NURSING CARE OF CHILDREN –
COMPREHENSIVE REVIEW
Dr. Shannon Henry, DNP, MHR,
CPNP-PC
The nurse is talking to a group of parents about different types of play in which
children engage. Which statement made by a parent would indicate a correct
understanding of the teaching?
A.
“Parallel-play children borrow and lend play materials and sometimes attempt to
control who plays in the group.”
B.
“In associative play, children play independently but among other children.”
C.
“During onlooker play, children play alone with toys different from those used by
other children in the same area.”
D.
“Cooperative play is organized, and children play in a group with other
children.”
Correct Answer Feedback -D
Play in which children borrow and lend play materials and attempt to control who
plays in the group is known as associative play. Parallel play occurs when children
play independently but among other children. Onlooker play is described as play in
which children watch but make no attempt to enter into play with other children.
Cooperative play is play that is organized; children play in a group with other
children and plan activities for purposes of accomplishing an end.
Which best describes Piaget’s cognitive stage of formal operations?
A.
Deductive and abstract reasoning
B.
Inductive reasoning and beginning logic
C.
Transductive reasoning and egocentrism
D.
Cause-and-effect reasoning and object permanence
Correct Answer Feedback-A
Piaget’s cognitive stage of formal operations occurs between the ages of 11 and 15;
deductive and abstract reasoning are developed. Inductive reasoning and beginning
logic begin in the concrete operations stage between the ages of 7 and 11.
Transductive reasoning and egocentrism occur in the preoperational stage at age 2 to
7. Cause-and-effect and object permanence occur during the sensorimotor stage from
birth to 2 years.
Parents are often confused by the terms growth and development and use the terms
interchangeably. Based on the nurse’s knowledge of growth and development, the
most appropriate explanation of development is
A.
a child grows taller all through early childhood.
B.
a child learns to throw a ball overhand.
C.
a child’s weight triples during the first year.
D.
a child’s brain increases in size until school age.
Correct Answer Feedback -B
Development is the mental and cognitive attainment of skills. Growth is the increase in
physical size—both height and weight.
A nurse is knowledgeable about both growth and development. Which assessment
finding indicates the child’s development is on target?
A.
The child has not gained weight for 3 months.
B.
The child can throw a large ball but not a small ball.
C.
The child’s arms are the most rapidly growing part of the child’s body.
D.
The child can pull herself or himself to her or his feet before the child is able to
sit steadily.
Correct Answer Feedback -B
Development is continuous and proceeds from gross to refined, so children whose
development is on target can usually throw large objects before small ones. Not
gaining weight for 3 months is an abnormal assessment finding; it would indicate that
the child’s development may not be on target. In children, the legs are normally the
most rapidly growing part of the body; if this is not the case, the child’s development
may not be on target. A child whose development is on target can sit steadily before
pulling herself or himself up to her or his feet.
Based on Piaget’s theory of cognitive development, what is one basic concept a child
is expected to attain during the first year of life?
A.
If an object is hidden, that does not mean that it is gone.
B.
He or she cannot be fooled by changing shapes.
C.
Parents are not perfect.
D.
Most procedures can be reversed.
Correct Answer Feedback -A
Part of learning permanence is learning that although an object is no longer visible, it
still exists. At 1 year of age, a child may not be able to understand that an object
that changes shape is still the same object. Understanding conservation occurs
between ages 7 and 11 years.
A nurse is examining a toddler and is discussing with the mother psychosocial
development according to Erikson’s theories. Based on the nurse’s knowledge of
Erikson, the most age-appropriate activity to suggest to the mother at this stage is to
A.
feed lunch.
B.
allow the toddler to start making choices about what to wear.
C.
allow the toddler to pull a talking-duck toy.
D.
turn on a TV show with bright colors and loud songs.
Correct Answer Feedback -B
A toddler is developing autonomy and is able to start making some choices about
what he or she can wear. A toddler is developing autonomy and focusing on doing
things for himself or herself and therefore would not want the mother to feed him or
her. The child is at the stage of autonomy versus shame and doubt, as defined by
Erikson. At this age, the mother should provide opportunities for the child to be active
and learn by experience and imitation. Providing toys the child can control will help
achieve this stage. A toddler might easily become overstimulated by images from TV
and loud sounds. Toddlers are more interested in manipulating and learning from
objects in the environment.
A preschool child watches a nurse pour medication from a tall, thin glass to a short,
wide glass. Which statement is appropriate developmentally for this age-group?
A.
The amount of medicine is less.
B.
The amount of medicine did not change, only its appearance.
C.
Pouring medicine makes the medicine hot.
D.
The glass changed shape to accommodate the medicine.
Correct Answer Feedback-A
A preschool child does not have the ability to understand the concept of conservation.
This concept is not developed until school age. Understanding conservation occurs
between 7 and 10 years of age, when a child begins to realize that physical factors,
such as volume, weight, and number, remain the same even though outward
appearances are changed. Children are able to deal with a number of different
aspects of a situation simultaneously. This is not an expected response by a child. A
preschool child will not typically believe the glass changed shape to accommodate
the medicine but rather that the amount of medicine is less in the short, wide glass.
During their school-age years, children best understand concepts that can be seen or
illustrated. The nurse knows this type of thinking is termed as
A.
concrete operations.
B.
preoperational.
C.
school-age rhetoric.
D.
formal operations.
Correct Answer Feedback-A
Black-and-white reasoning involves a situation in which only two alternatives are
considered, when in fact there are additional options. Preoperational thinking is
concrete and tangible. During the school-age years, children deal with thoughts and
learn through observation. They do not have the ability to do abstract reasoning and
learn best with illustration. Thought at this time is dominated by what the school-age
child can see, hear, or otherwise experience. School-age rhetoric simply refers to the
type of ideas that arise out of the years children attend school. Formal operations
are characterized by the adaptability and flexibility that occurs during the
adolescent years.
Which statement helps explain the growth and development of children?
A.
Development proceeds at a predictable rate.
B.
The sequence of developmental milestones is predictable.
C.
Rates of growth are consistent among children.
D.
At times of rapid growth, there is also acceleration of development.
Correct Answer Feedback-B
There is a fixed, precise order to development. There are periods of both
accelerated and decelerated growth and development. Each child develops at his or
her own rate. Physical growth and development proceed at differing rates.
The nurse is discussing toddler development with a parent. Which intervention will
foster the achievement of autonomy in the toddler?
A.
Helping the toddler complete tasks
B.
Providing opportunities for the toddler to play with other children
C.
Helping the toddler learn the difference between right and wrong
D.
Encourage the toddler to do things for self when capable of doing them
Correct Answer Feedback-D
To successfully achieve autonomy, the toddler needs to have a sense of
accomplishment. This does not occur if parents complete tasks for the toddler. Children
at this age engage in parallel play. This will not foster autonomy. This concept is too
advanced for toddlers and will not contribute to autonomy. Toddlers have an
increased ability to control their bodies, themselves, and the environment. Autonomy
develops when children complete tasks of which they are capable.
During a well-baby visit, the parents of a 12 month old ask the nurse for advice on
age-appropriate toys for their child. Based on the nurse’s knowledge of
developmental levels, the most appropriate toys to suggest are (Select all that apply.)
A.
push-pull toys.
B.
toys with black-white patterns.
C.
pop-up toys, such as a Jack-in-the-box.
D.
soft toys that can be put in the mouth.
E.
toys that pop apart and go back together.
Correct Answer Feedback-A,C,E
Both gross and fine motor skills are becoming more developed and children at this
age enjoy toys that can help refine these skills. Children at this age enjoy more
colorful toys. Children at this age are less interested in placing toys in the mouth and
more interested in toys that can be manipulated.
The nurse is developing a teaching plan about preventing fetal exposure to
teratogens. The nurse should include which teratogenic agents or conditions? (Select all
that apply.)
A.
Acetaminophen (Tylenol)
B.
Isotretinoin (Accutane)
C.
Cocaine
D.
Hyperthermia
E.
Ethyl alcohol
F.
Phenytoin (Dilantin)
Correct Answer Feedback –B,C,D,E,F
Teratogens, agents that cause birth defects when present in the prenatal environment,
account for the majority of adverse intrauterine effects not attributable to genetic
factors. Types of teratogens include drugs (phenytoin [Dilantin], warfarin [Coumadin],
isotretinoin [Accutane]); chemicals (ethyl alcohol, cocaine, lead); infectious agents
(rubella, cytomegalovirus); physical agents (maternal ionizing radiation,
hyperthermia); and metabolic agents (maternal PKU). Many of these teratogenic
exposures and the resulting effects are completely preventable, such as ingestion of
alcohol resulting in fetal alcohol syndrome or fetal alcohol effects, which causes
severe birth defects, including cognitive impairment. The incidence of fetal alcohol
syndrome is estimated at 5.2 per 10,000 live births (American Academy of
Pediatrics, 2000).
The nurse is ready to begin a physical examination on an 8-month-old infant. The
child is sitting contentedly on his mother’s lap, chewing on a toy. What should the
nurse do FIRST?
A.
Elicit reflexes.
B.
Auscultate heart and lungs.
C.
Examine eyes, ears, and mouth.
D.
Examine head, systematically moving toward feet.
Correct Answer Feedback -B
This may disturb or upset the child, making auscultation and the remainder of the
physical examination difficult. Auscultation should be performed while the child is
quiet. This may disturb or upset the child, making auscultation and the remainder of
the physical examination difficult. Although this is the way most physical examinations
proceed, the nurse should perform the assessment for a child in an order that moves
from least disturbing to most disturbing from the child’s perspective.
The nurse needs to give an injection in the deltoid to a 4-year-old child. The BEST
approach to use is to
A.
smile while giving the injection to help child relax.
B.
tell the child that you will be so quick that the injection will not even hurt.
C.
explain that the child will experience a little stick in the arm.
D.
explain with concrete terms, such as putting medicine under the skin.
Correct Answer Feedback-D
This is too abstract. The young child will not correlate a smile with relaxation.
Distraction techniques are more appropriate. The nurse does not know that the
injection will not hurt the child. Lying or distorting the truth is never appropriate. This
response will block trust, especially if the injection does hurt the child. The child may
visualize an actual stick being placed in the arm. Children at this age are very literal.
By using concrete terms the nurse helps the child understand what the nurse is going
to do.
The most consistent indicator of pain in infants is
A.
increased respirations.
B.
increased heart rate.
C.
clenching the teeth and lips.
D.
facial expression of discomfort.
Correct Answer Feedback-D
Respiratory pattern may be markedly variable in an infant in pain and thus is not a
consistent indicator of pain. Heart rate may initially decrease in some infants with
pain and then increase; thus it is not a consistent indicator of pain. Clenching the teeth
and lips are signs of pain often assessed in the toddler, not the infant. Facial
expression of discomfort is the most consistent behavioral manifestation of pain in
infants.
The nurse is caring postoperatively for an 8-year-old child with multiple fractures and
other trauma resulting from a motor vehicle injury. The child is experiencing severe
pain. An important consideration in managing the child’s pain is to
A.
give only an opioid analgesic at this time.
B.
increase the dosage of analgesic until the child is adequately sedated.
C.
plan a preventive schedule of pain medication around the clock.
D.
give the child a clock and explain when he or she can have pain medications.
Correct Answer Feedback-C
This is appropriate for the immediate pain but will not facilitate the more long-term
plan of pain management. The dosage of analgesic is increased until pain is
controlled, not until sedation is adequate. An around-the-clock administration strategy
should be used for a child recovering from trauma and surgery. This schedule will
help prevent low plasma levels of the drug, leading to breakthrough pain. The child
should be frequently assessed for pain, and medication doses titrated accordingly. It
is inappropriate to give a child a clock with instructions as to when pain medication
can be given, especially a child who has experienced a traumatic event.
A 6-year-old is hospitalized with a fractured femur. Based on the nurse’s knowledge
of opioid side effects, the nurse should include which actions in the patient’s plan of
care to prevent constipation? (Select all that apply.)
A.
Instruct the child to remain supine while in bed.
B.
Administer docusate sodium (Colace).
C.
Encourage fluid intake.
D.
Encourage the child to eat fruit.
E.
Administer diphenhydramine (Benadryl).
Correct Answer Feedback-B,C,D
Administration of Colace, a stool softener, can help prevent constipation. Increased
fluid and fruit intake (high fiber content) can help prevent constipation. Increased
activity helps stimulate peristalsis. Diphenhydramine would not increase peristalsis or
prevent constipation.
When changing a dressing on the leg of a 16-year-old patient who suffered second
degree burn injuries, the nurse expects to observe which characteristics of pain
expression? (Select all that apply.)
A.
Stomping feet on the ground and screaming, “No.”
B.
Attempting to move leg out of reach of the nurse.
C.
Repeatedly stating, “You are hurting me.”
D.
Clinching fists and tensing arms in anticipation.
E.
Scooting away and asking parents to stop the nurse.
Correct Answer Feedback – C, D
Developmental characteristics of the adolescent’s response to pain include: less vocal
protest; less motor activity; more verbal expressions, such as “It hurts” or “You are
hurting me”; and increased muscle tension and body control. Stating “You are hurting
me” and muscle tension are expected responses to pain for the adolescent.
The nurse expects which characteristic of fine motor skills in a 5-month-old infant?
A.
Strong grasp reflex
B.
Neat pincer grasp
C.
Able to build a tower of two cubes
D.
Able to grasp object voluntarily
Correct Answer Feedback -D
A strong grasp reflect is characteristic of a 1-month-old infant. A neat pincer grasp is
characteristic of a 10-month-old infant. The ability to build a tower of 2 cubes is
characteristic of a 15-month-old infant. The ability to grasp objects voluntarily is
appropriate for a 5-month-old infant.
The nurse is assessing a 6-month-old infant who smiles, coos, and has a strong head
lag. The nurse should recognize that
A.
this assessment is normal.
B.
the child is probably cognitively impaired.
C.
developmental/neurologic evaluation is needed.
D.
the parent needs to work with the infant to stop head lag.
Correct Answer Feedback -C
A 6-month-old infant should have social interaction beyond smiling and cooing. The
child requires evaluation. The head lag should be almost gone by 4 months of age.
This child requires evaluation. The child requires evaluation before interventions can
be determined.
The nurse educator instructs a nursing student that according to Erikson, infancy is
concerned with acquiring a sense of
A.
trust.
B.
industry.
C.
initiative.
D.
separation.
Correct Answer Feedback -A
The task of infancy is the development of trust. Industry versus inferiority is the
developmental task of school-age children. Initiative versus guilt is the developmental
task of preschoolers. Separation occurs during the sensorimotor stage as described
by Piaget.
A parent of an 8-month-old infant tells the nurse that the baby cries and screams
whenever he or she is left with the grandparents. The nurse’s reply should be based
on knowledge that
A.
the infant is most likely spoiled.
B.
this is a normal reaction for this age.
C.
this is an abnormal reaction for this age.
D.
grandparents are not responsive to that infant.
Correct Answer Feedback-B
These are developmentally appropriate. The infant is experiencing stranger anxiety,
which is expected for this age child. These are developmentally appropriate. No
data have been shown to support this. This could also be separation anxiety from
being away from the parent.
At what age would the nurse advise parents to expect their infant to be able to say
“mama” and “dada” with meaning?
A.
4 months
B.
6 months
C.
0 months
D.
14 months
Correct Answer Feedback -C
Consonants are added to infant vocalizations. Babbling resembles one-syllable
sounds. At this age infants say sounds with meaning. This is late for the development
of sounds with meaning.
The parents of a 9-month-old infant tell the nurse that they are worried about their
baby’s thumb-sucking. What is the nurse’s BEST reply?
A.
A pacifier should be substituted for the thumb.
B.
Thumb-sucking should be discouraged by age 12 months.
C.
Thumb-sucking should be discouraged when the teeth begin to erupt.
D.
There is no need to restrain nonnutritive sucking during infancy.
Correct Answer Feedback -D
Evidence is inconclusive regarding whether a pacifier or thumb is better for satisfying
sucking needs. Thumb-sucking and the use of pacifier should be stopped after 4
years of age. Thumb-sucking and the use of pacifier should be stopped after 4 years
of age. Nonnutritive sucking reaches its peak at about 18 to 20 months of age.
The MOST appropriate recommendation for relief of teething pain is to instruct the
parents to
A.
rub gums with aspirin to relieve inflammation.
B.
apply hydrogen peroxide to gums to relieve irritation.
C.
give child a frozen teething ring to relieve inflammation.
D.
have child chew on a warm teething ring to encourage tooth eruption.
Correct Answer Feedback -C
Gums should not be rubbed with aspirin. It can be dangerous if the child aspirates
aspirin. Hydrogen peroxide would not be effective. Cold reduces inflammation and
should be used for relief of teething irritation. Cold, not warmth, reduces
inflammation.
The mother of a 3-month-old breastfed infant asks about giving her baby water since
it is summer and very warm. The nurse should recommend that
A.
fluids in addition to breast milk are not needed.
B.
water should be given if the infant seems to nurse longer than usual.
C.
water once or twice a day will make up for losses caused by environmental
temperature.
D.
clear juices would be better than water to promote adequate fluid intake.
Correct Answer Feedback-A
The child will nurse according to needs. Additional fluids are not necessary for the
breastfed baby. Supplemental water should not be given. It may cause water
intoxication. Supplemental water should not be given. It may cause water intoxication.
Clear juices do not provide sufficient caloric or nutrient intake and may interfere with
breastfeeding.
The parent of a 12-month-old infant says to the nurse, “He pushes the teaspoon right
out of my hand when I feed him. I cannot let him feed himself; he makes too much of
a mess.” The nurse’s BEST response is
A.
“It is important not to give into this kind of temper tantrum at this age. Simply
ignore the behavior and the mess.”
B.
“You need to try different types of utensils, bowls, and plates. Some are
specifically designed for young children.”
C.
“It is important to let him make a mess. Just try not to worry about it so much.”
D.
“Feeding himself will help foster his growth and development. Perhaps we can
discuss ways to make the messes more tolerable.”
Correct Answer Feedback-D
The child is developmentally ready for self-feeding. Ignoring the behavior and not
allowing the child to self-feed is not fostering the child’s development. The child is
developmentally ready for self-feeding. The parent should not force the use of the
spoon but should substitute finger foods. This response minimizes the parent’s concerns
about the mess created by self-feeding. At 12 months the child should be selffeeding. Since children this age eat primarily finger foods, it is useful to offer the
parent suggestions for keeping the mess to a minimum.
The parents of a 5-month-old girl complain to the nurse that they are exhausted
because she still wakes up as often as every 1 to 2 hours during the night. When she
awakens, they change her diaper, and her mother nurses her back to sleep. What
should the nurse suggest to help them deal with this problem?
A.
Putting her in parents’ bed to cuddle
B.
Beginning to put her to bed while still awake
C.
Letting her cry herself back to sleep
D.
Giving her a bottle of formula instead of breastfeeding her so often at night
Correct Answer Feedback-B
The nurse needs to discuss the issue of co-sleeping with parents. Having the infant in
bed with them may still interfere with their sleep. Parents need to develop bedtime
rituals that involve putting the child in bed when awake. If the child is put in bed
awake, she will be able to return to sleep more easily if she awakens at night.
Providing formula at night contributes to bottle-mouth caries.
A 4-month-old infant is brought to the clinic by his parents for a well-baby checkup.
What should the nurse include at this time concerning injury prevention?
A.
“Never shake baby powder directly on your infant because it can be aspirated
into his lungs.”
B.
“Do not permit your child to chew paint from window ledges because he might
absorb too much lead.”
C.
“When your baby learns to roll over, you must supervise him whenever he is on a
surface from which he might fall.”
D.
“Keep doors of appliances closed at all times.”
Correct Answer Feedback -C
This is appropriate guidance for a first-month appointment. This information should be
included at the 9-month visit when the infant is beginning to crawl and pull to a stand.
Rolling over from abdomen to back occurs between 4 and 7 months. This is the
appropriate anticipatory guidance for this age. This information should be included
at the 9-month visit when the infant is beginning to crawl and pull to a stand.
The exhausted parents of a 2-month-old infant with colic ask the nurse what is the
best method to promote comfort and sleep for the infant. The nurse’s initial action is to
A.
advise the mother to follow a milk-free diet for 3 to 5 days.
B.
take a thorough, detailed history of usual daily events.
C.
administer simethicone drops to provide relief from gas pains.
D.
explain that the parents need to stay calm so the infant will remain calm.
Correct Answer Feedback-B
The initial step in managing colic is to take a thorough, detailed history of the usual
daily events including: diet, time of day when child cries, presence of family
members, type of cry, etc. Before suggesting formula changes or medications to
relieve symptoms, a detailed history is needed. It is important that the nurse convey
an empathetic and compassionate attitude and reassure the parents that they are not
doing anything wrong.
A mother is bringing her 4-month-old infant into the clinic for a routine well-baby
check. The mother is exclusively breastfeeding. There are no other liquids given to the
infant. What vitamin does the nurse anticipate the provider will prescribe for this
infant?
A.
Vitamin B
B.
Vitamin D
C.
Vitamin C
D.
Vitamin K
Correct Answer Feedback-B
The American Academy of Pediatrics recommends that infants who are exclusively
breast-fed receive 400 international units (IU) of vitamin D daily in the first few days
of life and continued daily supplementation to decrease vitamin D deficiency. Vitamin
B is not needed. Vitamin C is not needed. Vitamin K is not needed.
The nurse should provide further teaching about sudden infant death syndrome (SIDS)
prevention when hearing the mother of an 8 week old make which statement? (Select
all that apply.)
A.
“I only smoke in the kitchen.”
B.
“I put my baby to sleep on her back.”
C.
“I have my baby sleep with me instead of alone in the crib.”
D.
“I make sure my baby wears a flannel sleeper and has two blankets to keep
warm in her crib.”
E.
“I always leave my baby’s favorite stuffed bunny rabbit in the crib to keep her
from crying at night.”
Correct Answer Feedback-A,C,D,E
Maternal smoking increases the risk of SIDS. Smoking anywhere in the home with an
infant present is not recommended. The “Back to Sleep” Campaign is given credit for
reducing the rate of SIDS in the United States. Co-sleeping increases the risk of SIDS.
Overheating increases the risk of SIDS. Leaving a stuffed animal in the crib is a
suffocation risk but still needs to be addressed as a safety hazard.
The nurse is teaching the parents of a 24-month-old about motor skill development.
The nurse should include which statement in the teaching?
A.
The toddler walks alone but falls easily.
B.
The toddler’s activities begin to produce purposeful results.
C.
The toddler is able to grasp small objects but cannot release them at will.
D.
The toddler’s motor skills are fully developed but occur in isolation from the
environment.
Correct Answer Feedback-B
The child is able to walk up and down stairs at this age. Gross and fine motor
mastery occur with other activities. This is a task of infancy. Interaction with the
environment is essential at this age.
When completing the health assessment for a 2-year-old child, the nurse should
expect the child to
A.
engage in parallel play.
B.
fully dress self with supervision.
C.
have a vocabulary of at least 500 words.
D.
be one third of the adult height.
Correct Answer Feedback -A
Two year olds typically play alongside each other. The child still needs help with
clothing at 2 years of age. A vocabulary of 300 words is expected at this age. The
child typically has grown to one half of adult height.
A 2-year-old child has recently started having temper tantrums during which she
holds her breath and sometimes faints. The nurse should
A.
refer the child for respiratory evaluation.
B.
refer the child for psychologic evaluation.
C.
explain to the parent that this is not harmful.
D.
explain to the parent that the child is spoiled.
Correct Answer Feedback-C
This is not a respiratory issue. Temper tantrums are part of this developmental stage;
if they persist, an evaluation may be indicated. The rising carbon dioxide levels in the
child will automatically restart the breathing process. No data have been shown to
support this.
The nurse is teaching the parent of a 2-year-old child how to care for the child’s
teeth. Which of the following should be included?
A.
Flossing is not recommended at this age.
B.
The child is old enough to brush teeth effectively.
C.
Brush teeth with plain water if child does not like toothpaste.
D.
Toothbrush should be small and have hard, rounded, nylon bristles.
Correct Answer Feedback-C
Flossing should be done after brushing. Two year olds cannot effectively brush their
own teeth; parental assistance is necessary. Some children do not like the flavor of
toothpaste or the foam; water alone can be used. Soft, multitufted, bristled
toothbrushes are recommended.
A parent has a 2-year-old in the clinic for a well-child checkup. Which statement by
the parent would indicate to the nurse that the parent needs more instruction
regarding accident prevention?
A.
“We locked all the medicines in the bathroom cabinet.”
B.
“We turned the thermostat down on our hot water heater.”
C.
“We placed gates at the top and bottom of the basement steps.”
D.
“We stopped using the car seat now that my child is older.”
Correct Answer Feedback-D
These are appropriate actions. A car seat should be used until child weighs 40 lb, at
approximately 4 years of age.
The parents of a toddler ask the nurse for suggestions about discipline. When
discussing the use of timeouts, which of the following suggestions should the nurse
include?
A.
Send the child to his or her room.
B.
If the child cries, refuses, or is more disruptive, try another approach.
C.
Select an area that is safe and nonstimulating, such as a hallway.
D.
The general rule for length of time is 1 hour per year of age.
Correct Answer Feedback-C
The area must be nonstimulating and safe. The child becomes bored in this
environment and then changes his or her behavior to rejoin activities. The child’s room
may have toys and other forms of amusement that may negate the effect of being
separated from family activities. When the child engages in this type of behavior, the
timeout begins when the child becomes quiet. The general rule is 1 minute per year.
An hour per year is excessive.
The nurse is discussing toddler development with a parent. Which intervention will
foster the achievement of autonomy?
A.
Help the toddler complete tasks.
B.
Provide opportunities for the toddler to play with other children.
C.
Help the toddler learn the difference between right and wrong.
D.
Encourage the toddler to do things for himself or herself when he or she is
capable of doing them.
Correct Answer Feedback-D
Toddlers have an increased ability to control their bodies, themselves, and the
environment. Autonomy develops when children complete tasks of which they are
capable. To successfully achieve autonomy, the toddler needs to have a sense of
accomplishment. This does not occur if parents complete tasks. Children at this age
engage in parallel play. This will not foster autonomy. This concept is too advanced
for toddlers and will not contribute to autonomy.
The parents of a toddler ask the nurse how to handle their child’s increasing number
of temper tantrums. The nurse should include which positive reinforcement methods of
reducing the number of tantrums? (Select all that apply.)
A.
Suggest that parents provide the child an “all or none” position.
B.
Suggest that parents ignore the behavior as long as child is not harming self.
C.
Encourage the parents to provide comfort once the child has calmed down.
D.
Ask parents to praise the child for positive behavior when not having a tantrum.
E.
Tell parents not to give in to the original request that started the temper tantrum.
Correct Answer Feedback-B,C,D,E
During tantrums ignore the behavior, provided the behavior is not injurious to the
child. During periods of no tantrums, practice developmentally appropriate positive
reinforcement. Other suggestions for handling tantrums include: Offering the child
options instead of an “all or none” position. Picking one’s battles carefully and
ignoring small skirmishes over unimportant issues. Giving comfort once the child is
able to control emotions but not giving in to the original request. Praising the child for
positive behavior when he or she is not having a tantrum.
According to Erikson, the primary psychosocial task of the preschool period is
developing a sense of
A.
identity.
B.
intimacy.
C.
initiative.
D.
industry.
Correct Answer Feedback -C
Preschoolers focus on developing initiative. Identity is the stage associated with
adolescence. Intimacy is an adult stage. The stage is known as initiative versus guilt.
Industry is an adult stage.
The nurse’s BEST approach for effective communication with a preschool-age child is
through
A.
speech.
B.
play.
C.
drawing.
D.
actions.
Correct Answer Feedback-B
Language is not specific for children. Play is the child’s way to learn to understand
and adjust to situations. Drawing is not developed at this age. Actions are not
effective for communication.
The parents of a 4-year-old girl are worried because she has an imaginary
playmate. The nurse’s BEST response is to tell the parents
A.
a psychosocial evaluation is indicated.
B.
an evaluation of possible parent-child conflict is indicated.
C.
having imaginary playmates is normal and useful at this age.
D.
having imaginary playmates is abnormal after about age 2 years.
Correct Answer Feedback-C
Since an imaginary playmate is part of normal development, an evaluation is not
necessary. Since an imaginary playmate is part of normal development, an
evaluation is not necessary. Imaginary playmates are a part of normal development
at this age. The peak incidence of imaginary playmates occurs at 2.5 to 3 years of
age. These “playmates” usually are not present once school starts.
During a well-child visit, the father of a 4-year-old boy tells the nurse that he is not
sure if his son is ready for kindergarten. His birthday is close to the cutoff date, and
he has not attended preschool. The nurse’s BEST recommendation is to
A.
start kindergarten.
B.
perform developmental screening.
C.
observe a kindergarten class.
D.
postpone kindergarten and go to preschool.
Correct Answer Feedback-B
This does not address the father’s concern about readiness. A developmental
screening will provide the necessary information to help the family determine
readiness. Observing will provide information about kindergarten but not whether the
child is ready. If the child is ready for kindergarten, preschool may lead to boredom.
A 4-year-old female child sometimes wakes her parents up at night screaming,
thrashing, sweating, and apparently frightened. Yet she is not aware of her parents’
presence when they check on her. She lies down and sleeps without any parental
intervention. This is MOST likely described as
A.
a nightmare.
B.
sleep terror.
C.
seizure activity.
D.
sleep apnea.
Correct Answer Feedback-B
A nightmare is a frightening dream followed by full awakening. In sleep terrors, the
child is only partially aroused; therefore she does not remember her parents’
presence. This does not resemble seizure activity. Sleep apnea is a cessation of
breathing during sleep.
A nurse is presenting a class on injury prevention to parents of preschoolers. Which
injuries should the nurse identify as occurring in this age-group? (Select all that apply.)
A.
Falls
B.
Drowning
C.
Poisoning
D.
Sports injuries
E.
Tricycle and bicycle accidents
Correct Answer Feedback-A,B,C,E
Falls occur frequently in preschoolers. Closely monitor playground activities such as
climbing a jungle-gym. Closely supervise around any water and ensure swimming
pools are securely fenced to prevent near drowning. Place all medications and
poisons out of reach and in locked cabinets. Administer medications as a drug, not
“candy.” Keep poison control phone number by telephone. When riding tricycles and
bicycles, children often forget not to ride in the streets. Sports injuries occur in older
children.
The nurse is preparing the playroom on a newly opened pediatric unit. The nurse
should include which items to foster the development of the preschool child? (Select all
that apply.)
A.
Large blocks
B.
Alphabet flash cards
C.
100-piece puzzles
D.
Dolls
E.
Hand puppets
Correct Answer Feedback-A,B,D,E
Manipulative, constructive, creative, and educational toys provide for quiet activities,
fine motor development, and self-expression. Easy construction sets, large blocks of
various sizes and shapes, a counting frame, alphabet or number flash cards, paints,
crayons, simple carpentry tools, musical toys, illustrated books, simple sewing or
handicraft sets, large puzzles, and clay are suitable. Probably the most characteristic
and pervasive preschool activity is imitative, imaginative, and dramatic play. Dressup clothes, dolls, housekeeping toys, dollhouses, play store toys, telephones, farm
animals and equipment, village sets, trains, trucks, cars, planes, hand puppets, and
medical kits provide hours of self-expression toys. Large puzzles are appropriate for
preschoolers, but 100-piece puzzles are likely too small and may cause frustration
for the preschooler.
A parent tells the nurse, “I am worried about my 13-year-old son. He has not started
puberty, and my daughter did when she was 11 years of age.” The nurse should
explain to this parent that this is
A.
unusual and requires further evaluation of the son.
B.
unusual because the onset of pubescence is usually the same in siblings.
C.
normal because the onset of pubescence is usually earlier in girls than it is in
boys.
D.
abnormal because the onset of pubescence is usually earlier in boys than it is in
girls.
Correct Answer Feedback-C
The average age of onset for puberty in boys is 12 years old. Age of pubescence is
gender related. Girls begin puberty an average of approximately 2 years before
boys. The average age of onset for puberty in boys is 12 years old.
The school nurse knows that which attribute is characteristic of the psychosocial
development of school-age children?
A.
A developing sense of initiative is very important.
B.
Peer approval is not yet a motivating power.
C.
Motivation comes from extrinsic rather than intrinsic sources.
D.
Feelings of inferiority or lack of worth can be derived from children themselves
or from the environment.
Correct Answer Feedback-D
Developing initiative is characteristic of preschoolers. Peer group formation is one of
the major characteristics of this age-group. School-age children gain satisfaction from
independent behaviors. This age child is eager to develop skills and participate in
activities. All children are not able to do all tasks well, and the child must be
prepared to accept some feeling of inferiority.
The nurse should teach volunteers in the after school program that which characteristic
is MOST descriptive of the social development of school-age children?
A.
Identification with peers is minimal.
B.
Children frequently have “best friends.”
C.
Boys and girls play equally well with children of either gender.
D.
Peer approval is not yet an influence toward conformity.
Correct Answer Feedback-B
Identification with peer group is an important factor toward gaining independence
from families. Same-sex peers form relationships that encourage sharing of secrets
and jokes and coming to each other’s aid. During the school-age years there are
more gender-specific groups. Conforming to the rules is an essential part of group
membership.
What information should the nurse include when giving parents guidelines about
helping their children in school?
A.
Help children as much as possible with their homework.
B.
Punish children who fail to perform adequately.
C.
Communicate with teachers if there appears to be a problem.
D.
Accept responsibility for children’s successes and failures.
Correct Answer Feedback-C
Children need to do their own homework. This cultivates responsibility. Discipline
should be used to help children control behaviors. School-age children can use
reasoning skills. Parents should communicate with teachers if there is a problem and
not wait for a scheduled conference. School-age children need to develop
responsibility. This helps with keeping promises and meeting deadlines, thereby laying
successful foundations for adulthood.
The nurse is preparing a health teaching session for school-age children. The nurse
should include which information about injury prevention in the plan?
A.
Peer pressure is not strong enough to affect risk-taking behavior.
B.
Most injuries occur in or near school or home.
C.
Injuries from burns are the highest at this age because of fascination with fire.
D.
Lack of muscular coordination and control results in an increased incidence of
injuries.
Correct Answer Feedback-B
Peer pressure is significant in this age-group. This is where most injuries occur.
Automobile accidents account for the majority of severe accidents, either as a
pedestrian or passenger. School-age children have more refined muscle
development, which results in an overall decrease in the number of accidents.
What is an important consideration related to childhood stress?
A.
Children should be protected from stress.
B.
Children do not have coping strategies.
C.
Parents cannot prepare children for stress.
D.
Some children are more vulnerable to stress than others.
Correct Answer Feedback-D
Children’s age, temperament, life situation, and state of health affect their
vulnerability, reactions, and ability to handle stress. It is not feasible to protect
children from all stress. Children can be taught coping strategies. Supportive
interpersonal relationships are essential to the psychological well-being of children.
Adults need to recognize signs of stress before they become overwhelming. Providing
children with interpersonal security helps them develop coping strategies for dealing
with stress.
The school nurse is teaching a class on safety. Which activities require protective
athletic gear? (Select all that apply.)
A.
Lacrosse
B.
Football
C.
Swimming
D.
Gymnastics
E.
Skateboarding
Correct Answer Feedback-A,B,E
Any sport that involves body contact such as lacrosse, football, and skateboarding
requires a child to wear protective equipment. Swimming does not involve body
contact and requires no protective equipment. Gymnastics does not require protective
equipment.
At the beginning of the school year, the school nurse identifies several new children at
the school. The nurse knows that which factors place the children at high risk
adjustment problems? (Select all that apply.)
A.
The child is from a middle class family.
B.
The child has not attended a preschool program.
C.
The child exhibits signs of emotional immaturity.
D.
The parents of a child demonstrate warm, loving behaviors.
E.
The child appears physically immature.
Correct Answer Feedback-B,C,E
Successful adjustment is related to the child’s physical and emotional maturity and the
parent’s readiness to accept the separation associated with school entrance.
Unfortunately, some parents express their unconscious attempts to delay the child’s
maturity by clinging behavior, particularly with their youngest child. Middle-class
children have fewer adjustments to make and less to learn about expected behavior
because schools tend to reflect dominant middle class customs and values. If the child
has attended a preschool program, the focus of the preschool program also affects
the child’s adjustment. Some preschool programs provide custodial care only, but
others emphasize emotional, social, and intellectual development.
Girls experience an increase in weight and fat deposition during puberty. Nursing
considerations related to these changes include
A.
giving reassurance that these changes are normal.
B.
suggesting dietary measures to control weight gain.
C.
recommending increased exercise to control weight gain.
D.
encouraging low-fat diet to prevent fat deposition.
Correct Answer Feedback-A
A certain amount of fat is increased along with lean body mass to fill the
characteristic contours of the child’s gender. A healthy balance must be achieved
between expected healthy weight gain and obesity. Such advice would not be given
unless weight gain were excessive; eating disorders can develop in this group. Such
advice would not be given unless weight gain were excessive; eating disorders can
develop in this group. Some fat deposition is essential for normal hormone regulation.
Menarche is delayed in girls with body fat contents that are too low.
A hospitalized teenager and family are praying at the bedside. The nurse is aware
that the most accurate description of the spiritual development of the older
adolescent is that
A.
beliefs become more abstract.
B.
rituals and practices become increasingly important.
C.
strict observance of religious customs is common.
D.
emphasis is placed on external manifestations, such as whether a person goes to
church.
Correct Answer Feedback-A
Because of their abstract thinking abilities, adolescents are able to interpret
analogies and symbol. These become less important as the adolescent questions
values and ideals of families. These become less important as the adolescent
questions values and ideals of families. Adolescents question external manifestations
when they are not supported by adherence to supportive behaviors.
When discussing sex and sexual activities with adolescents, the nurse should
A.
present normal body functions in a straightforward manner.
B.
refer the adolescents to their parents for sexual information.
C.
use scientific terminology to convey content.
D.
defer giving information about pregnancy unless the adolescents are sexually
active.
Correct Answer Feedback-A
The nurse should provide accurate and complete information that is presented using
correct terminology. Parents are important influences regarding the morals and values
surrounding sexual activities; nurses should provide the adolescent with accurate,
complete information about the normal physical aspects of sex. The adolescent may
not understand the scientific names. Adolescents should have information before they
become sexually active.
An important consideration for the school nurse planning a class on injury prevention
for adolescents is that
A.
adolescents generally are not risk takers.
B.
adolescents can anticipate the long-term consequences of serious injuries.
C.
during adolescence a need exists for discharging energy, often at the expense of
logical thinking.
D.
during adolescence participation in sports should be limited to prevent permanent
injuries.
Correct Answer Feedback-C
Adolescents are risk takers because of their feelings of indestructibility. The feelings
of indestructibility that are common in adolescence interfere with understanding the
consequences. The physical, sensory, and psychomotor development of adolescents
provides a sense of strength and confidence. There is also an increase in energy
coupled with risk taking that puts them at risk. Sports can be a useful way for
adolescents to discharge energy. Care must be taken to avoid overuse injuries.
In planning sex education and contraceptive teaching for adolescents, the nurse
should consider which information?
A.
Most teenagers today are knowledgeable about reproductive anatomy and
physiology.
B.
Both sexual activity and contraception require planning.
C.
Most teenagers who become pregnant do so as an act of hostility, especially
toward their parents.
D.
Teenagers need contraception education in both oral and written form.
Correct Answer Feedback
Sex education and contraceptive teaching are independent of an adolescent’s
knowledge of reproductive anatomy and physiology. Contraception requires
planning. Most adolescents are sexually active for 6 months to 1 year before seeking
contraceptive information. This is not one of the major identified risks for teenage
pregnancy. Sex education and contraceptive information need to be concrete and
concise. Oral presentations with visual demonstrations and written information with
diagrams should be provided.
Nursing responsibilities in the management of adolescent obesity include
A.
planning a low-calorie, low-protein diet.
B.
incorporating favorite foods into the child’s diet.
C.
encouraging diversional activities during mealtimes.
D.
using nutritious foods as a method of reward.
Correct Answer Feedback-B
A food plan high in nutrients, with calories and fats kept at a healthy level, is
recommended. Incorporating small amounts of the adolescent’s favorite foods will
increase adherence to the nutritional plan. Diversional activities such as television
watching may contribute to overeating. Foods should not be used as a reward.
Nursing responsibilities when caring for the suicidal adolescent include
A.
emphasizing that a suicide attempt is an immature way of dealing with stress.
B.
recognizing the warning signs that indicate a young person might attempt suicide.
C.
ignoring threats of suicide because they are usually bids for attention.
D.
recognizing a suicide attempt as an impulsive act resulting from a temporary
crisis.
Correct Answer Feedback-B
For the depressed young person, suicide may appear to be the only way out. It is
imperative that the nurse recognize warning signs of a potential suicide. All threats
must be taken seriously. Even if the crisis is temporary, the child’s perception still may
be that suicide is the only way out.
When teaching about the effects of social media on the adolescent population, the
nurse should include which negative impacts? (Select all that apply.)
A.
Possibility of cyberbullying
B.
Opportunity for adolescents without many friends to interact with others
C.
Disruptive texting during school
D.
Sharing of personal information with sexual predators
E.
Time management
Correct Answer Feedbac-A,C,D
Adolescents without many friends may benefit from social media outlets. Time
management would be a positive impact, not negative. The other responses place the
adolescent at risk for injury, harm, or acts of violence.
A 9-year-old child has several physical disabilities. His father explains to the nurse
that his son concentrates on what he can, rather than cannot do and is as independent
as possible. The nurse’s best interpretation of this is that
A.
the father is experiencing denial.
B.
the father is expressing his own views.
C.
the child is using an adaptive coping style.
D.
the child is using a maladaptive coping style.
Correct Answer Feedback-C
The father is describing an adaptive coping style. The father views his son’s coping as
adaptive. This description is characteristic of a child using an adaptive coping style.
The child learns to accept physical limitations but finds achievements in a variety of
compensatory motor and intellectual pursuits. This is an adaptive coping style.
The nurse is caring for a child dying from cancer. Physical signs that the child is
approaching death include
A.
rapid pulse.
B.
change in respiratory pattern.
C.
sensation of cold, although body feels hot.
D.
loss of hearing followed by loss of other senses.
Correct Answer Feedback-B
The pulse becomes weak and slowed. In the final hours of life the respiratory pattern
may become labored, with periods of apnea. The opposite is true; there is a
sensation of heat, although the body feels cold. Hearing is the last sense to fail.
Several nurses tell their nursing supervisor that they want to be able to attend the
funeral of a child for whom they had cared. They say they felt especially close to
both the child and the family. The supervisor should recognize that attending the
funeral is
A.
appropriate because families expect this expression of concern.
B.
appropriate because it can assist in the resolution of personal grief.
C.
inappropriate because it is unprofessional.
D.
inappropriate because it increases burnout.
Correct Answer Feedback-B
Families may or may not expect this expression of concern. Nurses should attend the
funeral of a child if they felt closeness with the family. This will help the nurses grieve
and gain closure. The behavior is appropriate if a relationship existed between the
nurses and family. This may prevent burnout.
When planning a child safety health fair presentation addressing causes of death in
children, the nurse should include which topics? (Select all that apply.)
A.
Suicide prevention support groups for 5 to 9 year olds.
B.
Sexually transmitted infection prevention for 15 to 19 years old.
C.
Blood pressure screenings for 5 to 9 year olds.
D.
Gun safety for 10 to 14 year olds.
E.
Information on bullying and violence prevention for 15 to 19 year olds.
Correct Answer Feedback-B,D,E
The leading causes of death in children 5 to 9 years old include injuries (accidents),
malignant neoplasms, congenital anomalies, assault (homicide), and heart disease. In
children 10 to 14 years old, suicide is the third leading cause of death after injuries
(accidents) and malignant neoplasms. In youths 15 to 19 years old, assault (homicide),
suicide, malignant neoplasms, and heart disease follow accidents as the most
prevalent causes of death (Anderson and Smith, 2005). Suicide is not a prevalent
concern in the 5- to 9-year old age-group. Hypertension is not a leading cause of
death or safety concern for the 5- to 9-year old age-group.
The primary goal in caring for the child with cognitive impairment is to
A.
encourage play.
B.
promote optimum development.
C.
help families adjust to future care.
D.
develop vocational skills.
Correct Answer Feedback-B
Provide parents guidance for the selection of developmentally appropriate activities.
A comprehensive approach is desirable to establish acceptable social behavior and
feelings of self-worth in the child. This is an ongoing process that changes as the child
meets developmental milestones. These skills will be addressed as the child’s
capabilities are developing.
The parents of a cognitively impaired child ask the nurse for guidance with discipline.
The nurse’s BEST response is
A.
“Discipline is ineffective with cognitively impaired children.”
B.
“Discipline is not necessary for cognitively impaired children.”
C.
“Behavior modification is an excellent form of discipline.”
D.
“Physical punishment is the most appropriate form of discipline.”
Correct Answer Feedback-C
Behavior modification with positive reinforcement is effective in children with cognitive
impairment. Discipline is essential in assisting the child in developing boundaries.
Positive behaviors and desirable actions should be reinforced. Most children with
cognitive impairment will not be able to understand the reason for the physical
punishment; consequently behavior will not change as a result of the punishment.
Early detection of a hearing impairment is critical because of its effect on areas of a
child’s life. The nurse should evaluate further for effects of the hearing impairment on
A.
reading development.
B.
speech development.
C.
relationships with peers.
D.
performance at school.
Correct Answer Feedback-B
The child will have greater difficulty learning to read, but the primary issue of
concern is the effect on speech. The ability to hear sounds is essential for the
development of speech. Babies imitate the sounds that they hear. Relationships with
peers and performance at school will be affected by the child’s lack of hearing. The
effect will be augmented by difficulties with oral communication. Relationships with
peers and performance at school will be affected by the child’s lack of hearing. The
effect will be augmented by difficulties with oral communication.
Autism is a complex developmental disorder. Diagnostic criteria for autism include
delayed or abnormal functioning in which area(s) before 3 years of age? (Select all
that apply.)
A.
Parallel play
B.
Social interaction
C.
Gross motor development
D.
Inability to maintain eye contact
E.
Language as used in social communication
Correct Answer Feedback-B,D,E
Children diagnosed with autism show delayed or abnormal functioning in social
interactions. A hallmark characteristic of autism is the child’s inability to make and
maintain eye contact. A characteristic of autism is the child’s delay of language at an
early age or the sudden deterioration in extant expressive speech. Parallel play is
not an area in which autistic children may show delay. When interacting with other
children in other forms of play they display functional limitations. Gross motor
development is not an area in which autistic children show delayed or abnormal
functioning.
A humidified atmosphere is recommended for a young child with an upper
respiratory tract infection because this environment facilitates
A.
liquefying secretions.
B.
improving oxygenation.
C.
promoting ventilation.
D.
soothing inflamed mucous membrane.
Correct Answer Feedback-D
The size of the droplets is too large to liquefy secretions. No additional oxygen is
provided with humidified air. The humidity has no effect on ventilation. By humidifying
the inspired air, the membranes inflamed by the infection and dry air are soothed.
t is important that a child with Group A β-hemolytic streptococci (GABHS) infection be
treated with antibiotics to prevent
A.
otitis media.
B.
diabetes insipidus.
C.
nephrotic syndrome.
D.
acute rheumatic fever.
Correct Answer Feedback-D
Otitis media and diabetes insipidus are not sequelae to group A β-hemolytic
streptococci (GABHS). Otitis media and diabetes insipidus are not sequelae to
GABHS. Children are at risk for glomerulonephritis, not nephritic syndrome. Children
with Group A β-hemolytic streptococci (GABHS) infection are at risk for acute
rheumatic fever and acute glomerulonephritis.
When caring for a child after a tonsillectomy, the nurse should
A.
watch for continuous swallowing.
B.
encourage gargling to reduce discomfort.
C.
position the child on the back for sleeping.
D.
apply warm compresses to the throat.
Correct Answer Feedback-A
This is the most obvious early sign of bleeding from the operative site. Gargling
should be avoided because of potential trauma to the suture line. The child should be
positioned on the side or abdomen to facilitate drainage. Cold is preferred. Ice
collars and cold liquids are encouraged.
The mother of a 20-month-old boy tells the nurse that he has a barking cough at
night. His temperature is 37°C. The nurse suspects croup and should recommend
A.
controlling fever with acetaminophen and calling if the cough gets worse during
the night.
B.
trying a cool-mist vaporizer at night and watching for signs of difficulty
breathing.
C.
trying over-the-counter cough medicine and coming to the clinic in the morning if
there is no improvement.
D.
admitting to the hospital and observing for impending epiglottitis.
Correct Answer Feedback-B
The child does not have a temperature to manage. Because the child is not having
difficulty breathing, the nurse should teach the parents the signs of respiratory
distress and tell them to come to the emergency room if they develop. Cool mist is
recommended to provide relief. Cough suppressants are not indicated. This is
characteristic of laryngotracheobronchitis, not epiglottitis.
A 4-year-old boy needs to use a metered-dose inhaler to treat asthma. He cannot
coordinate the breathing to use it effectively. The nurse should suggest that he use a
A.
spacer.
B.
nebulizer.
C.
peak expiratory flowmeter.
D.
trial of chest physiotherapy.
Correct Answer Feedback-A
The medication in a metered-dose inhaler is sprayed into the spacer. The child can
then inhale the medication without having to coordinate the spraying and breathing.
A nebulizer is a mechanism used to administer medications, but it cannot be used with
metered-dose inhalers. A peak expiratory flowmeter is a measure of pulmonary
function not related to medication administration. Chest physiotherapy is unrelated to
medication administration.
One of the goals for children with asthma is to prevent respiratory infection. This is
because respiratory infection
A.
lessens effectiveness of medications.
B.
encourages exercise-induced asthma.
C.
increases sensitivity to allergens.
D.
can trigger an episode or aggravate an asthmatic state.
Correct Answer Feedback-D
The infection affects the asthma, not the medications. Exercise-induced asthma is
caused by vigorous activity. Sensitivity to allergens is independent of respiratory
infection. Respiratory infections can trigger an asthmatic attack. Annual influenza
vaccine is recommended. All respiratory equipment should be kept clean.
Cystic fibrosis may affect singular or multiple systems of the body. The primary factor
responsible for possible multiple clinical manifestations is
A.
atrophic changes in the mucosal wall of intestines.
B.
hypoactivity of the autonomic nervous system.
C.
hyperactivity of the sweat glands.
D.
mechanical obstruction caused by increased viscosity of mucous gland secretions.
Correct Answer Feedback-D
Thick mucus secretions are the probable cause of the multiple body system
involvement. There is an identified autonomic nervous system anomaly, but it is not
hypoactivity. The sweat glands are not hyperactive. The child loses a greater amount
of salt because of abnormal chloride movement. Children with cystic fibrosis have
thick mucus gland secretions. The viscous secretions obstruct small passages in organs
such as the pancreas.
Because the absorption of fat-soluble vitamins is decreased in children with cystic
fibrosis, supplementation of which vitamins is necessary?
A.
C, D
B.
A, E, K
C.
A, D, E, K
D.
C, folic acid
Correct Answer Feedback-C
C is not one of the fat-soluble vitamins. D also needs to be supplemented. A, D, E, and
K are the fat-soluble vitamins that need to be supplemented in higher doses. C and
folic acid are not fat soluble.
An immediate intervention when an infant chokes on a piece of food would be to
A.
have infant lie quietly while a call is placed for emergency help.
B.
position the infant in a head-down, face-down position and administer five quick
blows between the shoulder blades.
C.
administer mouth-to-mouth resuscitation.
D.
give water by cup to relieve the obstruction.
Correct Answer Feedback-B
The infant needs to receive treatment immediately. Emergency help is called after
attempting to remove the obstruction. This is the correct initial sequence of actions for
an infant with an obstructed airway. Mouth-to-mouth resuscitation should not be used.
This may push the object further into the child’s respiratory system. If the child’s
airway is obstructed, the water will not be able to pass. This will increase the risk of
aspiration.
A 5-year-old child is brought to the Emergency Department with abrupt onset of sore
throat, pain with swallowing, fever, and sitting upright and forward. Acute epiglottitis
is suspected. What are the most appropriate nursing interventions? (Select all that
apply.)
A.
Vital signs
B.
Throat culture
C.
Medical history
D.
Assessment of breath sounds
E.
Emergency airway equipment readily available
Correct Answer Feedback-A,C,D,E
Vital signs should always be taken as a part of the assessment. Medical history is
important in assisting with the diagnosis in addition to knowing immunization status.
Assessment of breath sounds is important in assisting with the diagnosis. Suprasternal
and substernal retractions may be noted. Emergency airway equipment must be
readily available in case the airway becomes obstructed. Throat culture should never
be done when diagnosis of epiglottis is suspected. Manipulation of the throat can
stimulate the gag reflex in an already inflamed airway and cause laryngeal spasm
that will cause occlusion of the airway.
What factor predisposes an infant to fluid imbalances?
A.
Decreased surface area
B.
Lower metabolic rate
C.
Immature kidney functioning
D.
Decreased daily exchange of extracellular fluid
Correct Answer Feedback-C
The infant has a proportionately greater body surface area, which allows for greater
insensible water loss. The infant has a higher metabolic rate. The infant’s kidneys are
unable to concentrate or dilute urine, conserve or excrete sodium, or acidify urine.
This is an increased amount of extracellular fluid in the infant. Approximately 60% of
fluid loss is from extracellular space.
When evaluating the extent of an infant’s dehydration, the nurse should recognize
that the symptoms of severe dehydration include
A.
tachycardia, decreased tears, 5% weight loss.
B.
normal pulse and blood pressure, intense thirst.
C.
irritability, moderate thirst, normal eyes, and fontanel.
D.
sunken eyes and sunken fontanel.
Correct Answer Feedback-D
In severe dehydration there is more than a 10% weight loss in infants. Tachycardia,
orthostatic hypotension and shock, and intense thirst would be expected. The infant
would be extremely irritable, with sunken eyes and fontanel. These are the symptoms
of severe dehydration.
A school-age child with acute diarrhea and mild dehydration is being given oral
rehydration solution (ORS). The child’s mother calls the clinic nurse because he is also
occasionally vomiting. The nurse should recommend
A.
bringing the child to the hospital for intravenous fluids.
B.
alternating giving the child ORS and carbonated drinks.
C.
continuing to give the child ORS frequently in small amounts.
D.
maintaining the child on NPO for 8 hours and resuming ORS if vomiting has
subsided.
Correct Answer Feedback-C
A school-age child with mild dehydration can be rehydrated safely at home with oral
rehydration solutions (ORS). Carbonated drinks should not be given to the child. They
may have high carbohydrate content and contain caffeine, which is a diuretic.
Vomiting is not a contraindication to the use of ORS unless it is severe. The mother
should continue to give the ORS in small amounts and at frequent intervals. NPO
status is not indicated. Small, frequent intake of ORS is recommended.
A 2-month-old breastfed infant is successfully rehydrated with oral rehydration
solutions for acute diarrhea. Instructions to the mother about breastfeeding should
include to
A.
continue breastfeeding.
B.
stop breastfeeding until breast milk is cultured.
C.
stop breastfeeding until diarrhea is absent for 24 hours.
D.
express breast milk and dilute with sterile water before feeding.
Correct Answer Feedback-A
Breastfeeding should continue. Culturing the breast milk is not necessary.
Breastfeeding can continue along with oral rehydration solution to replace the
ongoing fluid loss caused by the diarrhea. Breast milk should not be diluted.
Which statement best describes Hirschsprung’s disease?
A.
The colon has an aganglionic segment.
B.
There is passage of excessive amounts of meconium in the neonate.
C.
It results in excessive peristaltic movements within the gastrointestinal tract.
D.
It results in frequent evacuation of solids, liquid, and gas.
Correct Answer Feedback-A
Hirschsprung’s disease is a mechanical obstruction caused by a lack of motility of a
segment of the intestine resulting from the lack of ganglion. It is associated with an
inability to pass meconium or feces if the child is older. There is a lack of peristalsis in
the affected segment, which interferes with the evacuation of solid waste. There is a
lack of peristalsis in the affected segment, which interferes with the evacuation of
solid waste.
A child has a nasogastric (NG) tube inserted after surgery for acute appendicitis. The
purpose of the NG tube is to
A.
maintain electrolyte balance.
B.
maintain an accurate record of output.
C.
prevent the spread of infection.
D.
prevent abdominal distention.
Correct Answer Feedback-D
The nasogastric (NG) tube may adversely affect electrolyte balance by removing
stomach secretions. NG drainage is one part of the child’s output. The nurse would
need to incorporate the NG drainage with other output. There is no relationship to
the spread of infection. The NG tube is used to maintain gastric decompression until
the return of intestinal activity.
The nurse is discussing home care with a mother whose 6-year-old child has hepatitis
A. What action should the nurse include?
A.
Informing her that bed rest is important until 1 week after the icteric phase
B.
Telling her that the child should not return to school until 3 weeks after icteric
phase
C.
Giving reassurance that hepatitis A cannot be transmitted to other family
members
D.
Teaching infection control measures to family members
Correct Answer Feedback-D
The disease does not usually have an icteric phase and often is subclinical. The period
of communicability is from the latter half of the incubation period to 1 week after
onset of clinical illness. Hepatitis A infection is spread through the fecal-oral route.
Hepatitis A is a contagious disease that is transmitted through the fecal-oral route.
The nurse should teach infection control measures to the family.
The nurse assesses the neonate immediately after birth. A tracheoesophageal fistula
should be suspected if what condition is present?
A.
Jaundice
B.
Clubfeet
C.
Absence of sucking
D.
Excessive amount of frothy saliva in the mouth
Correct Answer Feedback-D
Jaundice is not usually associated with a tracheoesophageal fistula. Clubfeet are not
usually associated with a tracheoesophageal fistula. The infant is able to suck, just not
manage the secretions. Excessive salivation and drooling indicates tracheoesophageal
fistulas. With a fistula the child has difficulty managing the secretions, causing
choking, coughing, and cyanosis.
The nurse is caring for a boy with probable intussusception. He had diarrhea before
admission; but, while waiting for administration of air pressure to reduce the
intussusception, he passes a normal brown stool. What is the most appropriate nursing
action?
A.
Notify physician.
B.
Measure abdominal girth.
C.
Auscultate for bowel sounds.
D.
Take vital signs, including blood pressure.
Correct Answer Feedback-A
Passage of a normal stool indicates that the intussusception has resolved.
Notification of the physician is essential to determine whether a change in treatment
plan is indicated. These actions may be indicated, but the physician still should be
notified as to the change in status. These actions may be indicated, but the physician
still should be notified as to the change in status. These actions may be indicated, but
the physician still should be notified as to the change in status.
The doctor suggests that surgery be performed for patent ductus arteriosus (PDA) to
prevent
A.
pulmonary infection.
B.
right-to-left shunt of blood.
C.
decreased workload on left side of heart.
D.
increased pulmonary vascular congestion.
Correct Answer Feedback-D
The increased pulmonary vascular congestion is the primary complication. The shunt
of blood is left to right. The increased pulmonary vascular congestion is the
primary complication. Patent ductus arteriosus (PDA) allows blood to flow from the
aorta (high pressure) to the pulmonary artery (low pressure). If the PDA stays open,
increased pulmonary congestion can occur.
A young child with tetralogy of Fallot may assume a posturing position as a
compensatory mechanism. The position automatically assumed by the child is
A.
low Fowler’s.
B.
prone.
C.
supine.
D.
squatting.
Correct Answer Feedback-D
Low Fowler’s would assist with respiratory issues but would not assist with the need
for cardiac compensation. Prone does not offer any advantage to the child. Supine
does not offer any advantage to the child. The squatting or knee-chest position
decreases the amount of blood returning to the heart and allows the child time to
compensate.
An early sign of congestive heart failure that the nurse should recognize is
A.
tachypnea.
B.
bradycardia.
C.
inability to sweat.
D.
increased urine output.
Correct Answer Feedback-A
Tachypnea is one of the early signs that should be identified. Tachycardia at
rest, dyspnea, retractions, and activity intolerance are other physical signs and
symptoms. Tachycardia, not bradycardia, is one of the symptoms suggestive of
congestive heart failure. The child may be diaphoretic. Urine output usually will be
decreased due to decreased kidney perfusion.
The nurse should explain to the parents that their child is receiving Lasix for severe
congestive heart failure because it is a/an
A.
diuretic.
B.
â-blocker.
C.
form of digitalis.
D.
angiotensin converting enzyme (ACE) inhibitor.
Correct Answer Feedback-A
Furosemide (Lasix) is a loop diuretic used to eliminate excess water and salt
to prevent reaccumulation of the fluid. Lasix is a loop diuretic. Lasix is a loop
diuretic. Lasix is a loop diuretic.
Nursing care of the infant or child with congestive heart failure would include
A.
forcing fluids appropriate to age.
B.
monitoring respirations during active periods.
C.
organizing activities to allow for uninterrupted sleep.
D.
giving larger feedings less often to conserve energy.
Correct Answer Feedback-C
The child who has congestive heart failure has an excess of fluid. Monitoring
vital signs is appropriate, but minimizing energy expenditure is a priority. The child
needs to be well rested before feeding. The child’s needs should be met as quickly
as possible to minimize crying. The nurse must organize care to facilitate a decrease
in his or her energy expenditure. The child often cannot tolerate larger feedings.
Nurses counseling parents regarding the home care of the child with a cardiac defect
before corrective surgery should stress the
A.
importance of reducing caloric intake to decrease cardiac demands.
B.
importance of relaxing discipline and limit-setting to prevent crying.
C.
need to be extremely concerned about cyanotic spells.
D.
desirability of promoting normalcy within the limits of the child’s condition.
Correct Answer Feedback-D
Child needs increased caloric intake. Child needs discipline and appropriate
limits. Because cyanotic spells occur in children with some defects, the parents need to
be taught how to manage these. The child needs to have social interactions,
discipline, and appropriate limit-setting. Parents need to be encouraged to promote
as normal a life as possible for their child.
The primary therapy for secondary hypertension in children is
A.
weight reduction.
B.
low-salt diet.
C.
increased exercise and fitness.
D.
treatment of underlying cause.
Correct Answer Feedback-D
These therapies are usually effective for essential hypertension. These therapies
are usually effective for essential hypertension. These therapies are usually effective
for essential hypertension. Secondary hypertension is a result of an underlying
disease process or structural abnormality. It is usually necessary to treat the problem
before the hypertension will be resolved.
What should the nurse recognize as an early clinical sign of compensated shock in a
child?
A.
Confusion
B.
Sleepiness
C.
Hypotension
D.
Apprehension
Correct Answer Feedback-D
Confusion indicates uncompensated shock. Sleepiness is not an indication of
shock. Hypotension is a symptom of irreversible shock. Apprehension indicates
compensated shock.
The school nurse is called to the cafeteria because a child “has eaten something he is
allergic to.” The child is in severe respiratory distress. FIRST the nurse should
A.
determine what the child has eaten.
B.
administer diphenhydramine (Benadryl).
C.
move the child to the nurse’s office or hallway.
D.
have someone call for an ambulance/paramedic rescue squad.
Correct Answer Feedback-D
Because severe respiratory distress is occurring, treatment of the response
is indicated first. The cause of the response can be determined later.
Diphenhydramine will not be effective for this type of allergic reaction. The child
should not be moved unless the child is in a place that puts the child at greater
hazard. Because the child is in severe respiratory distress, the nurse should remain
with the child while someone else calls for the rescue squad.
When assessing for hypertension in an infant, the nurse will expect the infant to
exhibit which signs? (Select all that apply.)
A.
Dizziness
B.
Changes in vision
C.
Irritability
D.
Head rubbing
E.
Waking up screaming in the night
Correct Answer Feedback-C,D,E
Clinical manifestations of hypertension are: For adolescents and older
children: Frequent headaches. Dizziness. Changes in vision. For infants or young
children: Irritability. Head banging or head rubbing. Waking up screaming in the
night.
The parent of a child receiving an iron preparation tells the nurse that the child’s
stools are a tarry green color. The nurse should explain that this is a/an
A.
symptom of iron-deficiency anemia.
B.
adverse effect of the iron preparation.
C.
indicator of an iron preparation overdose.
D.
normally expected change caused by the iron preparation.
Correct Answer Feedback-D
These descriptions are not relevant. If the stools do not become a tarry green
or black color, it may indicate administration issues. An adequate dosage of iron
turns the stools a tarry green or black color.
The MOST important nursing consideration when caring for a child with sickle cell
anemia is to
A.
teach parents and child how to minimize crises.
B.
refer parents and child for genetic counseling.
C.
help the child and family to adjust to a short-term disease.
D.
observe for complications of multiple blood transfusions.
Correct Answer Feedback-A
Parents need specific instructions about changes in the child’s condition that
they should watch for, penicillin administration, adequate hydration, and
environmental concerns. Genetic counseling is important, but teaching care of the
child is a priority. Sickle cell anemia is a long-term, chronic illness. Multiple blood
transfusions are an option for some children with sickle cell disease. The priority for
all children with this condition is having parents who are properly prepared to care
for them.
The school nurse is caring for a boy with hemophilia who fell on his arm during recess.
What supportive measure should the nurse do until factor replacement therapy can
be instituted?
A.
Apply warm, moist compresses.
B.
Apply pressure for at least 1 minute.
C.
Elevate area above the level of the heart.
D.
Begin passive range of motion unless pain is severe.
Correct Answer Feedback-C
Cold should be applied to the arm. This will aid in vasoconstriction. Pressure
is effective in small areas but would not work for an extremity. The initial
response should include elevation. Passive range of motion is not recommended. The
child can perform active range of motion after the bleeding episode has resolved.
What is the most appropriate action for stopping an occasional episode of epistaxis?
A.
Have child sit up and lean forward.
B.
Apply ice under the nose and above lip.
C.
Have the child lie down quietly with feet elevated.
D.
Apply continuous pressure to the nose with thumb and forefinger for at least 1
minute.
Correct Answer Feedback-A
Epistaxis refers to nose bleeding. This is the position used to prevent the child
from aspirating the blood. Pressure, notice, is indicated. This position could potentially
lead to aspiration. Continuous pressure for 10 minutes is recommended.
What are the most common signs and symptoms of leukemia related to bone marrow
involvement?
A.
Petechiae, infection, fatigue
B.
Headache, papilledema, irritability
C.
Muscle wasting, weight loss, fatigue
D.
Decreased intracranial pressure, psychosis, confusion
Correct Answer Feedback-A
These are signs of infiltration of the bone marrow: Petechiae from lowered
platelet count, infection from the depressed number of effective leukocytes, and
fatigue from the anemia. These are not signs of bone marrow involvement.
A child with sickle cell anemia develops severe chest pain, fever, a cough, and
dyspnea. Which priority actions should be taken by the nurse? (Select all that apply.)
A.
Administer 100% oxygen to relieve hypoxia.
B.
Administer meperidine (Demerol) to relieve symptoms.
C.
Notify the practitioner because chest syndrome is suspected.
D.
Notify the practitioner because child may be having a stroke.
E.
Administer meperidine (Demerol) orally to relieve pain.
Correct Answer Feedback-A,C
Administration of oxygen along with notifying the physician are the priority
actions that should be taken by the nurse at this time. Oxygen therapy is of little
therapeutic value unless the patient has hypoxia. Pain medications may be indicated,
but evaluation is necessary first. Demerol is not recommended, because it produces
a metabolite that is a CNS stimulant causing: anxiety, tremors, myoclonus, and
seizures. These are the signs and symptoms of chest syndrome. The nurse must notify
the practitioner immediately. These are not signs of a stroke. Oral demerol is
also contraindicated for treatment in sickle cell disease.
The nurse is preparing to administer ondansetron (Zofran) to a pediatric patient. For
which clinical symptom is this considered to be the drug of choice?
A.
Headache relief
B.
To promote increased energy
C.
Nausea and vomiting
D.
Pain relief
Correct Answer Feedback-C
Zofran is a 5-hydroxytryptamine-3 receptor antagonist and is considered
the antiemetic of choice for oncology patients as it produces no extrapyramidal
side effects. This medication does not treat headaches. This medication does not
promote energy. This medication does not provide pain relief.
A young child is diagnosed with vesicoureteral reflux. The nurse should know that this
usually is associated with
A.
incontinence.
B.
urinary obstruction.
C.
recurrent kidney infections.
D.
infarction of renal vessels.
Correct Answer Feedback-C
Incontinence may be associated with urinary tract infections. When reflux
is associated with vesicoureteral reflux, it can cause renal scarring but not
obstruction. Reflux allows urine to flow back to the kidneys. When the urine is
infected, this contributes to kidney infections. Infarction of renal vessels does not occur.
A 5-year-old female child has been sent to the school nurse for urinary incontinence
three times in the past two days. The nurse should recommend to her parent that the
FIRST action is to have the child evaluated for
A.
school phobia.
B.
emotional causes.
C.
possible urinary tract infection.
D.
possible structural defects of the urinary tract.
Correct Answer Feedback-C
A physical cause of the problem needs to be eliminated before a psychologic
cause is considered. A physical cause of the problem needs to be eliminated before
a psychologic cause is considered. Incontinence in a previously toilet-trained child
can be an indication of a urinary tract infection. Structural defects would be
explored after a urinary tract infection is confirmed.
External defects of the genitourinary tract such as hypospadias are usually repaired
as early as possible to
A.
prevent urinary complications.
B.
prevent separation anxiety.
C.
promote acceptance of hospitalization.
D.
promote development of normal body image.
Correct Answer Feedback-D
Preventing urinary complications is important for defects that affect function, but
all external defects should be repaired as soon as possible.
Proper preprocedure preparation can facilitate coping with these issues.
Proper preprocedure preparation can facilitate coping with these issues. This is
extremely important. Surgery involving sexual organs can be very upsetting to
children, especially preschoolers who fear mutilation and castration.
In a non–potty-trained child with nephrotic syndrome, the best way to detect fluid
retention is to
A.
weigh the child daily.
B.
test the urine for hematuria.
C.
measure the abdominal girth weekly.
D.
count the number of wet diapers.
Correct Answer Feedback-A
Measuring weight at the same time each day is the most accurate way to
determine fluid gains and losses. The presence or absence of blood in the urine will
not help with the determination of fluid retention. Abdominal girth is reflective of
edema, but weekly is too infrequent a measure. The number of wet diapers reflects
how often they have been changed. The diapers should be weighed to reflect fluid
balance.
The nurse is caring for a child with Wilms’ tumor. The MOST important nursing
intervention before surgery is to
A.
avoid abdominal palpation.
B.
closely monitor arterial blood gases.
C.
prepare child/family for long-term dialysis.
D.
prepare child/family for renal transplantation.
Correct Answer Feedback-A
Wilms’ tumors are encapsulated. It is extremely important to avoid any palpation
of the mass to minimize the risk of dissemination of cancer cells to adjacent and
other sites. This is not indicated before this abdominal surgery. This is not indicated
unless both kidneys have to be removed. This option is considered a last resort. If
both kidneys are involved, preoperative radiation and/or chemotherapy are used
to minimize the size of the tumor. Renal transplantation is a last resort if both
kidneys need to be removed and a compatible living donor exists.
A toddler is hospitalized with acute renal failure secondary to severe dehydration.
The nurse should assess the child for what possible complication?
A.
Hypotension
B.
Hypokalemia
C.
Hypernatremia
D.
Water intoxication
Correct Answer Feedback-D
The child needs to be monitored for hypertension. Hyperkalemia is a concern in
acute renal failure. Hyponatremia may develop in acute renal failure. The child with
acute renal failure has the tendency to develop water intoxication with
hyponatremia. Control of water balance requires careful monitoring of intake, output,
body weight, and electrolytes.
A 6-year-old child with acute renal failure is being transferred out of the intensive
care unit. Considering their diagnoses, which child would be the MOST appropriate
roommate for this child?
A.
6-year-old child with pneumonia
B.
4-year-old child with gastroenteritis
C.
5-year-old child who has a fractured femur
D.
7-year-old child who had surgery for a ruptured appendix
Correct Answer Feedback-C
These children have potentially infectious disease processes. The 5-yearold orthopedic patient would be the best choice for a roommate. This child does not
have an illness of viral or bacterial origin.
A nurse is caring for an infant with a suspected urinary tract infection (UTI). Based on
the nurse’s knowledge of UTIs, which clinical manifestation would be observed? (Select
all that apply.)
A.
Vomiting
B.
Jaundice
C.
Swelling of the face
D.
Persistent diaper rash
E.
Failure to gain weight
Correct Answer Feedback-A,D,E
Vomiting is a clinical manifestation observed in an infant with a urinary tract
infection (UTI) and can be related to poor feeding. Persistent diaper rash is a
clinical manifestation of UTI in an infant. Failure to gain weight is a clinical
manifestation of UTI in an infant related to poor feeding and vomiting. Jaundice is
not a clinical manifestation of UTI in an infant. Swelling of the face is not a clinical
manifestation of UTI in an infant.
The nurse who is concerned about increased intracranial pressure in an infant should
assess for
A.
irritability.
B.
photophobia.
C.
pulsating anterior fontanel.
D.
vomiting and diarrhea.
Correct Answer Feedback-A
Irritability is one of the changes that may indicate increased intracranial
pressure. Photophobia does not indicate increased intracranial pressure in infants.
Frequently pulsations are visible in the anterior fontanel. It is not an indication of
increased intracranial pressure. Bulging anterior fontanel may be indicative of
increased intracranial pressure. Vomiting is one of the signs in children but, when
present with diarrhea, indicates a gastrointestinal disturbance.
What nursing intervention is used to prevent increased intracranial pressure (ICP) in
an unconscious child?
A.
Suctioning child frequently
B.
Providing environmental stimulation
C.
Turning head side to side every hour
D.
Avoiding activities that cause pain or crying
Correct Answer Feedback-D
Suctioning is a distressing procedure. In addition the resultant decrease in
carbon dioxide can increase ICP. Environmental stimulation should be minimized. The
child’s head should not be turned side to side. If the jugular vein is compressed, ICP
can rise. Nursing interventions should focus on assessment and interventions to
minimize pain. These activities can cause the intracranial pressure to increase.
The nurse is caring for a 2-year-old girl who is unconscious but stable following a car
accident. Her parents are staying at the bedside most of the time. An appropriate
nursing intervention is to
A.
suggest that the parents go home until she is alert enough to know that they are
present.
B.
use ointment on her lips but do not attempt to cleanse her teeth until swallowing
returns.
C.
encourage the parents to hold, talk, and sing to her as they usually would.
D.
position her with proper body alignment and head of bed lowered 15 degrees.
Correct Answer Feedback-C
This is not recommended. The daughter may be able to hear that they are
present. Oral care is essential in the unconscious child. Mouth care should be done at
least twice daily. The parents should be encouraged to interact with their daughter.
Senses of hearing and tactile perception may be intact, and stimulation of these
senses is important. The head of the bed should be elevated, not lowered.
The nurse is caring for a toddler who has had surgery for a brain tumor. During an
assessment, the nurse notes that the child is becoming irritable and pupils are unequal
and sluggish. The MOST appropriate nursing action is to
A.
notify the health care provider immediately.
B.
document level of consciousness.
C.
observe closely for signs of increased intracranial pressure (ICP).
D.
administer pain medication and assess for response.
Correct Answer Feedback-A
The worsening of symptoms may indicate that intracranial pressure (ICP) is
increasing. The practitioner should be notified immediately. The health care provider
should be notified first before documenting. The nurse is already noting signs of
potentially increased ICP. Pain medication should not be given. Consultation with the
practitioner should occur first.
The nurse is admitting a young child to the hospital with suspected diagnosis of
bacterial meningitis. The PRIORITY of nursing care is to
A.
initiate isolation precautions as soon as the diagnosis is confirmed.
B.
initiate isolation precautions as soon as the causative agent is identified.
C.
administer antibiotic therapy as soon as it is ordered.
D.
administer sedatives/analgesics on a preventive schedule to manage pain.
Correct Answer Feedback-C
Isolation should be instituted as soon as diagnosis is suspected. Isolation should
be instituted as soon as diagnosis is suspected. This is the priority action. Antibiotics
are begun as soon as possible to prevent death and avoid resultant
disabilities. Antibiotics are the priority function; pain should be managed if it occurs.
The nurse is planning care for a school-age child with bacterial meningitis. The plan
should include
A.
keeping environmental stimuli at a minimum.
B.
avoiding giving pain medications that could dull sensorium.
C.
measuring head circumference to assess developing complications.
D.
having child move head side to side at least every 2 hours.
Correct Answer Feedback-A
Children with meningitis are sensitive to noise, bright lights, and other external
stimuli. The nurse should keep the room as quiet as possible, with a minimum of
external stimuli. After consultation with the practitioner, pain medications can be used
if necessary. A school-age child will have closed sutures. Head circumference should
not change. The child is placed in side-lying position with the head of the bed
slightly elevated. The nurse should avoid measures such as lifting the child’s head that
would increase discomfort.
A young child is having a seizure that has lasted 35 minutes. There is a loss of
consciousness. The nurse should recognize that this is
A.
absence seizure.
B.
generalized seizure.
C.
status epilepticus.
D.
simple partial seizure.
Correct Answer Feedback-C
Absence seizures are brief losses of consciousness. Generalized seizures are the
most common of seizures. They have a tonic phase of approximately 10 to 20
seconds. They involve both hemispheres of the brain. Status epilepticus is a
generalized seizure that lasts more than 30 minutes. Simple partial seizures are
characterized by varying sensations.
The nurse is discussing long-term care with the parents of a child who has a
ventriculoperitoneal shunt to correct hydrocephalus. In the discussion the nurse should
include that
A.
parental protection is essential until the child reaches adulthood.
B.
cognitive impairment is to be expected with hydrocephalus.
C.
shunt malfunction or infection requires immediate treatment.
D.
most usual childhood activities must be restricted.
Correct Answer Feedback-C
Limits should be appropriate to the developmental age of the child. Except
for contact sports, the child will have few restrictions. Cognitive impairment depends
on the extent of damage before the shunt was placed. Because of the potentially
severe sequelae, symptoms of shunt malfunction or infection must be assessed and
treated immediately if present. Limits should be appropriate to the developmental
age of the child. Except for contact sports, the child will have few restrictions.
A 3-year-old child is status postshunt revision for hydrocephaly. Part of the discharge
teaching plan for the parents is signs of shunt malformation. Which signs are of shunt
malformation? (Select all that apply.)
A.
Personality change
B.
Bulging anterior fontanel
C.
Vomiting
D.
Dizziness
E.
Fever
Correct Answer Feedback-A,C,E
Personality change can be a sign of shunt malformation related to
increased intracranial pressure. Vomiting can be a sign of shunt malformation related
to increased intracranial pressure. Fever can be a sign of shunt malformation and is
a very serious complication. The anterior fontanel closes between 12 and 18
months old. Dizziness is difficult to assess in a 3 year old and is not necessarily a sign
of shunt malformation.
The MOST appropriate nursing interventions when caring for a child experiencing a
seizure include (Select all that apply.)
A.
restraining the child when a seizure occurs to prevent bodily harm.
B.
placing a padded tongue between the teeth if they become clenched.
C.
avoid suctioning the child during the seizure.
D.
describing and documenting the seizure activity observed.
E.
applying supplemental oxygen after inserting an artificial oral airway.
Correct Answer Feedback-C,D
The priority nursing intervention is to observe the child and seizure, and document
the activity observed. The child should not be restrained, because this may cause
an injury. Nothing should be placed in the child’s mouth, because this may cause an
injury not only to the child but also to the nurse. To prevent aspiration, the child should
be placed on the side if possible to facilitate drainage.
When discussing a child’s precocious puberty with the parents, the nurse should tell
them that
A.
the child is not yet fertile.
B.
heterosexual interest is usually advanced.
C.
dress and activities should be appropriate to chronologic age.
D.
appearance of secondary sexual characteristics does not proceed in the usual
order.
Correct Answer Feedback-C
Functioning sperm or ova may be produced, thereby making the child fertile at an
early age. Heterosexual interest is usually appropriate to chronologic age. Because
of the early sexual maturation of the child, both family and child require extensive
teaching. Included in this is the information that the child should be engaged in
activities according to chronologic age. The secondary sexual characteristics proceed
in the usual order.
An infant is born with ambiguous genitalia. Tests are being done to assist in gender
assignment. The parents tell the nurse that family and friends are asking what caused
the baby to be this way. The nurse’s MOST appropriate action is to
A.
explain the disorder so parents can explain it to others.
B.
help parents understand that no one knows how this occurs.
C.
suggest that parents avoid family and friends until the gender is assigned.
D.
encourage parents not to worry while the tests are being done.
Correct Answer Feedback-A
This is the most therapeutic approach while the parents await the gender
assignment of their child. The disorder is caused by decreased enzyme activity
required for adrenal cortical production of cortisol. This is impractical and would
isolate the family from their support system while awaiting test results. The parents
will be concerned. Telling the parents not to worry without giving them specific
alternative actions would not be effective.
The nurse is explaining that the destruction of pancreatic beta-cells is the cause of
which disorder?
A.
Type 1 diabetes
B.
Type 2 diabetes
C.
Impaired glucose tolerance
D.
Gestational diabetes
Correct Answer Feedback-A
Type 1 diabetes is characterized by destruction of the insulin-producing
pancreatic beta-cells. Type 2 diabetes is a result of insulin resistance combined with
relative (versus absolute) insulin deficiency. The insulin-producing pancreatic beta-cells
are destroyed in type 1 diabetes. The insulin-producing pancreatic beta-cells
are destroyed in type 1 diabetes.
he mother of a child with type 1 diabetes mellitus asks why her child cannot avoid all
those “shots” and take pills as an uncle does. The nurse’s BEST reply is
A.
“The pills work with an adult pancreas only.”
B.
“The drugs affect fat and protein metabolism, not sugar.”
C.
“Your child needs insulin replaced, and the oral hypoglycemics only add to an
existing supply of insulin.”
D.
“Perhaps when your child is older the pancreas will produce its own insulin, and
then your child can take oral hypoglycemics.”
Correct Answer Feedback-C
The oral medications have different modes of action, which supplement
insulin production by the pancreas, decreasing insulin resistance or affecting liver
production of glucose. They are not insulin substitutes. The oral medications have
different modes of action, which supplement insulin production by the pancreas,
decreasing insulin resistance or affecting liver production of glucose. They are not
insulin substitutes. In type 1 diabetes, the beta-cells have been destroyed. It is
necessary to supply the insulin that they no longer produce. In type 1 diabetes, the
beta-cells are destroyed. Without a pancreas beta-cell transplant, it is unlikely that
insulin would be produced.
A school-age child recently diagnosed with type 1 diabetes mellitus asks the nurse if
he can still play soccer, baseball, and swim. The nurse’s response should be based on
knowledge that
A.
exercise is contraindicated.
B.
soccer and baseball are too strenuous, but swimming is acceptable.
C.
exercise is not restricted unless indicated by other health conditions.
D.
the level of activity depends on the type of insulin required.
Correct Answer Feedback-C
Exercise is highly encouraged. The decrease in blood glucose can be
accommodated by having snacks available. Sports are encouraged to help regulate
the insulin, and food should be adjusted according to the amount of exercise. The
child needs to be cautioned to monitor responses to the exercises. Exercise is
encouraged for children with diabetes because it lowers blood glucose levels. Insulin
and meal requirements require careful monitoring to ensure that the child has
sufficient energy for exercise. The level of activity does not depend on the type of
insulin used. Long- and short-acting insulin both may be used to compensate for the
effects of training and sporting events.
During the summer many children are more physically active. What changes in the
management of the child with diabetes should be expected as a result of more
exercise?
A.
Increased food intake
B.
Decreased food intake
C.
Increased risk of hyperglycemia
D.
Decreased risk of insulin shock
Correct Answer Feedback-A
Food intake should be increased in the summer when the child is more active.
Races and other competitions may require more food than other practice times. The
child will require increased food on days of increased activity. The increased
activity lowers blood glucose levels. Blood sugars must be monitored closely to avoid
the administration of too much insulin during a time of reduced need.
A 17-year-old boy with diabetes mellitus tells the school nurse that he has recently
started drinking alcohol with his friends on weekends. The nurse should
A.
tell him not to do this.
B.
ask him why he is drinking alcohol.
C.
teach him about the effects of alcohol on diabetes and how to prevent problems
associated with alcohol intake.
D.
provide an immediate referral for counseling so he understands the serious
consequences of alcohol consumption.
Correct Answer Feedback-C
Admonishing him will not help the adolescent if he chooses to continue drinking.
Asking him why will provide information to the nurse but will not address the
information that the adolescent needs to have about managing his disease. The nurse
is taking a proactive approach. The adolescent is provided with information to
facilitate the management of his illness. A recommendation for counseling can be
included in the teaching plan but providing an immediate referral for counseling may
be viewed as adversarial.
The nurse is teaching an adolescent, newly diagnosed with type I diabetes, ways to
minimize discomfort with insulin injections. Which interventions are helpful in
minimizing injection discomfort? (Select all that apply.)
A.
Do not reuse needles.
B.
Inject insulin when it is cold.
C.
Flex or tense the muscle during injection.
D.
Rotate sites.
E.
Do not move the direction of the needle-syringe during insertion or withdrawal.
Correct Answer Feedback-A,D,E
The reuse of needles leads to more discomfort on injection from decreased
sharpness of the needle and being an infection control problem. Rotate sites to
enhance absorption and minimize skin irritation. Keeping the direction of the syringe
constant during the insertion and withdrawal minimizes discomfort. Insulin should be
injected at room temperature to minimize discomfort. Flexing or tensing muscles
during injections causes more discomfort.
The nurse is discharging a 10-year-old patient admitted to the hospital in diabetic
ketoacidosis. The child has been newly diagnosed with type 1 diabetes mellitus (DM)
on this admission. The nurse should teach the child and parents which signs of type 1?
(Select all that apply.)
A.
Weight gain
B.
Nocturia
C.
Irritability
D.
Cool, clammy skin
E.
Blurred vision
Correct Answer Feedback-B,C,E
Clinical manifestations of type 1 diabetes mellitus include: Polyphagia, polyuria,
polydipsia, weight loss, enuresis or nocturia, irritability; not himself or herself,
shortened attention span, lowered frustration tolerance, dry skin, blurred vision, poor
wound healing, fatigue, flushed skin, headache, frequent infections, hyperglycemia,
elevated blood glucose levels, glucosuria, diabetic ketosis, ketones and glucose in
urine, dehydration in some cases, diabetic ketoacidosis, dehydration, electrolyte
imbalance, acidosis, deep, rapid breathing (Kussmaul respirations).
Which is a secondary effect when a child experiences decreased muscle strength,
tone, and endurance from immobilization?
A.
Increased metabolism
B.
Increased venous return
C.
Increased cardiac output
D.
Decreased exercise tolerance
Correct Answer Feedback-D
Metabolism decreases during periods of immobility. There is decreased venous
return because of decreased muscle activity. There is decreased cardiac output.
Muscle disuse leads to tissue breakdown and loss of muscle mass. It may take weeks
or months to recover.
Which is characteristic of fractures in children?
A.
Fractures rarely occur at the growth plate site, because it absorbs shock well.
B.
Rapidity of healing is inversely related to the age of the child.
C.
Pliable bones of growing children are less porous than those of the adult.
D.
Periosteum of a child’s bone is thinner, weaker, and has less osteogenic potential
compared with that of the adult.
Correct Answer Feedback-B
The cartilage epiphyseal plate is the weakest point of the long bone. Therefore, it
is a frequent site of damage. Fractures heal in children in less time than they do
in adults. As the child ages, the healing time increases. The periosteum is thickened,
and there is a great production of osteoclasts when a bone injury occurs. Bone
healing in children is rapid because of the thickened periosteum and generous blood
supply.
Therapeutic management of the patient with systemic lupus erythematosus includes
A.
cold salts to suppress the inflammatory process.
B.
a high-protein, low-salt diet.
C.
an exercise regimen focusing on weight training.
D.
corticosteroids to control inflammation.
Correct Answer Feedback-D
This will not affect the inflammatory process. A balanced diet without
exceeding caloric expenditures is recommended. Exercise should be done in
moderation and should not focus on weight training. Currently this is the primary
mode of therapy.
A nurse is caring for an infant with developmental dysplasia of the hip (DDH). Based
on the nurse’s knowledge of DDH, which clinical manifestation should the nurse expect
to observe? (Select all that apply.)
A.
Lordosis
B.
Positive Babinski sign
C.
Asymmetric thigh and gluteal folds
D.
Positive Ortolani and Barlow tests
E.
Shortening of limb on affected side
Correct Answer Feedback-C,D,E
Asymmetric thigh and gluteal folds are a clinical manifestation of DDH and seen from
birth to 2 months old. Positive Ortolani and Barlow tests are clinical manifestations of
DDH. Ortolani test is the abducting of the thighs to test for hip subluxation or
dislocation. Barlow test is the adducting to feel if the femoral head slips out of the
socket posterolaterally. Shortening of limb on affected side is another clinical
manifestation of DDH. Lordosis is the inward curve of the lumbar spine just above the
buttocks and is not a clinical manifestation of DDH. A negative Babinski sign is not a
clinical manifestation of DDH. It is a neurologic reflex which should be present in the
normal newborn.
Cerebral palsy may result from a variety of causes. It is now known that the most
common cause of cerebral palsy is
A.
birth asphyxia.
B.
neonatal diseases.
C.
cerebral trauma.
D.
prenatal brain abnormalities.
Correct Answer Feedback
These issues were previously thought to be factors. Cerebral palsy results
from existing brain abnormalities during the prenatal period.
The major goals of therapy for children with cerebral palsy include
A.
reversing degenerative processes that have occurred.
B.
curing underlying defect causing the disorder.
C.
preventing spread to individuals in close contact with the child.
D.
recognizing the disorder early and promoting optimal development.
Correct Answer Feedback-D
It is very difficult to reverse degenerative processes. The underlying defect cannot
be cured. Cerebral palsy is not contagious. Since cerebral palsy is currently a
permanent disorder, the goal of therapy is to promote optimal development. This is
done through early recognition and beginning of therapy.
An 8-year-old female child is diagnosed with moderate cerebral palsy (CP). She
recently began participation in a regular classroom for part of the day. Her mother
asks the school nurse about having her daughter join the after-school Girl Scout troop.
The nurse’s response should be based on knowledge that
A.
most activities such as Girl Scouts cannot be adapted for children with CP.
B.
after-school activities usually result in extreme fatigue for children with CP.
C.
trying to participate in activities such as Girl Scouts leads to lowered self-esteem
in children with CP.
D.
after-school activities often provide children with CP opportunities for
socialization and recreation.
Correct Answer Feedback-D
Most activities can be adapted for children. The child, family, and activity
director should assess the degree of activity to ensure that it meets with the
child’s capabilities. A supportive environment will add to the child’s self-esteem.
Recreational outlets and after-school activities should be considered for the child who
is unable to participate in athletic programs.
A neural tube defect that is not visible externally in the lumbosacral area would be
called
A.
meningocele.
B.
myelomeningocele.
C.
spina bifida cystica.
D.
spina bifida occulta.
Correct Answer Feedback-D
Meningocele contains meninges and spinal fluid but no neural tissue. Unless there
are associated cutaneous findings, it is often not identified until later.
Myelomeningocele is a neural tube defect that contains meninges, spinal fluid, and
nerves. This is a cystic formation with an external saclike protrusion. Spina bifida
occulta is completely enclosed. Often this defect will not be noticed.
A woman who is 6 weeks’ pregnant tells the nurse that she is worried that the baby
might have spina bifida because of a family history. The nurse’s BEST response is
A.
“There is no genetic basis for the defect.”
B.
“Prenatal detection is not possible yet.”
C.
“Chromosome studies done on amniotic fluid can diagnose the defect prenatally.”
D.
“The concentration of alpha-fetoprotein in amniotic fluid can indicate the
presence of the defect prenatally.”
Correct Answer Feedback-D
The origin of neural tube defects is unknown, but it appears to have a
multifactorial inheritance pattern. Prenatal detection is possible through amniotic fluid
or chorionic villi sampling. There is no chromosome study at this time. Fetal ultrasound
and elevated concentrations of alpha-fetoprotein in amniotic fluid may indicate
the presence of anencephaly or myelomeningocele.
What most accurately describes bowel function in children born with a
myelomeningocele?
A.
Incontinence cannot be prevented.
B.
Enemas and laxatives are contraindicated.
C.
Some degree of fecal continence can usually be achieved.
D.
Colostomy is usually required by the time the child reaches adolescence.
Correct Answer Feedback-C
Although a lengthy process, continence can be achieved with modification of diet,
use of laxatives, and/or enemas. These are part of the strategy to achieve
continence. There is no general contraindication. With diet modification and regular
toilet habits to prevent constipation and impaction, some degree of fecal continence
can be achieved. Colostomy usually is not required.
Which statement BEST describes pseudohypertrophic (Duchenne) muscular dystrophy?
A.
It is inherited as an autosomal dominant disorder.
B.
It is characterized by weakness of proximal muscles of both pelvic and shoulder
girdles.
C.
It is characterized by muscle weakness usually beginning about 3 years old.
D.
Onset occurs in later childhood and adolescence.
Correct Answer Feedback-C
It is inherited as an X-linked recessive trait. The first weakness is usually noted
in walking. Then a progressive involvement of other muscle groups
occurs. Usually children with Duchenne muscular dystrophy reach the early
developmental milestones; the muscular weakness is usually observed in the third year
of life. Onset usually develops in the third year of life.
What is frequently associated with infant botulism?
A.
Contaminated soil
B.
Honey and corn syrup
C.
Commercial infant cereals
D.
Improperly sterilized bottles
Correct Answer Feedback-B
These substances are not usually associated with infants who have become
affected. Unlike adult botulism, infant botulism is caused by ingesting spores
of C. botulinum and the resultant release of toxin. The bacterium has been found in
honey and corn syrup that was fed to affected infants. These substances are not
usually associated with infants who have become affected. These substances are not
usually associated with infants who have become affected.
A 15 year old is admitted to the intensive care unit (ICU) with a spinal cord injury. The
MOST appropriate nursing interventions for this adolescent are (Select all that apply.)
A.
monitoring neurologic status.
B.
administering corticosteroids.
C.
monitoring for respiratory complications.
D.
discussing long-term care issues with the family.
E.
monitoring and maintaining hemodynamic status.
Correct Answer FeedbackA,B,C,E
Close monitoring of sensory and motor function is important to prevent further
deterioration of neurologic status as a result of spinal cord edema. Corticosteroids
are administered to minimize the inflammation associated with the injury. Close
monitoring of respiratory status for possible need of ventilator support. Remember
“A-B-C’s,” airway, breathing, and circulation. Monitoring and maintaining
hemodynamic status may require immediate attention related to increased
intracranial pressure resulting in hypotension and bradycardia. The discussion of longterm care issues with the family is not appropriate in the acute phase of spinal
cord injury.
The pediatric clinic nurse completes an assessment on a 4-month-old infant brought in
because the parents are concerned that something is “just not right” with their baby.
The nurse should alert the health care provider to which assessment findings? (Select
all that apply.)
A.
Inability to sit up without support
B.
Poor head control and clenched fists
C.
Inability to crawl
D.
Failure to smile
E.
Extreme irritability
Correct Answer Feedback-B,D,E
The infant would be expected to sit up without support until 6 or 7 months old. Crawling would not be an expected finding in
a 4-month-old infant. Early signs of cerebral palsy include
Failure to meet any developmental milestones such as rolling over, raising head, sitting up, crawling
Persistent primitive reflexes such as Moro, asymmetrical tonic neck reflex
Poor head control (head lag) and clenched fists after 3 months old
Stiff or rigid arms or legs; scissoring legs
Pushing away or arching back; stiff posture
Floppy or limp body posture, especially while sleeping
Inability to sit up without support by 8 months
Using only one side of the body or only the arms to crawl
Feeding difficulties
Persistent gagging or choking when fed
After 6 months old, tongue pushing soft food out of the mouth
Extreme irritability or crying
Failure to smile by 3 months old
Lack of interest in surroundings