

Type: MCSA

Which of these measures used by a nurse will help relieve parental anxiety related to the changing appetite in the toddler who is gaining weight along the 50th percentile?

  1. Discussing the growth of the toddler as compared to the growth chart
  2. Suggesting ways to have the toddler eat higher calorie foods
  3. Instructing the mother to feed the toddler alone without any distractions such as TV or music
  4. Teaching the mother to avoid disciplining the toddler within one-half hour of eating

Question 9

Type: MCSA

Parents of a preschool child report that they find it necessary to spank the child at least once a day. Which response should the nurse make to the parents?

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

Question 10

Type: MCSA

A parent questions how her toddler plays with other toddlers. Which response by the nurse displays the best description of the differences in play between the toddler and the preschooler?

  1. Toddlers play side by side, while preschoolers play cooperatively.
  2. Toddlers play house and imitate adult roles, while preschoolers become the Mom or Dad while playing house.
  3. Toddlers play cooperatively, while preschoolers play interactive games.
  4. There are no differences between toddlers and preschoolers since both groups play cooperatively.

CHAPTER 9

Question 1

Type: MCSA

An adolescent female presents at a nurse practitioner’s office and requests a signature for working papers. The nurse reviews her chart and notes that the last physical examination was two years ago. In addition to providing the signature for the working papers, what else should the nurse use this visit?

  1. An opportunity to discuss birth-control measures
  2. A time to discuss exercise and sports participation
  3. A health-supervision opportunity
  4. A chance to discuss the importance of pursuing post secondary education

Question 2

Type: MCMA

An adolescent is accompanied by the mother for an annual physical examination. The nurse is aware of privacy issues related to the adolescent. While the mother is in the room, the nurse should avoid which questions?

Standard Text: Select all that apply.

  1. Sexual activity
  2. Cigarette smoking
  3. School performance
  4. Use of alcohol
  5. Car seatbelt use

Question 3

Type: MCMA

The school nurse performs screenings on all students in the middle school. In addition, the nurse will perform selected screenings on individual school-age children. When planning the screenings for the year, which screenings will the nurse include for all school-age children?

Standard Text: Select all that apply.

  1. Hearing
  2. Height and weight
  3. Blood-pressure measurement
  4. Hepatitis B profile serology
  5. Chest x-ray

Question 4

Type: MCSA

A school nurse is performing annual height and weight screening. The nurse notes that three females who are close friends each lost 15 pounds over the past year. What is the priority nursing action in this situation?

  1. Call the respective parents to discuss the eating patterns of each adolescent.
  2. Speak with the girls in a group to discuss the problems associated with anorexia nervosa.
  3. Refer these adolescents to the school psychologist.
  4. Obtain a nutritional history for each of these adolescents.

Question 5

Type: MCSA

An school-age client who recently moved to a new school in a different town presents to an ambulatory care center and describes the following: “I have no friends in my new school, and I no longer want to go to play soccer. I know I will be lonely there, too.” Which of these takes priority when speaking with the school-age client?

  1. Helping the school-age client realize the value of soccer
  2. Promoting healthy mental-health outcomes
  3. Acknowledging the fact that it takes several months to make new friends at a new school
  4. Stressing the importance of remaining in a close parent–child relationship during these stressful times

Question 6

Type: MCSA

An adolescent reports participating in an exercise program at school each Wednesday throughout the school year. Further history reveals that the adolescent does not participate in any other physical activities. Which outcome is most appropriate for this adolescent?

  1. The adolescent is reporting information consistent with what 60 percent of adolescents report as participation in physical activities.
  2. The adolescent is not meeting the recommendations of the Healthy People 2020initiative.
  3. The adolescent should be encouraged to continue this program of exercise, since something is better than nothing.
  4. The adolescent should be encouraged to vigorously exercise for at least five minutes each day.

Question 7

Type: MCSA

An adolescent reports the following: “I get up at 6 am, I attend early-morning band classes three times each week, I play sports for two hours each day after school, and homework takes me three hours each night. I always feel tired.” Which question by the nurse is most appropriate based on this information?

  1. “How many hours of sleep do you get each night?”
  2. “Do you consume foods high in iron?”
  3. “Do you think you are doing too much?”
  4. “Have you considered talking with your teachers about decreasing your homework, since you have so many extracurricular activities?”

Question 8

Type: MCSA

The nurse working in the clinic includes an adolescent history in every client intake interview. Which issue should the nurse address when the parents are not present?

  1. Possible domestic violence
  2. Teen job responsibilities
  3. Activities that are done as a family
  4. The adolescent’s role in the family

Question 9

Type: MCSA

The nurse is reviewing the immunization record of an adolescent who will be seen later in the day. Which item in the client’s history makes heptatis B status a priority?

  1. Chronic acne
  2. Overuse injuries from playing varsity sports
  3. Chronic asthma
  4. Plans to get a tattoo

Question 10

Type: MCSA

An obese adolescent who adamantly denies sexual activity has a positive pregnancy test, which was performed in the adolescent clinic. Which statement by the nurse is the most appropriate in this situation?

  1. “Tell me how you feel about your body image.”
  2. “When was your last menstrual period (LMP)?”
  3. “Let’s discuss some activities that you have done within the past few months that could possibly lead to pregnancy.”
  4. “Were you involved in a date rape and are you hesitant to speak about it?”

CHAPTER 10

Question 1

Type: MCSA

The community-health nurse visits the child-care center. Which finding indicates the need for staff education?

  1. A group of 2-year-olds are eating a snack of Cheerios.
  2. Several 4-year-olds are outside playing on a slide.
  3. An 18-month-old is pushing a toy truck.
  4. A 2-month-old is sleeping in a crib on his stomach.

Question 2

Type: MCSA

An adolescent client has a long leg cast secondary to a fractured femur. Which action by the nurse would effectively facilitate the adolescent’s return to school?

  1. Meet with teachers and administrators at the school to make sure entrances and classrooms are wheelchair accessible.
  2. Develop an individualized health plan (IHP) that focuses on long-term needs of the adolescent.
  3. Prior to the student’s return to school, meet with all of the other students to emphasize the special needs of the injured teen.
  4. Meet with parents of the injured student to encourage homebound schooling until a short leg cast is applied.

Question 3

Type: MCSA

The community-health nurse is planning an education session for recently hired teachers at a child-care center. Which item is priority for the community-health nurse to include in the educational session?

  1. The schedule for immunizations
  2. Principles of infection control
  3. How to interpret healthcare records
  4. How to take a temperature

Question 4

Type: MCSA

The nurse is providing care for several pediatric clients. Which client would require an Individualized Health Plan (IHP) prior to returning to school?

  1. A school-age clientwho has recently developed a penicillin allergy.
  2. An adolescent clientnewly diagnosed with insulin-dependent diabetes mellitus.
  3. A school-age clientwho has been treated for head lice.
  4. An adolescent clientwho has missed two weeks of school due to mononucleosis.

Question 5

Type: MCSA

The school nurse is preparing a plan of care specific to several children in the school who have asthma. What is the initial action on the plan of care?

  1. Call 911 to request emergency medical assistance.
  2. Call the child’s parents to come and pick up the child.
  3. Have the child use his or her metered-dose inhaler.
  4. Have the child lie down to see if the symptoms subside.

Question 6

Type: MCSA

The telephone triage nurse receives a call from a parent who states that her 18-month-old is making a crowing sound when he breathes and is hard to wake up. Which action by the nurse is the most appropriate?

  1. Obtain the history of the illness from the parent.
  2. Advise the parent to hang up and call 911.
  3. Make an appointment for the child to see the healthcare provider.
  4. Reassure the parent and provide instructions on home care for the child.

Question 7

Type: MCSA

A young school-age client who has had a tracheostomy for several years is scheduled to begin school in the fall. The teacher is concerned about this child’s being in her class and consults the school nurse. Which action by the nurse is the most appropriate?

  1. Make arrangements for the child to go to a special school.
  2. Ask the parents of the child to provide a caregiver during school hours.
  3. Recommend that the child be home schooled.
  4. Teach the teacher how to care for the child in the classroom.

Question 8

Type: MCSA

A 2-month-old infant with bronchopulmonary dysplasia (BPD) is being prepared for discharge from the neonatal intensive-care unit (NICU). The infant will continue to receive oxygen via nasal cannula at home. Prior to discharge, the home-health nurse assesses the home. Which finding poses the greatest risk to this infant?

  1. Small toys strewn on the floor
  2. A woodstove used for heating
  3. A sibling who has an ear infection
  4. Paint peeling on the walls

Question 9

Type: MCSA

A child who is dependent on a ventilator is being discharged from the hospital. Prior to discharge, the home-health nurse discusses development of an emergency plan of care with the family. Which is the most essential part of the plan?

  1. Acquisition of a backup generator
  2. Designation of an emergency shelter site
  3. Provision for an alternate heating source if power is lost
  4. Notifying the power company that the child is on life support

Question 10

Type: MCSA

What must a home-health nurse realize prior to accepting an assignment?

  1. All decisions will be made by the healthcare provider.
  2. The family will adapt their lifestyle to the needs of the nurse.
  3. Independent decisions regarding emergency care of the child will be made by the nurse.
  4. The family is in charge.

CHAPTER 11

Question 1

Type: MCSA

The parents of a critically injured child wish to stay in the room while the child is receiving emergency care. Which action by the nurse is the most appropriate?

  1. Escort the parents to the waiting room and assure them that they can see their child soon.
  2. Allow the parents to stay with the child.
  3. Ask the physician if the parents can stay with the child.
  4. Tell the parents that they do not need to stay with the child.

Question 2

Type: MCSA

The charge nurse on a hospital unit is developing plans of care related to separation anxiety. The charge nurse recognizes that which hospitalized child at highest risk to experience separation anxiety when parents cannot stay?

  1. 6-month-old
  2. 18-month-old
  3. 3-year-old
  4. 4-year-old

Question 3

Type: MCSA

A group of children on one hospital unit are all suffering separation anxiety. Which child is experiencing the “despair” stage of separation anxiety?

  1. Does not cry if parents return and leave again
  2. Screams and cries when parents leave
  3. Appears to be happy and content with staff
  4. Lies quietly in bed

Question 4

Type: MCSA

A preschool-age client is seen in the clinic for a sore throat. In this child’s mind, what is the most likely causative agent for the sore throat?

  1. Was exposed to someone else with a sore throat.
  2. Did not eat the right foods.
  3. Yelled at his brother.
  4. Did not take his vitamins.

Question 5

Type: MCSA

The charge nurse is concerned with reducing the stressors of hospitalization. Which nursing intervention is most helpful in decreasing the stressors for the toddler-age client?

  1. Assign the same nurse to the toddler as much as possible.
  2. Let the child listen to an audiotape of the mother’s voice.
  3. Place a picture of the family at the bedside.
  4. Encourage a parent to stay with the child.

Question 6

Type: MCSA

The nurse is working with a school-age child who is hospitalized. Which action by the nurse will promote a sense of industry in this child?

  1. Allow the child to assist with her care.
  2. Encourage parents to participate in the child’s care.
  3. Give the child a detailed scientific explanation of the illness.
  4. Speak to the child in a high-pitched voice.

Question 7

Type: MCSA

The nurse is caring for a client in the pediatric intensive-care unit (PICU). The parents have expressed anger over the nursing care their child is receiving. Which nursing intervention is most appropriate based on the situation?

  1. Ask the physician to talk with the family.
  2. Explain to the parents that their anger is affecting their child so they will not be allowed to visit the child until they calm down.
  3. Acknowledge the parents’ concerns and collaborate with them regarding the care of their child.
  4. Call the chaplain to sit with the family.

Question 8

Type: MCSA

A toddler recently diagnosed with a seizure disorder will be discharged home on an anticonvulsant. Which action by the mother best demonstrates understanding of how to give the medication?

  1. Verbalizing how to give the medication
  2. Acknowledging understanding of written instructions
  3. Drawing up the medication correctly in an oral syringe and administering it to the child
  4. Observing the nurse draw up the medication and administering it to the child.

Question 9

Type: MCSA

The nurse must perform a procedure on a toddler. Which technique is the most appropriate when performing the procedure?

  1. Ask the mother to restrain the child during the procedure.
  2. Ask the child if it is okay to start the procedure.
  3. Perform the procedure in the child’s hospital bed.
  4. Allow the child to cry or scream.

Question 10

Type: MCSA

A young school-age client is in the playroom when the respiratory therapist arrives on the pediatric unit to give the child a scheduled breathing treatment. Which action by the nurse is the most appropriate?

  1. Reschedule the treatment for a later time.
  2. Show the respiratory therapist to the playroom so the treatment may be performed.
  3. Escort the child to his room and ask the child-life specialist to bring toys to the bedside.
  4. Assist the child back to his room for the treatment but reassure the child that he may return when the procedure is completed.

CHAPTER 12

Question 1

Type: MCMA

The nurse in the long-term–care clinic is reviewing the charts of a group of children with chronic physical, psychological, functional, and/or social limitations. Which conditions are most likely to lead to chronic limitations?

Standard Text: Select all that apply.

  1. Near drowning
  2. Congenital heart defect
  3. Sinusitis
  4. Fetal insult when the mother contracted rubella in the first trimester of pregnancy
  5. Sepsis contracted as a neonate

Question 2

Type: MCSA

The school nurse completes an assessment of a school-age client to determine the services this child will need in the classroom. The client is a newly diagnosed with type I diabetes mellitus. Based on this information, which special healthcare need category is the most appropriate?

  1. Dependent on medication or special diet
  2. Dependent on medical technology
  3. Increase use of healthcare services
  4. Functional limitations

Question 3

Type: MCSA

The nurse can instruct parents to expect children in which age group to begin to assume more independent responsibility for their own management of a chronic condition, such as blood-glucose monitoring, insulin administration, intermittent self-catheterization, and appropriate inhaler use?

  1. Toddlers
  2. Preschoolers
  3. School-age
  4. Adolescents

Question 4

Type: MCSA

The nurse is working in an adolescent medical clinic. What can the nurse anticipate when comparing adolescents in the clinic with chronic conditions to their peers?

  1. Ahigh level self-esteem
  2. Aconcern for their parents
  3. An altered body image
  4. A decreased concern about their appearance

Question 5

Type: MCSA

The nurse is working with a child with a chronic condition. The nurse observes that over time, the parents have experienced a pattern of periodic grieving alternating with denial. What are the parents currently experiencing based on this assessment finding?

  1. Chronic sorrow
  2. Compassion fatigue
  3. Dysfunctional parenting
  4. Pathological grieving

Question 6

Type: MCMA

In working with parents of children with chronic diseases, the nurse is concerned with helping the parents to protect themselves from compassion fatigue. Which activities are appropriate for the nurse to encourage?

Standard Text: Select all that apply.

  1. Sleeping more than 9 hours per 24-hour period
  2. Exercising
  3. Fostering social relationships
  4. Developing a hobby
  5. Moving away

Question 7

Type: MCSA

The nurse is working with a group of parents who have children with chronic conditions. Which statement by a parent would indicate a risk for a caregiver burden that could become overwhelming?

  1. “My mother moved in and helped us take our quadruplets home.”
  2. “Our health insurance sent us a rejection letter for my child’s brand-name medication, and we must fill out forms to get the generic.”
  3. “I chose to quit my job to be home with my child, and my husband helps in the evening when he can.”
  4. “I have to care for my child day and night, which leaves little time for me.”

Question 8

Type: MCSA

The clinic nurse is working with a child with multiple disabilities. The parents have asked the nurse to help them in meeting with the school board to develop an Individualized Education Plan (IEP) and an Individualized Health Plan (IHP). Which nursing intervention is most appropriate?

  1. Providing a written list of the child’s medical diagnoses for the IEP meeting.
  2. Offering to wait with the child while the parents attend the IEP meeting.
  3. Listening to the parents’ concerns and complaints about the school district.
  4. Presenting verbally the child’s cognitive, physical, and social skills to school officials at the IEP meeting.

Question 9

Type: MCSA

The nurse is planning activities for a toddler with a birth injury of a torn brachial plexus that resulted in muscle atrophy and weakness of his right arm. Which nursing intervention is most appropriate for this client?

  1. Offering the toddler a choice of clothing
  2. Asking the toddler if he would like to take his medicine
  3. Dressing the toddler
  4. Feeding the toddler

Question 10

Type: MCSA

The nurse has set up a group discussion for several families with chronically ill children. The nurse informs these parents that they may face which ethical issue?

  1. Normalization
  2. Withholding and refusal of treatment
  3. Repeated hospital admissions
  4. Lack of proper dietary needs

CHAPTER 13

Question 1

Type: MCSA

The parents of a toddler-age child who sustained severe head trauma from falling out a second-story window are arguing in the pediatric intensive-care unit (PICU) and blaming each other for the child’s accident. Which nursing diagnosis is most appropriate for this family?

  1. Parental Role Conflict Related to Protecting the Child
  2. Hopelessness Related to the Child’s Deteriorating Condition
  3. Anxiety Related to the Critical-Care-Unit Environment
  4. Family Coping: Compromised, Related to the Child’s Critical Injury

Question 2

Type: MCMA

The emergency-room nurse receives a preschool-age child who was hit by a car. Which nursing interventions are a priority for this child?

Standard Text: Select all that apply.

  1. Performing a rapid head-to-toe assessment
  2. Recording the parents’ insurance information
  3. Assessing airway, breathing, and circulation
  4. Asking the parents about organ donation
  5. Asking the parents if anyone witnessed the accident

Question 3

Type: MCMA

A young school-age child is in the pediatric intensive-care unit (PICU) with a fractured femur and head trauma. The child was not wearing a helmet while riding his new bicycle on the highway and collided with a car. Which nursing diagnoses may be appropriate for this family?

Standard Text: Select all that apply.

  1. Guilt Related to Lack of Child Supervision and Safety Precautions
  2. Family Coping: Compromised, Related to the Critical Injury of the Child
  3. Parental Role Conflict Related to Child’s Injuries and PICU Policies
  4. Knowledge Deficit Related to Home Care of Fractured Femur
  5. Anger Related to Feelings of Helplessness

Question 4

Type: MCSA

The nurse must prepare parents to see their adolescent daughter in the pediatric intensive-care unit (PICU). The child arrived by life flight after experiencing multiple traumas in a car accident involving a suspected drunk driver. At this time, which statement by the nurse to the family is the most appropriate?

  1. “Don’t worry; everything will be okay. We will take excellent care of your child.”
  2. “You should press charges against the drunk driver.”
  3. “Your child’s leg was crushed and may have to be amputated.”
  4. “Your child’s condition is very critical; her face is swollen, and she may not look like herself.”

Question 5

Type: MCSA

An adolescent with cystic fibrosis is intubated with an endotracheal tube. Which nursing diagnosis is most appropriate for this adolescent?

  1. Potential for Imbalanced Nutrition, More Than Body Requirements Related to Inactivity
  2. Anxiety Related to Leaving Chores Undone at Home
  3. Potential for Fear of Future Pain Related to Medical Procedures
  4. Powerlessness (Moderate) Related to Inability to Speak to or Communicate with Friends

Question 6

Type: MCSA

An adolescent client has a stiff neck, a headache, a fever of 103 degrees Fahrenheit, and purpuric lesions noted on the legs. Although the adolescent’s physical needs take priority at the present time, the nurse can expect which to be the most significant psychological stressor forthis adolescent?

  1. Separation from parents and home.
  2. Separation from friends and permanent changes in appearance
  3. Fear of painful procedures and bodily mutilation
  4. Fear of getting behind in schoolwork

Question 7

Type: MCSA

A school bus carrying children in grades K–12 crashed into a ravine. The critically injured children were transported by ambulance and admitted to the pediatric intensive-care unit (PICU). The nurse is concerned about calming the frightened children. Which nursing intervention is most appropriate to achieve the goal of calming the frightened children?

  1. Tell the children that the physicians are competent.
  2. Assure the children that the nurses are caring.
  3. Explain that the PICU equipment is state of the art.
  4. Call the children’s parents to come into the PICU.

Question 8

Type: MCSA

A school-age child with congenital heart block codes in the emergency department (ED). The parents witness this and stare at the resuscitation scene unfolding before them. Which nursing intervention is most appropriate in this situation?

  1. Ask the parents to leave until the child has stabilized.
  2. Ask the parents to call the family to come into watch the resuscitation.
  3. Ask the parents to sit near the child’s face and hold her hand.
  4. Ask the parents to stand at the foot of the cart to watch.

Question 9

Type: MCSA

A child is admitted to the neonatal intensive care unit (NICU). The parents are concerned because they cannot stay for long hours to visit. Which statement made by the nurse is most appropriate?

  1. “One of you might take a leave of absence to be here more.”
  2. “Parents often feel this way; would you be interested in talking with others who have experienced having a child in the NICU?”
  3. “Perhaps the grandparents can make the visits for you.”
  4. “Why can’t you visit after work every day?”

Question 10

Type: MCSA

A school-age client is admitted to the pediatric intensive care unit (PICU) in critical condition after a motor vehicle accident. Which intervention should be implemented at this time?

  1. Maintain consistent caregivers.
  2. Turn the lights off at night.
  3. Keep alarm levels low.
  4. Consult the hospital play therapist.

CHAPTER 14

Question 1

Type: MCSA

A school-age client, recently diagnosed with asthma, also has a peanut allergy. The nurse instructs the family to not only avoid peanuts but also to carefully check food label ingredients for peanut products and to make sure dishes and utensils are adequately washed prior to food preparation. The mother asks why this is specific for her child. Based on the client’s history, the nurse knows that this client is at an increased risk for which complication?

  1. Urticaria
  2. Diarrhea
  3. Anaphylaxis
  4. Headache

Question 2

Type: MCSA

While teaching the parents of a newborn about infant care and feeding, which instruction by the nurse is the most appropriate?

  1. Delay supplemental foods until the infant is 4 to 6 months old.
  2. Delay supplemental foods until the infant reaches 15 pounds or greater.
  3. Begin diluted fruit juice at 2 months of age, but wait three to five days before trying a new food.
  4. Add rice cereal to the nighttime feeding if the infant is having difficulty sleeping after 2 months of age.

Question 3

Type: MCSA

During a 4-month-old’s well-child check, the nurse discusses introduction of solid foods into the infant’s diet and concerns for foods commonly associated with food allergies. Due to allergies, which foods will the nurse instruction the parents to avoid until after 1 year of age?

  1. Strawberries, eggs, and wheat
  2. Peas, tomatoes, and spinach
  3. Carrots, beets, and spinach
  4. Squash, pork, and tomatoes

Question 4

Type: MCSA

The mother of a toddler is concerned because her child does not seem interested in eating. The child is drinking five to six cups of whole milk per day and one cup of fruit juice. When the weight-to-height percentile is calculated, the child is in the 90th to 95th percentile. What is the best advice the nurse can provide to the mother?

  1. Eliminate the fruit juice from the child’s diet.
  2. Offer healthy snacks, presented in a creative manner, and let the child choose what he wants to eat without pressure from the parents.
  3. Change from whole milk to 2 percent milk and decrease milk consumption to three to four cups per day and the fruit juice to a half cup per day, offering water if the child is still thirsty in between.
  4. Make sure that the child is getting adequate opportunities for exercise, as this will increase his appetite and help lower the child’s weight-to-height percentile.

Question 5

Type: MCSA

A nurse is talking to the mother of an exclusively breast-fed African American 3-month-old infant who was born in late fall. Which supplement will the nurse recommend for this infant?

  1. Iron
  2. Vitamin D
  3. Fluoride
  4. Calcium

Question 6

Type: MCSA

The nurse is teaching the parents of a 4-month-old infant about good feeding habits. The nurse emphasizes the importance of holding the baby during feeding and not letting the infant go to sleep with the bottle. Which disorder is associated with propped feedings and going to sleep with the bottle?

  1. Otitis media
  2. Aspiration
  3. Malocclusion problems
  4. Sleeping disorders

Question 7

Type: MCMA

The parents of a toddler are concerned about their child’s finicky eating habits. While counseling the parents, which statements by the nurse are the most appropriate?

Standard Text: Select all that apply.

  1. “The child is experiencing physiologic anorexia, which is normal for this age group.”
  2. “A general guideline for food quantity at a meal is one-quarter cup of each food per year of age.”
  3. “It is more appropriate to assess a toddler’s nutritional demands over a 1-week period rather than a 24-hour one.”
  4. “Nutritious foods should be made available at all times of the day so that she is able to ‘graze’ whenever she is hungry.”
  5. “The toddler should drink 16 to 24 ounces of milk daily.”

Question 8

Type: MCSA

The nurse is providing nutritional guidance to the parents of a toddler. Which comment by the parent would prompt the nurse to provide additional education?

  1. “I should not give my child raw oysters.”
  2. “It is safe to leave my meat red in the center as long as there are no juices running.”
  3. “We always wash our hands well before any food preparation.”
  4. “We use separate utensils for preparing raw meat and preparing fruits, vegetables, and other foods.”

Question 9

Type: MCSA

During a well-child physical, an adolescent female has a normal history and physical except for an excessive amount of tooth enamel erosion, a greater-than-normal number of filled cavities, and calluses on the back of her hand. Her body mass index is in the 50th to 75th percentile for her age. Which disorder is the nurse concerned about based on the assessment findings?

  1. Anorexia nervosa
  2. Kwashiorkor
  3. Bulimia nervosa
  4. Marasmus.

Question 10

Type: MCSA

The nurse is instructing a parent of a newborn on the foods that are to be started based on age. The nurse instructs the parent that the first food given to a newborn is rice cereal. What statement by the parent suggests appropriate understanding of the next food that can be introduced?

  1. “Chicken can be given next.”
  2. “Eggs can be given next.”
  3. “Fruits should be given next.”
  4. “Whole milk should be started.”

CHAPTER 15

Question 1

Type: MCMA

The nurse is admitting a school-age Vietnamese client who hit a parked car while riding a bike. The child has a fracture of the left radius and femur in addition to a fractured orbit. The child is stoic and denies pain. Which nursing actions are most appropriate in this situation?

Standard Text: Select all that apply.

  1. Use the FLACC scale to determine the child’s pain level.
  2. Tell the child to ring the call bell if the leg starts hurting.
  3. Administer pain medication now and continue on a regular basis.
  4. Ask the child’s parents to notify the nurse if the child complains of pain.
  5. Use the NIPS scale to determine the child’s pain level.

Question 2

Type: MCSA

During the nurse’s initial assessment of a school-age child, the child reports a pain level of 6 out of 10. The child is lying quietly in bed watching television. Which action by the nurse is most appropriate?

  1. Administer prescribed analgesic.
  2. Ask the child’s parents if they think the child is hurting.
  3. Reassess the child in 15 minutes to see if the pain rating has changed.
  4. Do nothing, since the child appears to be resting.

Question 3

Type: MCSA

A school-age client has been receiving morphine every two hours for postoperative pain as ordered. The medication relieves the pain for approximately 90 minutes, and then the pain returns. Which action by the nurse is the most appropriate?

  1. Tell the child that pain medication cannot be administered more frequently than every two hours.
  2. Reposition the child and quietly leave the room.
  3. Inform the parents that the child is dependent on the medication.
  4. Call the healthcare provider to see if the child’s orders for pain medication can be changed.

Question 4

Type: MCSA

The nurse is working in a pediatric surgical unit. In discussing patient-controlled analgesia (PCA) in a preoperative parental meeting, which client would be a candidate for PCA?

  1. Developmentally delayed 16-year-old, postoperative bone surgery
  2. 5-year-old, postoperative tonsillectomy
  3. 10-year-old who has a fractured femur and concussion from a bike accident
  4. 12-year-old, postoperative spinal fusion for scoliosis

Question 5

Type: MCSA

A toddler is hospitalized with a fractured femur. In addition to pain medication, which will best provide pain relief for this child?

  1. Parents’ presence at the bedside
  2. Age-appropriate toys
  3. Deep-breathing exercises
  4. Videos for the child to watch

Question 6

Type: MCSA

The nurse is caring for a toddler client in the postoperative period. Which pain assessment tool is most appropriate for this client?

  1. FLACC Behavioral Pain Assessment Scale
  2. FACES pain scale
  3. Oucher scale
  4. Poker-chip tool

Question 7

Type: MCSA

A hospitalized toddler-age client needs to have an IV restarted. The child begins to cry when carried into the treatment room by the mother. Which nursing diagnosis is most appropriate?

  1. Ineffective Individual Coping Related to an Invasive Procedure
  2. Anxiety Related to Anticipated Painful Procedure
  3. Fear Related to the Unfamiliar Environment
  4. Knowledge Deficit of the Procedure

Question 8

Type: MCSA

A parent asks the nurse if there is anything that can be done to reduce the pain that his 3-year-old experiences each morning when blood is drawn for lab studies. Which intervention would the nurse implement based on the parent’s concern?

  1. Intravenous sedation 15 minutes prior to the procedure
  2. EMLA cream (lidocaine 2.5% and prilocaine 2.5%) applied to skin at least one hour prior to the procedure
  3. Use of guided imagery during the procedure
  4. Use of muscle-relaxation techniques

Question 9

Type: MCSA

As an advocate for the child undergoing bone-marrow aspiration, which intervention would the nurse suggest to decrease the pain experienced due to the procedure?

  1. General anesthesia
  2. Conscious sedation
  3. Intravenous narcotics ten minutes before the procedure
  4. Oral pain medication for discomfort after the procedure

Question 10

Type: MCSA

A school-age client is being discharged from the outpatient surgical center. Which statement by the parent would indicate the need for further teaching?

  1. “I can expect my child to have some pain for the next few days.”
  2. “I will plan to give my child pain medicine around the clock for the next day or so.”
  3. “Since my child just had surgery today, I can expect the pain level to be higher tomorrow.”
  4. “I will call the office tomorrow if the pain medicine is not relieving the pain.”

CHAPTER 16

Question 1

Type: MCSA

A nurse is providing information to a group of new mothers. Which statement best explains why newborns and young infants are more susceptible to infection?

  1. “They havehigh levels of maternal antibodies to diseases to which the mother has been exposed.”
  2. “They havepassive transplacental immunity from maternal immunoglobulin G.”
  3. “They haveimmune systems that are not fully mature at birth.”
  4. “They havebeen exposed to microorganisms during the birth process.”

Question 2

Type: MCSA

The nurse is discussing ways to treat fever in the home environment to a group of parents in the community.  Which statement is appropriate for the nurse to include in the presentation?

  1. “Ibuprofen is the only effective means to reduce fever.”
  2. If the child requires more than one dose of acetaminophen antibiotics are needed.”
  3. “Purchase a new bottle of acetaminophen for your newborn because it will have recommended medication concentration.”
  4. “It is not necessary to follow the recommendations on the bottle of ibuprofen as this will not prevent an overdose for your child.”

Question 3

Type: MCSA

The nurse prepares the second diphtheria, tetanus toxoid, and acellular pertussis (DTaP) and second inactivated polio vaccine (IPV) immunization injections for an infant who is 4 months old. The nurse may also give which of immunizations during the same well-child-care appointment?

  1. Var (varicella)
  2. TIV (influenza)
  3. MMR (measles, mumps, rubella)
  4. Haemophilus influenza type B (HIB)

Question 4

Type: MCSA

A mother refuses to have her child be immunized with measles, mumps, and rubella (MMR) vaccine because she believes that letting her infant get these diseases will help him fight off other diseases later in life. Which response by the nurse is most appropriate?

  1. Honor her request because she is the parent.
  2. Explain that antibodies can fight many diseases.
  3. Tell her that not immunizing her infant may protect pregnant women.
  4. Explain that if her child contracts measles, mumps, or rubella, there could be very serious and permanent complications from these diseases.

Question 5

Type: MCSA

A parent reports that her school-age child, who has had all recommended immunizations, had a mild fever one week ago and now has bright red cheeks and a lacy red maculopapular rash on the trunk and arms. Which disease process does the nurse suspect based on the parent’s description?

  1. Chicken pox (varicella)
  2. German measles (rubella)
  3. Roseola (exanthem subitum)
  4. Fifth disease (erythema infectiosum)

Question 6

Type: MCSA

The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis) immunization for a 6-month-old infant. To administer this injection safely, the nurse chooses which needle, size and length, injection type, and injection site?

  1. 25-gauge, 5/8-inch needle; IM (intramuscular); anterolateral thigh.
  2. 22-gauge, 1/2-inch needle; IM (intramuscular); ventrogluteal.
  3. 25-gauge, 5/8-inch needle; ID (intradermal); deltoid.
  4. 25-gauge, 3/4-inch needle; SQ (subcutaneous); anterolateral thigh.

Question 7

Type: MCSA

Reducing the number of preventable childhood illnesses is a major national goal in Healthy People 2020. What will the school nurse teach families regarding immunizations in order to reach this goal?

  1. A minor illness with a low-grade fever is a contraindication to receiving an immunization according to Healthy People 2020.
  2. Vaccines should be given one at a time for optimum active immunity in the prevention of illness and disease.
  3. Premature infants and low-birth-weight infants should receive half doses of vaccines for protection from communicable diseases.
  4. It is important to maintain vaccination coverage for recommended vaccines in early childhood and to maintain them through kindergarten.

Question 8

Type: MCSA

A toddler client with a fever is prescribed amoxicillin clavulanate 250 mg/5 cc three times daily by mouth × 10 days for otitis media. Which teaching point will guard against antibiotic resistance to the disease process?

  1. Administer a loading dose for the first dose.
  2. Measure the prescribed dose in a household teaspoon.
  3. Give the antibiotic for the full 10 days.
  4. Stop the antibiotic if the child is afebrile.

Question 9

Type: MCSA

The hospital has just provided its nurses with information about biologic threats and terrorism. After completing the course, a group of nurses is discussing its responsibility in relation to bioterrorism. Which statement by the nurse indicates a correct understanding of the concepts presented?

  1. It is important toseparate clients according to age and illness to prevent the spread of disease.”
  2. It is important to dispose blood-contaminated needles in the lead-lined container.”
  3. I willnotify the Centers for Disease Control (CDC) if a large number of persons with the same life-threatening infection present to the emergency room.”
  4. I willinitiate isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA).”

Question 10

Type: MCMA

The school nurse is trying to prevent the spread of a flu virus through the school. Which infection-control strategies can be employed to prevent the spread of the flu virus?

Standard Text: Select all that apply.

  1. Teaching parents safe food preparation and storage
  2. Withholding immunizations for children with compromised immune systems
  3. Sanitizing toys, telephones, and door knobs to kill pathogens
  4. Separating children with infections from children who are well
  5. Teaching children to wash their hands after using the bathroom

CHAPTER 17

Question 1

Type: MCSA

Concerned parents call the school nurse because of changes in their 15-year-old adolescent’s behavior. Which behavior would the nurse indicate as indicative of adolescent substance abuse?

  1. Buying baggy, oversized clothing at thrift shops and dying her hair black
  2. Becoming very involved with friends and in activities related to the basketball team that she is on; never seeming to be home; and, when she is home, preferring to be in her room with the door shut
  3. Receiving numerous detentions lately from teachers for sleeping in class
  4. Becoming very moody, dramatically crying and weeping one minute and then being cheerful and excited the next

Question 2

Type: MCSA

During a well-child exam, the parents of a preschool-age child inform the nurse that they are thinking of buying a television for their child’s bedroom and ask for advice as to whether this is appropriate. Which response by the nurse is the most appropriate?

  1. “Research has shown that children with a television in their bedroom spend significantly less time playing outside than other children, and physical inactivity in children has been linked to many chronic diseases such as obesity and type 2 diabetes.”
  2. “Research has shown that watching educational television shows improves a child’s performance in school.”
  3. “Don’t buy a television for your child’s room; he is much too young for that.”
  4. “It is okay for children to have a television in their room as long as you limit the amount of time they watch it to less than two hours per day.”

Question 3

Type: MCSA

A high school student calls to ask the nurse for advice on how to care for a new navel piercing. Which response by the nurse is the most appropriate?

  1. “Apply warm soaks to the area for the first two days to minimize swelling.”
  2. “Do not move or turn the jewelry for the first three days.”
  3. “Avoid contact with another person’s bodily fluids until the area is well healed.”
  4. “Apply lotion to the area, rubbing gently, to prevent skin from becoming dry and irritated.”

Question 4

Type: MCSA

While working at a weekend “free clinic,” the nurse is assessing a toddler when the mother of the child confides that it has been very difficult providing for her family of four children on her limited budget. She is not sure that she has enough money to buy food for the rest of the month and the antibiotic that is needed for the child’s ear infection. Which intervention would be the most beneficial for this family?

  1. Giving the mother enough free samples of the antibiotic for the recommended course of treatment
  2. Putting the mother in contact with a local agency that provides food on a regular basis to needy families and helps them access other resources in the community
  3. Talking with the mother about the factors that increase a child’s risk of acquiring an ear infection
  4. Talking with the mother about the importance of a balanced diet in the growth and development of children and providing her with a list of inexpensive, nutritious foods

Question 5

Type: MCSA

A school-age child has been seen in the pediatric clinic three times in the last two months for complaints of abdominal pain. Physical exam and all ordered lab work have been normal. Which question by the nurse would most likely help determine the etiology of the child’s abdominal pain?

  1. “Have there been any changes in your child’s school or home life recently?”
  2. “How many meals does your child eat each day?”
  3. “Are your child’s immunizations up to date?”
  4. “Has your child had any fevers or viral illnesses in the last three months?”

Question 6

Type: MCSA

A recently divorced mother who must return to work is concerned about the effects of placing her child in day care full time. In counseling the mother, which factor does the nurse share as the most influential in determining whether or not day care has a positive or negative effect on the child?

  1. The ratio of day-care workers to children
  2. The closeness of the parent–child relationship
  3. The amount of time that the children spend playing outside
  4. The cleanliness of the facility

Question 7

Type: MCSA

When examining a toddler-age child during a well-child physical, which assessment is the priority?

  1. Visual acuity
  2. Helmet use
  3. Risk of lead exposure
  4. Whether household drinking water contains fluorine

Question 8

Type: MCSA

The nurse is conducting a health promotion class for adolescents. In counseling an adolescent about lifestyle choices, what should the adolescent eliminate in order to decrease the risk of the most preventable cause of adult death?

  1. Alcohol use
  2. Obesity
  3. Tobacco use
  4. Cocaine use

Question 9

Type: MCSA

The school nurse is planning a smoking-prevention program for middle school students. Which intervention is most likely to be effective in preventing middle school children from smoking?

  1. Having a local high school basketball star come to talk to the students about the importance of not smoking
  2. Having the school’s biology teacher demonstrate the pathophysiology of the effects of smoking tobacco on the body
  3. Developing colorful posters with catchy slogans and placing them all over the school
  4. Having a pledge campaign with prizes awarded, during which students sign contracts saying that they will not use tobacco products

Question 10

Type: MCMA

While the nurse is conducting the history of a school-age child, the parents admit to owning firearms. Which safety measures are appropriate to include in the teaching plan for this family?

Standard Text: Select all that apply.

  1. Using a gun lock on all firearms in the house
  2. Taking the child to a shooting range for lessons on how to use a gun properly
  3. Storing the guns and ammunition in separate places
  4. Keeping all the guns in a locked cabinet
  5. Explaining the dangers of a gun to the child and telling her explicitly to never touch it

CHAPTER 18

Question 1

Type: MCSA

A nurse is taking care of four different pediatric clients. Which client poses the great risk for dehydration?

  1. 15-year-old working out in a weight room for an hour before football practice
  2. 10-year-old playing baseball outdoors in 85 degree heat
  3. 5-year-old refusing to eat because of a virus
  4. A newborn under a radiant warmer for an hour after the first bath

Question 2

Type: MCSA

The nurse is assessing an infant brought to the clinic with diarrhea. The infant is alert but has dry mucous membranes. Which other sign indicates the infant is still in the early or mild stage of dehydration?

  1. Tachycardia
  2. Bradycardia
  3. Increased blood pressure
  4. Decreased blood pressure

Question 3

Type: MCSA

A 1-month-old client is admitted to the emergency room with severe diarrhea. Which assessment suggests the client is severely dehydrated?

  1. Skin moist and flushed; mucous membranes dry
  2. Low specific gravity of urine; skin color pale
  3. Fontanels depressed; capillary refill greater than three seconds
  4. High specific gravity of urine; moist mucous membranes

Question 4

Type: MCSA

The nurse is expecting the admission of a child with severe isotonic dehydration. Which intravenous fluid should the nurse anticipate the practitioner to order initially to replace fluids?

  1. D5W
  2. 0.9 percent Normal Saline (NS)
  3. Albumin
  4. D5 0.2 percent (¼) Normal Saline

Question 5

Type: MCSA

Parents of an infant with slow weight gain ask the nurse if they can feed their baby a highly concentrated formula. Which response by the nurse is the most appropriate?

  1. “A higher-concentrated formula could lead to dehydration because of high sodium content; let’s discuss other strategies.”
  2. “An undiluted formula concentrate could be given to help the child gain weight; let’s look at brands.”
  3. “Evaporated milk could be given to the infant instead of the current formula you’re using.”
  4. “A higher-concentrated formula could be given for daytime feedings; let’s work on a schedule.”

Question 6

Type: MCSA

The nurse finishes a parent-teaching session on preventing heat-related illnesses for children who exercise. Which statement by a parent indicates understanding of preventive techniques taught?

  1. Hydration should occur at the end of an exercise session.
  2. Water is the drink of choice to replenish fluids.
  3. Wearing dark clothing during exercise is recommended.
  4. During activity, stop for fluids every 15–20 minutes.

Question 7

Type: FIB

A child is being treated for dehydration with intravenous fluids. The child currently weighs 13 kg and is estimated to have lost 7 percent of the normal body weight. The nurse is double-checking the IV rate the practitioner has ordered. The formula the practitioner used was for maintenance fluids: 1000 mL for 10 kg of body weight plus 50 cc for every kg over 10 for 24 hours. Replacement fluid is the percentage of lost body weight × 10 per kg of body weight. According to the calculation for maintenance plus replacement fluid, this child’s hourly IV rate for 24 hours should be ____ mL.

Standard Text: Round the answer to the nearest whole number.

Question 8

Type: MCSA

In the morning, a nurse receives a report on four pediatric clients who have some form of fluid-volume excess. Which client should the nurse assess first?

  1. A client with periorbital edema, normal respiratory rate
  2. A client with tachypnea and pulmonary congestion
  3. A client with dependent and sacral edema, regular pulse
  4. A client with hepatomegaly, normal respiratory rate

Question 9

Type: MCSA

The nurse is caring for a child on bed rest who has severe edema in a left lower leg due to blocked lymphatic drainage. Which is the priority diagnosis for this child?

  1. Risk for Imbalanced Nutrition: Less Than Body Requirements
  2. Risk for Impaired Skin Integrity
  3. Risk for Altered Body Image
  4. Risk for Activity Intolerance

Question 10

Type: MCSA

A nurse is planning care for a child with hyponatremia. The nurse, delegating care of this child to a new RN on the pediatric unit, cautions the new nurse to be especially alert for which condition in the child?

  1. Seizures
  2. Bradycardia
  3. Respiratory distress
  4. Hyperthermia

CHAPTER 19

Question 1

Type: MCSA

A nurse is assessing infants for visually related developmental milestones. Which infant is showing a delay in meeting an expected milestone?

  1. 4-month-old who has a social smile
  2. 8-month-old who has just begun to inspect her own hand
  3. 12-month-old who stacks blocks
  4. 7-month-old who picks up a raisin by raking

Question 2

Type: MCSA

A neonate has been diagnosed with a herpes simplex viral infection of the eye. Which medication will the nurse prepare to administer?

  1. Fluoroquinolone eye drops or ointment
  2. Intravenous penicillin
  3. Oral erythromycin
  4. Parenteral acyclovir (Zovirax) and vidarabine (VIRA-A) ophthalmic ointment

Question 3

Type: MCSA

The nurse suspects that an infant has a visual disorder caused by abnormal musculature. Which test will the nurse perform to detect this disorder?

  1. A cover/uncover test
  2. An ophthalmologic exam
  3. A vision-acuity exam
  4. A pupil-reaction-to-light test

Question 4

Type: MCSA

The nurse is caring for four clients. Which client has the highest risk of developing retinopathy of prematurity?

  1. 30-week-gestation infant who was in an Oxy-Hood for 12 hours and weighed 1800 grams.
  2. 32-week-gestation infant who needed no oxygen and weighed 1850 grams.
  3. 28-week-gestation infant who has been on long-term oxygen and weighed 1400 grams.
  4. 28-week-gestation infant who was on short-term oxygen and weighed 1420 grams.

Question 5

Type: MCSA

A nurse is caring for a visually impaired 20-month-old who has not begun to walk. Which nursing diagnosis is the most appropriate for this client?

  1. Delayed growth and development
  2. Impaired physical mobility
  3. Self-care deficit
  4. Impaired home maintenance

Question 6

Type: MCSA

A nurse is caring for a visually impaired school-age child. Which nursing intervention is the highest priority for this child during the admission process?

  1. Explaining playroom policies
  2. Orienting the child to where furniture is placed in the room
  3. Letting the child touch equipment that will be used during the hospitalization
  4. Taking the child on a tour of the unit

Question 7

Type: MCSA

An infant is diagnosed with acute otitis media. Which intervention is most appropriate for the nurse to teach the infant’s parents?

  1. Keep the baby in a flat lying position during sleep.
  2. Administer acetaminophen (Tylenol) to relieve discomfort.
  3. Administer a decongestant.
  4. Place baby to sleep with a pacifier.

Question 8

Type: MCMA

The nurse teaches parents how to care for their child who has tympanostomy tubes inserted. Which actions by the parents indicate appropriate understanding of the teaching session?

Standard Text: Select all that apply.

  1. Encouraging the child to drink generous amounts of fluids
  2. Administering a decongestant for one to two weeks following surgery
  3. Restricting the child to quiet activities after surgery
  4. Limiting diet to soft, bland foods
  5. Avoiding getting water in ears during bath time

Question 9

Type: MCSA

Which action by the nurse can assist a child who has a mild hearing loss and reads lips to adapt to hospitalization?

  1. Speaking directly to the parents for communication
  2. Speaking in a loud voice while facing the child
  3. Using a picture board as the main means of communication
  4. Touching the child lightly before speaking

Question 10

Type: MCSA

A school-age child has epistaxis. Which intervention by the school nurse is the most appropriate?

  1. Tilting the child’s head forward, squeezing the nares below the nasal bone, and applying ice to the nose
  2. Tilting the child’s head back, squeezing the bridge of the nose, and applying a warm, moist pack to the nose
  3. Lying the child down and applying no pressure, ice, or warm pack
  4. Immediately packing the nares with a cotton ball soaked with Neo-Synephrine

CHAPTER 20

Question 1

Type: MCSA

A child is showing signs of acute respiratory distress. Which position will the nurse place this child?

  1. Upright
  2. Side-lying
  3. Flat
  4. In semi-Fowler’s

Question 2

Type: MCSA

A nurse delegates the task of neonatal vital-sign assessment to a nurse technician. Which instruction will the nurse give to the technician prior to assign care?

  1. Report any neonate using abdominal muscles to breathe.
  2. Report any neonate with apnea for 10 seconds.
  3. Count respirations for 15 seconds and multiply by 4 to get the rate for 1 minute.
  4. Report any neonate with a breathing pause that lasts 20 seconds or longer.

Question 3

Type: MCSA

A child is admitted to the hospital with the diagnosis of laryngotracheobronchitis (LTB). Which nursing intervention is the priority for this child?

  1. Administer nebulized epinephrine and oral or IM dexamethasone.
  2. Administer antibiotics and assist with possible intubation.
  3. Swab the throat for a throat culture.
  4. Obtain a sputum specimen.

Question 4

Type: MCSA

The nurse is teaching a group of mothers of infants about the benefits of immunization. Which immunization will the nurse teach to the mothers that can assist in preventing the life-threatening disease epiglottitis?

  1. Measles, mumps, and rubella (MMR)
  2. Haemophilus influenzae type B (HIB)
  3. Hepatitis B
  4. Polio

Question 5

Type: MCSA

A nurse is assessing a neonate. Which assessment finding indicates that the neonate’s respiratory status is worsening?

  1. Acrocyanosis
  2. Arterial CO2of 40
  3. Periorbital edema
  4. Grunting respirations with nasal flaring

Question 6

Type: MCSA

Which nursing diagnosis is most appropriate for an infant with acute bronchiolitis due to respiratory syncytial virus (RSV)?

  1. Activity Intolerance
  2. Decreased Cardiac Output
  3. Pain, Acute
  4. Tissue Perfusion, Ineffective (peripheral)

Question 7

Type: MCSA

A child is admitted to the hospital with pneumonia. The child’s oximetry reading is 88 percent upon admission to the pediatric floor. Which is the priority nursing intervention for this child?

  1. Obtain a blood sample to send to the lab for electrolyte analysis.
  2. Begin oxygen per nasal cannula.
  3. Medicate for pain.
  4. Begin administration of intravenous fluids.

Question 8

Type: MCSA

The practitioner changes the medications for the child with asthma to salmeterol (Serevent). The mother asks the nurse what this drug will do. The nurse explains that salmeterol (Serevent) is used to treat asthma because the drug produces which characteristic?

  1. Decreases inflammation
  2. Decreases mucous production
  3. Controls allergic rhinitis
  4. Dilates the bronchioles

Question 9

Type: MCSA

Following parental teaching, the nurse is evaluating the parents’ understanding of environmental control for their child’s asthma management. Which statement by the parents’ indicates appropriate understanding of the teaching?

  1. “We will replace the carpet in our child’s bedroom with tile.”
  2. “We’re glad the dog can continue to sleep in our child’s room.”
  3. “We’ll be sure to use the fireplace often to keep the house warm in the winter.”
  4. “We’ll keep the plants in our child’s room dusted.”

Question 10

Type: MCSA

A newborn is suspected of having cystic fibrosis. As the child is being prepared for transfer to a pediatric hospital, the mother asks the nurse which symptoms made the practitioner suspect cystic fibrosis. Which response by the nurse is the most appropriate?

  1. Steatorrheic stools
  2. Constipation
  3. Meconium ileus
  4. Rectal prolapse

AND MUCH MORE