Mobility (Musculoskeletal) Health

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Review
Physiological Integrity of
Children
Question and
Answer
1. According to JCAHO, which statement is inappropriate related
to pediatric restraints?
A. Substitute mummy restraints for therapeutic holding in
newborns undergoing IV insertion
B. The restraint order must be written by the health care
provider within 1 hour of applying the restraint
C. No specific order is required for elbow restraints after cleft
lip or palate repair
D. Restraint safety must be assessed and documented at
least every 2 hours
1. According to JCAHO, which statement is inappropriate related
to pediatric restraints?
A. Substitute mummy restraints for therapeutic holding in
newborns undergoing IV insertion
B. The restraint order must be written by the health care
provider within 1 hour of applying the restraint
C. No specific order is required for elbow restraints after cleft
lip or palate repair
D. Restraint safety must be assessed and documented at
least every 2 hours
A. Therapeutic holding is always appropriate as first line
restraint if it is available and effective.
2. Why would a 3-year-old child be more likely to take 5 mL of
medication from a 10 mL syringe than a 5 mL syringe if given
both options?
A. This child doesn’t yet comprehend the principle of
conservation of mass
B. The child is empowered by being given a choice
C. There is more dilution when given in a larger container
D. The child wants to please the nurse and chooses the larger
container
2. Why would a 3-year-old child be more likely to take 5 mL of
medication from a 10 mL syringe than a 5 mL syringe if given
both options?
A. This child doesn’t yet comprehend the principle of
conservation of mass
B. The child is empowered by being given a choice
C. There is more dilution when given in a larger container
D. The child wants to please the nurse and chooses the larger
container
A. Conservation of mass usually develops at school age.
Before that time it looks like a smaller volume when placed
in a larger container.
3. The nurse is preparing to give an IM injection to a 1 ½- yearold. Where should this be given?
A.
B.
C.
D.
Deltoid
Gluteus Maximus
Ventrogluteus
Vastus Lateralis
3. The nurse is preparing to give an IM injection to a 1 ½- yearold. Where should this be given?
A.
B.
C.
D.
Deltoid
Gluteus Maximus
Ventrogluteus
Vastus Lateralis
D. This is preferred until age 2, then the ventrogluteus or
deltoid may be used. The gluteus maximus should not be
used until the child has been walking for at least 1 year.
Physiological Integrity of Children
Pediatric Safety
Intramuscular
4. Which statement is true regarding the collection of blood for a
CBC from a toddler?
A. Since it must be arterial blood, the needle stick should be
fast and the blood collected quickly
B. Children fear the loss of any blood and must be reassured
they will make more
C. Because the pain sensors are not yet fully developed, the
pain is minimal
D. Bandages should not be applied as they increase the
chance for infection at the blood draw site
4. Which statement is true regarding the collection of blood for a
CBC from a toddler?
A. Since it must be arterial blood, the needle stick should be
fast and the blood collected quickly
B. Children fear the loss of any blood and must be reassured
they will make more
C. Because the pain sensors are not yet fully developed, the
pain is minimal
D. Bandages should not be applied as they increase the
chance for infection at the blood draw site
B. Making comments about how red the blood is and how well
they are making it will help reassure children. Bandages
are helpful so the child will not think more will leak out. Any
needle stick is painful and a CBC does not require arterial
blood.
5. Which potential nursing action to assess hydration status in a
child should be changed?
A. Assess urine output with 35 mL/Kg/day indicating good
hydration
B. Obtain daily weight before breakfast
C. Evaluate specific gravity by squeezing urine from the
diaper on to the test strip
D. Weight each diaper with each gram of urine equal to 1 mL
of output
5. Which potential nursing action to assess hydration status in a
child should be changed?
A. Assess urine output with 35 mL/Kg/day indicating good
hydration
B. Obtain daily weight before breakfast
C. Evaluate specific gravity by squeezing urine from the
diaper on to the test strip
D. Weight each diaper with each gram of urine equal to 1 mL
of output
A. While 1 mL/Kg/hour is what is desired, it is not possible to
determine this unless the child is catheterized.
6. Which is the most serious symptom of acute dehydration?
A.
B.
C.
D.
Dry mucus membranes
Hypotension
Capillary refill 1-2 seconds
Skin color pale
6. Which is the most serious symptom of acute dehydration?
A.
B.
C.
D.
Dry mucus membranes
Hypotension
Capillary refill 1-2 seconds
Skin color pale
B. Hypotension, tachycardia, and capillary refill over 3
seconds corresponds to severe dehydration with circulatory
system manifestations.
7. In educating a class of school teachers about immunizations,
which statement indicates the need for further clarification?
A. If a child is up to date on immunizations, there is decreased
risk of a chicken pox outbreak
B. Immunizations are a form of passive immunity
C. Passive immunity to hepatitis A is only temporary
D. Natural active immunity is the longest lasting and most
effective type of immunity
7. In educating a class of school teachers about immunizations,
which statement indicates the need for further clarification?
A. If a child is up to date on immunizations, there is decreased
risk of a chicken pox outbreak
B. Immunizations are a form of passive immunity
C. Passive immunity to hepatitis A is only temporary
D. Natural active immunity is the longest lasting and most
effective type of immunity
B. Immunizations are active immunity.
8. A client is exhibiting itchy eyes, bronchoconstriction and
allergic rhinitis. The RN would expect which aspect of
immunoglobulin to be elevated?
A.
B.
C.
D.
IgA
IgE
IgG
IgD
8. A client is exhibiting itchy eyes, bronchoconstriction and
allergic rhinitis. The RN would expect which aspect of
immunoglobulin to be elevated?
A.
B.
C.
D.
IgA
IgE
IgG
IgD
B. IgE is related to allergic reactions.
9. A child has received a kidney transplant. Which part of the
immune system needs to be suppressed?
A.
B.
C.
D.
Th and Tc
Ts and Th
Ts and NK
Ts and Tc
9. A child has received a kidney transplant. Which part of the
immune system needs to be suppressed?
A.
B.
C.
D.
Th and Tc
Ts and Th
Ts and NK
Ts and Tc
A. The T-helper, T-cytokins, and Natural Killer cells all need to
be suppressed to prevent tissue rejection.
10. Which client does the RN assess to be most likely to benefit
from immune globulin administration?
A.
B.
C.
D.
Cut hand with kitchen knife and no tetanus immunization
Lymphocytosis
Neutrophil shift-to-the-left
Congenital B-cell deficiency
10. Which client does the RN assess to be most likely to benefit
from immune globulin administration?
A.
B.
C.
D.
Cut hand with kitchen knife and no tetanus immunization
Lymphocytosis
Neutrophil shift-to-the-left
Congenital B-cell deficiency
D. B-cells make antibodies of which immunoglobulin is one
type. A would be at little risk for tetanus and B and C are
dysfunctions of WBC, not immunoglobulin deficiency.
11. Which level of prevention would the nurse perform by giving
influenza vaccines in a local clinic?
A.
B.
C.
D.
Primary prevention
Secondary prevention
Tertiary prevention
All three levels of prevention
11. Which level of prevention would the nurse perform by giving
influenza vaccines in a local clinic?
A.
B.
C.
D.
Primary prevention
Secondary prevention
Tertiary prevention
All three levels of prevention
A. Primary prevention = health promotion and disease/injury
prevention; secondary prevention = screening and early
diagnosis of disease; tertiary prevention = maximizing
function and minimizing effects of disabilities/chronic
conditions.
12. Which immunization should a 2-month-old infant receive?
A.
B.
C.
D.
Varicella vaccine
Diphtheria, tetanus and pertussis vaccine (DTaP)
Tetanus and diphtheria vaccine (Td)
Measles, mumps, and rubella vaccine (MMR)
12. Which immunization should a 2-month-old infant receive?
A.
B.
C.
D.
Varicella vaccine
Diphtheria, tetanus and pertussis vaccine (DTaP)
Tetanus and diphtheria vaccine (Td)
Measles, mumps, and rubella vaccine (MMR)
B. The preferred age for initial immunization for pertussis is 2
months; the pertussis vaccine is administered in
combination with diphtheria and tetanus
13. What findings would the nurse anticipate when assessing a 6year-old client with possible rubella?
A.
B.
C.
D.
A pinkish maculopapular rash on the head and neck
A positive Kernig’s sign and nuchal rigidity
Koplik's spots on the soft palate and buccal mucosa
Conjunctivitis and malaise
13. What findings would the nurse anticipate when assessing a 6year-old client with possible rubella?
A.
B.
C.
D.
A pinkish maculopapular rash on the head and neck
A positive Kernig’s sign and nuchal rigidity
Koplik's spots on the soft palate and buccal mucosa
Conjunctivitis and malaise
A. Choice B reflects possible meningitis, and choice C reflects
possible rubeola. Conjunctivitis and malaise are part of the
prodromal phase of rubeola in children, and part of the
prodromal phase of rubella in adolescents and adults.
14. Which nursing diagnosis would be appropriate for the most
severe (though rare) complication of Rubella in a child?
A.
B.
C.
D.
Self-care deficit related to paralysis
Disorganized thought processes related to increased ICP
Fluid volume excess related to circulatory overload
Impaired skin integrity related to skin ulceration
14. Which nursing diagnosis would be appropriate for the most
severe (though rare) complication of Rubella in a child?
A.
B.
C.
D.
Self-care deficit related to paralysis
Disorganized thought processes related to increased ICP
Fluid volume excess related to circulatory overload
Impaired skin integrity related to skin ulceration
B. Encephalitis has occasionally but rarely been identified
after Rubella.
15. A child with Cystic Fibrosis (CF) contracts Rubeola. Which
nursing intervention is most appropriate?
A. Isolate the child for 2 weeks after desquamation develops
B. Stress the need to keep pregnant friends/relatives from
visiting
C. Administer antibiotics per physician order
D. Use maximum dose of antipyretic medications as fever
spikes on the 1st-2nd day of the rash
15. A child with Cystic Fibrosis (CF) contracts Rubeola. Which
nursing intervention is most appropriate?
A. Isolate the child for 2 weeks after desquamation develops
B. Stress the need to keep pregnant friends/relatives from
visiting
C. Administer antibiotics per physician order
D. Use maximum dose of antipyretic medications as fever
spikes on the 1st-2nd day of the rash
C. Prophylactic antibiotics are used for high-risk children such
as with a chronic disease like CF. Contagion occurs 4
days before to 5 days after rash develops. Desquamation
occurs 3-4 days after onset and fever spikes on 4th to 5th
day.
16. Which is the most appropriate in the plan of care for a child
with mumps?
A.
B.
C.
D.
Assess visual acuity every shift
Isolate the child for 14 days
Encourage soft foods and increased fluid intake
Discourage use of underwear for the male child on bedrest
16. Which is the most appropriate in the plan of care for a child
with mumps?
A.
B.
C.
D.
Assess visual acuity every shift
Isolate the child for 14 days
Encourage soft foods and increased fluid intake
Discourage use of underwear for the male child on bedrest
C. Chewing often increases pain in the ear and jaw, so soft
foods are encouraged. Assessing hearing is important as
well as wearing underwear to support the scrotum if orchitis
develops. Mumps is most contagious from just before to 4
days after onset of symptoms.
17. In teaching the parent of a child with chicken pox, which
measure would the nurse suggest to relieve pruritus?
A.
B.
C.
D.
Cleaning the vesicles with diluted hydrogen peroxide
Applying topical calamine lotion to irritated areas
Using cool saline compresses on top of the eruptions
Keeping the child's fingernails short and using mittens
when necessary
17. In teaching the parent of a child with chicken pox, which
measure would the nurse suggest to relieve pruritus?
A.
B.
C.
D.
Cleaning the vesicles with diluted hydrogen peroxide
Applying topical calamine lotion to irritated areas
Using cool saline compresses on top of the eruptions
Keeping the child's fingernails short and using mittens
when necessary
B. Although answer choice D is true, it does not answer the
question. To relieve pruritus, calamine lotion may prove
helpful.
18. The parent of a child with chickenpox asks when the child can
go back to school. Select the most appropriate response.
A.
B.
C.
D.
“When the child is no longer running a fever.”
“Once the blisters are all scabbed over.”
“When all of the scabs on the blisters have fallen off.”
“After completing antibiotics for 24 hours.”
18. The parent of a child with chickenpox asks when the child can
go back to school. Select the most appropriate response.
A.
B.
C.
D.
“When the child is no longer running a fever.”
“Once the blisters are all scabbed over.”
“When all of the scabs on the blisters have fallen off.”
“After completing antibiotics for 24 hours.”
B. When the open lesions are no longer draining, the disease
is no longer contagious.
Physiological Integrity of Children
Oxygenation (Respiratory) Health
Varicella
(Chickenpox)
19. The parent of a child with Down Syndrome who develops
Acute Lymphocytic Leukemia asks the nurse what causes
cancer. Which statement by the parent indicates further
discussion is needed?
A. “Some cancers are caused by faulty genes.”
B. “A weakened immune system can increase risk for
cancer.”
C. “Protooncogenes can cause normal cells to turn into
cancer cells.”
D. “Infection with certain viruses can lead to cancer.”
19. The parent of a child with Down Syndrome who develops
Acute Lymphocytic Leukemia asks the nurse what causes
cancer. Which statement by the parent indicates further
discussion is needed?
A. “Some cancers are caused by faulty genes.”
B. “A weakened immune system can increase risk for
cancer.”
C. “Protooncogenes can cause normal cells to turn into
cancer cells.”
D. “Infection with certain viruses can lead to cancer.”
C. Oncogenes can cause normal cells to transform into
cancer cells.
20. The client is receiving chemotherapy with Adriamycin
(doxorubicin). The nurse stops the infusion immediately and
notifies the physician if which symptom(s) occur(s)?
A.
B.
C.
D.
Urine turns reddish brown
Nausea occurs
Mouth soreness develops
Redness and swelling occur at the IV site
20. The client is receiving chemotherapy with Adriamycin
(doxorubicin). The nurse stops the infusion immediately and
notifies the physician if which symptom(s) occur(s)?
A.
B.
C.
D.
Urine turns reddish brown
Nausea occurs
Mouth soreness develops
Redness and swelling occur at the IV site
D. This type of drug may cause sclerosing and even minute
amounts can cause severe cellular damage if the IV
infiltrates although pain may not occur. While the other
symptoms may occur, the IV is the most important problem
to address immediately.
21. A 4-year-old pulls a pot of boiling soup off the stove causing
burns to the left arm. What would be the best immediate
intervention?
A.
B.
C.
D.
Remove food particles and apply burn cream
Apply an ice pack to the left arm
Remove food particles and shirt sleeve
Apply cool water and baking soda to the left arm
21. A 4-year-old pulls a pot of boiling soup off the stove causing
burns to the left arm. What would be the best immediate
intervention?
A.
B.
C.
D.
Remove food particles and apply burn cream
Apply an ice pack to the left arm
Remove food particles and shirt sleeve
Apply cool water and baking soda to the left arm
C. Remove the heat source and any non-adherent clothing;
apply cool water, not ice or any ointments or other agents,
and transport to the emergency department.
22. A 6-year-old is playing with the mother’s “beauty equipment”
and rubs hair remover cream on the legs. About 45 minutes
later, the child begins to cry and say the legs burn. What
should the mother be instructed to do first?
A.
B.
C.
D.
Neutralize by applying water and baking soda to the legs
Wipe off cream and wash legs with large amounts of water
Apply burn ointment to stop the burning action of the cream
Transport to the hospital without doing anything else
22. A 6-year-old is playing with the mother’s “beauty equipment”
and rubs hair remover cream on the legs. About 45 minutes
later, the child begins to cry and say the legs burn. What
should the mother be instructed to do first?
A.
B.
C.
D.
Neutralize by applying water and baking soda to the legs
Wipe off cream and wash legs with large amounts of water
Apply burn ointment to stop the burning action of the cream
Transport to the hospital without doing anything else
B. Chemicals left in contact with the skin longer than
recommended will cause burns. The area should be wiped
off and flushed with large amounts of water. Then
transport to the hospital.
23. A construction worker accidentally touches a high voltage
electric line and is thrown to the ground. What nursing
diagnosis would have highest priority?
A.
B.
C.
D.
Risk for increased energy field
Risk for situational trauma
Risk for decreased cardiac output
Risk for impaired skin integrity
23. A construction worker accidentally touches a high voltage
electric line and is thrown to the ground. What nursing
diagnosis would have highest priority?
A.
B.
C.
D.
Risk for increased energy field
Risk for situational trauma
Risk for decreased cardiac output
Risk for impaired skin integrity
C. The greatest concern with electrical situations is cardiac
arrest.
Physiological Integrity of Children
Pediatric Safety
Chemical Burns
•Gently flood with water
•Continue flooding while clothing
is being removed
•Avoid a hard blast of water, as
from a hose
Physiological Integrity of Children
Pediatric Safety
Electrical Burns
•Examine for cardiac or
respiratory arrest
•Institute cardiopulmonary
resuscitation
•Apply dry sterile dressings to
entry and exit wounds
24. A 4-year-old child is brought to the emergency room with a
deep partial thickness burn, sustained from hot grease. Upon
assessing the burn, which characteristic would a nurse expect
to find?
A. Dry skin surface that blanches readily to pressure and
quickly refills
B. Blistered, moist, mottled skin that is red or dull white
C. Tough, leathery skin surface that does not blanch and refill
with pressure
D. Brown, tan, black, or pearly white skin with no blisters
24. A 4-year-old child is brought to the emergency room with a
deep partial thickness burn, sustained from hot grease. Upon
assessing the burn, which characteristic would a nurse expect
to find?
A. Dry skin surface that blanches readily to pressure and
quickly refills
B. Blistered, moist, mottled skin that is red or dull white
C. Tough, leathery skin surface that does not blanch and refill
with pressure
D. Brown, tan, black, or pearly white skin with no blisters
B. A deep partial thickness burn is a second degree burn that
appears blistered, moist, and mottled and may be red, dull
white, or tan
Physiological Integrity of Children
Pediatric Safety
Deep Partial
Thickness
Burns
25. Which is the RN’s 1st priority after extensive deep partial
thickness and full thickness burns?
A.
B.
C.
D.
Obtain vascular access and start IV
Provide emotional support for client and significant others
Monitor for symptoms of hyperkalemia
Assess for symptoms of Acute Respiratory Distress
Syndrome
25. Which is the RN’s 1st priority after extensive deep partial
thickness and full thickness burns?
A.
B.
C.
D.
Obtain vascular access and start IV
Provide emotional support for client and significant others
Monitor for symptoms of hyperkalemia
Assess for symptoms of Acute Respiratory Distress
Syndrome
A. Due to rapid massive fluid 3rd spacing after severe burns,
securing airway patency and IV access are top priorities.
26. The nurse is caring for a child with circumferential full
thickness burns to the right arm and trunk. Which nursing
intervention has the highest priority in the plan of care?
A.
B.
C.
D.
Assess radial pulses several times a day
Enforce airborne infection control precautions
Perform range of motion several times a day
Remove blisters from the burn area
26. The nurse is caring for a child with circumferential full
thickness burns to the right arm and trunk. Which nursing
intervention has the highest priority in the plan of care?
A.
B.
C.
D.
Assess radial pulses several times a day
Enforce airborne infection control precautions
Perform range of motion several times a day
Remove blisters from the burn area
A. Circumferential burns often produce strictures and reduce
circulation causing tissue necrosis.
27. A 4-year-old child sustained full-thickness burns to the inner
thighs. There is no facial, airway or upper body involvement.
Which nursing diagnosis has the highest priority in the
emergent phase of burn care?
A.
B.
C.
D.
Diversional activity deficit
Less than nutritional requirements
Impaired skin integrity
Dysfunctional family process
27. A 4-year-old child sustained full-thickness burns to the inner
thighs. There is no facial, airway or upper body involvement.
Which nursing diagnosis has the highest priority in the
emergent phase of burn care?
A.
B.
C.
D.
Diversional activity deficit
Less than nutritional requirements
Impaired skin integrity
Dysfunctional family process
C. Priorities include stopping the burning process, removing
burned clothing if not adhering to the skin, and covering the
wound. Airway is also a priority.
28. As the RN plans care for a child with 30% body surface area
(BSA), partial thickness and full-thickness burns, which is the
best goal to assess fluid adequacy?
A.
B.
C.
D.
BP remains within normal range
Urine output is maintained at 1-2 mL/Kg/hour
Lung sounds remain clear
Weight remains within 10% of baseline
28. As the RN plans care for a child with 30% body surface area
(BSA), partial thickness and full-thickness burns, which is the
best goal to assess fluid adequacy?
A.
B.
C.
D.
BP remains within normal range
Urine output is maintained at 1-2 mL/Kg/hour
Lung sounds remain clear
Weight remains within 10% of baseline
B. Urine output is the best indicator of adequate fluid levels.
29. Which topical agent would be most appropriate for a client
with partial thickness and deep partial thickness burns with
renal insufficiency and Bactrim/Septra allergy?
A.
B.
C.
D.
Betadine (providone-iodine)
Sulfamylon (mafenideacetate)
Silvadene (silver sulfadiazine)
Garamycin (gentamycin sulfate)
29. Which topical agent would be most appropriate for a client
with partial thickness and deep partial thickness burns with
renal insufficiency and Bactrim/Septra allergy?
A.
B.
C.
D.
Betadine (providone-iodine)
Sulfamylon (mafenideacetate)
Silvadene (silver sulfadiazine)
Garamycin (gentamycin sulfate)
A. Choices B and C are sulfa based as is Bactrim/Septa and
D is nephrotoxic.
30. A client with full thickness burns to the right arm is going to
hydrotherapy for escharotomy. Which intervention has the
highest priority?
A.
B.
C.
D.
Pain control before the procedure
Psychosocial preparation for the procedure
Dietary therapy to enhance healing
Electrolyte replacement before the procedure
30. A client with full thickness burns to the right arm is going to
hydrotherapy for escharotomy. Which intervention has the
highest priority?
A.
B.
C.
D.
Pain control before the procedure
Psychosocial preparation for the procedure
Dietary therapy to enhance healing
Electrolyte replacement before the procedure
A. Though full thickness burns destroy nerve endings, there
are likely partial and deep partial thickness burns at the
periphery of the central burn, so pain control is a priority.
31. What would be the priority action for the nurse when a client
returns from surgery after split thickness skin grafts to both
feet?
A. Prevent movement of donor site
B. Monitor donor and receiver sites for infection
C. Plan activities to prevent boredom since client will be
immobilized
D. Maintain client on bedrest to promote graft adherence to
the capillary bed
31. What would be the priority action for the nurse when a client
returns from surgery after split thickness skin grafts to both
feet?
A. Prevent movement of donor site
B. Monitor donor and receiver sites for infection
C. Plan activities to prevent boredom since client will be
immobilized
D. Maintain client on bedrest to promote graft adherence to
the capillary bed
D. For this type of graft to be successful, contact between the
graft and recipient “bed” must be maintained, free of
bleeding and infection.
32. A hospitalized 5-year-old child with severe burns to the
abdomen and legs becomes upset and combative when it is
time to change the dressings and apply Sulfamylon (mafenide
acetate). Select the intervention that will help this child the
most.
A. Allow the child to determine the time of the dressing
change
B. Allow the child to help with the dressing change
C. Tell the child it is OK to cry but the child must lie quietly
D. Explain the importance of the dressing change to the child
32. A hospitalized 5-year-old child with severe burns to the
abdomen and legs becomes upset and combative when it is
time to change the dressings and apply Sulfamylon (mafenide
acetate). Select the intervention that will help this child the
most.
A. Allow the child to determine the time of the dressing
change
B. Allow the child to help with the dressing change
C. Tell the child it is OK to cry but the child must lie quietly
D. Explain the importance of the dressing change to the child
B. Some control may help the child cope with the frustration of
hospitalization and the discomfort of the dressing change.
33. A nurse just completed a presentation on pediculosis capitis
to the local school board. What statement, overheard by the
nurse, indicates the information was understood?
A. “Since I'm an adult, I no longer need to worry about getting
head lice.“
B. “The presence of head lice in a school indicates poor
cleanliness by the school's janitorial services.“
C. “This type of problem only occurs in schools located in
impoverished areas of a city.“
D. “Head lice can occur in anyone, regardless of age or
socioeconomic level.“
33. A nurse just completed a presentation on pediculosis capitis
to the local school board. What statement, overheard by the
nurse, indicates the information was understood?
A. “Since I'm an adult, I no longer need to worry about getting
head lice.“
B. “The presence of head lice in a school indicates poor
cleanliness by the school's janitorial services.“
C. “This type of problem only occurs in schools located in
impoverished areas of a city.“
D. “Head lice can occur in anyone, regardless of age or
socioeconomic level.“
D. Anyone can have head lice (pediculosis capitis) regardless
of age, cleanliness, or socioeconomic level.
34. Which intervention included in a care plan for a child with
scabies needs to be revised?
A. After application of Elimite (permethrin 5%), hold and
comfort the child
B. Bathe the child thoroughly after the Elimite has been on for
8-14 hours
C. Apply Elimite beneath fingernails and toenails with a
toothpick
D. If itching continues after treatment, reassure that treatment
does not need to be reapplied
34. Which intervention included in a care plan for a child with
scabies needs to be revised?
A. After application of Elimite (permethrin 5%), hold and
comfort the child
B. Bathe the child thoroughly after the Elimite has been on for
8-14 hours
C. Apply Elimite beneath fingernails and toenails with a
toothpick
D. If itching continues after treatment, reassure that treatment
does not need to be reapplied
A. There should be minimal touching and holding after
application of Elimite. If touching occurs, wash hands
immediately.
35. A 24-year-old client tells the nurse she and her husband are
considering starting a family soon. What teaching point would
the nurse include concerning the importance of dietary folic
acid?
A. “Folic acid will help reduce the chance of spinal cord
problems in your baby.”
B. “Your baby will develop a stronger immune system due to
the folic acid.”
C. “One action of folic acid is to prepare your body for the
pregnancy.”
D. “Folic acid is needed to help form your baby’s blood
components.”
35. A 24-year-old client tells the nurse she and her husband are
considering starting a family soon. What teaching point would
the nurse include concerning the importance of dietary folic
acid?
A. “Folic acid will help reduce the chance of spinal cord
problems in your baby.”
B. “Your baby will develop a stronger immune system due to
the folic acid.”
C. “One action of folic acid is to prepare your body for the
pregnancy.”
D. “Folic acid is needed to help form your baby’s blood
components.”
A. Folic acid taken prior to conception and early in pregnancy
will decrease the risk of neural tube defects in the fetus.
36. After surgery for reduction of spina bifida cystica, which is the
best rationale for why ventriculo-peritoneal shunt is not
indicated at this time?
A. The specific defect was meningocele
B. Lower extremity movement is symmetrical and active after
surgery
C. Occipital-frontal circumference preoperative and
postoperative are equal
D. There is an absence of Arnold-Chiari malformation
36. After surgery for reduction of spina bifida cystica, which is the
best rationale for why ventriculo-peritoneal shunt is not
indicated at this time?
A. The specific defect was meningocele
B. Lower extremity movement is symmetrical and active after
surgery
C. Occipital-frontal circumference preoperative and
postoperative are equal
D. There is an absence of Arnold-Chiari malformation
C. An increase in occipital-frontal circumference indicates
hydrocephalus and the need for a shunt.
Physiological Integrity of Children
Sensation, Perception, and Protection
Myelomeningocele
37. What response by the nurse will best help the parents of an
infant with spina bifida cope with this situation?
A. Encourage parents to resolve their grief as soon as
possible
B. Emphasize positive attributes of their infant
C. Avoid talking about the infant until the parents are ready to
bring up the subject
D. Do not allow the parents to become too upset over the
situation
37. What response by the nurse will best help the parents of an
infant with spina bifida cope with this situation?
A. Encourage parents to resolve their grief as soon as
possible
B. Emphasize positive attributes of their infant
C. Avoid talking about the infant until the parents are ready to
bring up the subject
D. Do not allow the parents to become too upset over the
situation
B. Pointing out unique physical or personality traits of an
infant helps parents to see their child as a unique individual
38. An infant with a myelomeningocele develops increased
intracranial pressure as a result of hydrocephalus. What
early sign of increased intracranial pressure would most likely
be seen by the nurse?
A.
B.
C.
D.
Altered pupil reactivity
Papilledema
Diminished response to painful stimuli
High-pitched cry
38. An infant with a myelomeningocele develops increased
intracranial pressure as a result of hydrocephalus. What
early sign of increased intracranial pressure would most likely
be seen by the nurse?
A.
B.
C.
D.
Altered pupil reactivity
Papilledema
Diminished response to painful stimuli
High-pitched cry
D. Only answer choice D is considered an early sign; the
other choices represent late signs of increased ICP.
39. What is a short-term preoperative goal for a 1-month-old
client scheduled for ventriculoperitoneal (VP) shunt for
congenital hydrocephalus?
A.
B.
C.
D.
Keep comfortable and limit crying
Feed on fixed schedule to ensure adequate hydration
Protect the head from injury with thick bandage
Provide wide variety of play objects for sensory stimulation
39. What is a short-term preoperative goal for a 1-month-old
client scheduled for ventriculoperitoneal (VP) shunt for
congenital hydrocephalus?
A.
B.
C.
D.
Keep comfortable and limit crying
Feed on fixed schedule to ensure adequate hydration
Protect the head from injury with thick bandage
Provide wide variety of play objects for sensory stimulation
A. Crying causes increased pressure in the cranial area and
blood vessels.
Physiological Integrity of Children
Sensation, Perception, and Protection
40. When assessing a client with nuchal rigidity, which objective
finding would the RN expect?
A.
B.
C.
D.
Positive Kernig’s sign
Positive Babinski reflex
Papilledema
Decorticate posturing
40. When assessing a client with nuchal rigidity, which objective
finding would the RN expect?
A.
B.
C.
D.
Positive Kernig’s sign
Positive Babinski reflex
Papilledema
Decorticate posturing
A. Positive Kernig’s and Brudzinski’s signs demonstrate
meningeal irritation.
Normal Kernig’s sign
Abnormal Kernig’s sign
Normal Brudzinski’s sign
Abnormal Brudzinski’s sign
41. Which would the RN expect to find in the cerebral spinal fluid
of a client with bacterial meningitis?
A.
B.
C.
D.
Decreased glucose, increased protein
Decreased glucose, decreased protein
Increased glucose, increased protein
Increased glucose, decreased protein
41. Which would the RN expect to find in the cerebral spinal fluid
of a client with bacterial meningitis?
A.
B.
C.
D.
Decreased glucose, increased protein
Decreased glucose, decreased protein
Increased glucose, increased protein
Increased glucose, decreased protein
A. Bacteria and WBC increase the protein count and bacteria
use up glucose so the glucose level decreases.
42. Which is a true statement regarding meningitis?
A. Both viral and bacterial meningitis may have an associated
fever
B. Stiff neck is the most common symptom in infants with viral
meningitis
C. Headaches only occur with bacterial meningitis
D. Viral meningitis is more easily detected than bacterial
meningitis in children
42. Which is a true statement regarding meningitis?
A. Both viral and bacterial meningitis may have an associated
fever
B. Stiff neck is the most common symptom in infants with viral
meningitis
C. Headaches only occur with bacterial meningitis
D. Viral meningitis is more easily detected than bacterial
meningitis in children
A. Fevers may occur with both bacterial and viral meningitis.
The other statements are not accurate.
43. Which statement is true concerning neuroblastoma?
A. Diagnosis is easily made based on symptoms
B. Tumors develop primarily along the retroperitoneal
sympathetic chain
C. Treatment begins with chemotherapy, then radiation and
surgery
D. Prognosis is best if the child is over age 2 when diagnosed
43. Which statement is true concerning neuroblastoma?
A. Diagnosis is easily made based on symptoms
B. Tumors develop primarily along the retroperitoneal
sympathetic chain
C. Treatment begins with chemotherapy, then radiation and
surgery
D. Prognosis is best if the child is over age 2 when diagnosed
B. This is where the “silent” tumors develop. Diagnosis is
difficult because there are few symptoms until the tumor
has metastasized.
44. What would the RN teach when instructing a class on
epilepsy?
A. Generalized seizures involve tonic-clonic contractions of
muscles in the lower part of the body
B. Absence seizures are partial seizures
C. Complex partial seizures lead to loss of consciousness
D. During an absence seizure, the nurse should attempt to
awaken the client
44. What would the RN teach when instructing a class on
epilepsy?
A. Generalized seizures involve tonic-clonic contractions of
muscles in the lower part of the body
B. Absence seizures are partial seizures
C. Complex partial seizures lead to loss of consciousness
D. During an absence seizure, the nurse should attempt to
awaken the client
C. Complex partial seizures occur in a focal part of the brain
and there is loss of consciousness for 1-3 minutes.
Generalized seizures involve the whole body. Absence are
generalized seizures and last only briefly.
45. A child is seen in the clinic with a chief complaint of
“Seizures”. Which finding by the RN is most indicative of
absence seizure?
A. Experiences 20-25 events a day lasting 5-10 seconds
B. Loses muscle control and displays head dropping
C. Displays repetitive muscle contractures without loss of
consciousness
D. Displays hyperkinesis and lack of attentiveness
45. A child is seen in the clinic with a chief complaint of
“Seizures”. Which finding by the RN is most indicative of
absence seizure?
A. Experiences 20-25 events a day lasting 5-10 seconds
B. Loses muscle control and displays head dropping
C. Displays repetitive muscle contractures without loss of
consciousness
D. Displays hyperkinesis and lack of attentiveness
A. “Petit mal” or absence seizures are generalized seizures
leading to a brief loss of consciousness, onset is abrupt,
and the child may drop things but seldom falls. B is atonic,
C is myoclonic, and D is related to ADHD.
Physiological Integrity of Children
Tonic-Clonic Seizure
46. Which action is the best way for the parent of an 8-year-old
client with a seizure disorder to determine if the child is
assuming responsibility for adhering to the anticonvulsant
medication schedule?
A.
B.
C.
D.
Asking the child each day when the medication is due
Having the child place a star on a calendar each day
Noting if the child has seizures at any time
Observing for behavioral changes in the child
46. Which action is the best way for the parent of an 8-year-old
client with a seizure disorder to determine if the child is
assuming responsibility for adhering to the anticonvulsant
medication schedule?
A.
B.
C.
D.
Asking the child each day when the medication is due
Having the child place a star on a calendar each day
Noting if the child has seizures at any time
Observing for behavioral changes in the child
B. As soon as the child is old enough, the child should
assume responsibility for taking own medications.
Reminders and incentives are often helpful
47. Which has highest priority for a client taking Dilantin for a
seizure disorder?
A.
B.
C.
D.
Assess for symptoms of aplastic anemia
Maintain optimal mouth care
Limit foods high in folic acid
If given IV, flush the tubing with D5W before and after
administration
47. Which has highest priority for a client taking Dilantin for a
seizure disorder?
A.
B.
C.
D.
Assess for symptoms of aplastic anemia
Maintain optimal mouth care
Limit foods high in folic acid
If given IV, flush the tubing with D5W before and after
administration
B. Aplastic anemia is not a major side effect, but gingival
hyperplasia is, so good mouth care is very important. The
diet should be high in folic acid and the IV should be
flushed with Normal Saline.
48. Select the action that the nurse should take first when a 12year-old client, sitting in a chair, begins to have tonic-clonic
seizure movements?
A. Restrain the child to prevent injury to arms and legs
B. Pad the environment around the chair
C. Quickly insert an oral airway in the mouth to keep the
airway patent
D. Move the client to a flat surface, positioning the client on
right or left side
48. Select the action that the nurse should take first when a 12year-old client, sitting in a chair, begins to have tonic-clonic
seizure movements?
A. Restrain the child to prevent injury to arms and legs
B. Pad the environment around the chair
C. Quickly insert an oral airway in the mouth to keep the
airway patent
D. Move the client to a flat surface, positioning the client on
right or left side
D. This is the only correct choice. Inserting an airway during
tonic-clonic movements can cause injury. The child should
be protected from injury, but not restrained. A flat, sidelying position will protect the airway and promote blood flow
to the brain.
49. A nurse is caring for a 6-year-old child who suddenly falls to
the floor and begins to have a generalized tonic-clonic
seizure. How can the nurse best insure the child’s safety?
A.
B.
C.
D.
Place a pillow under the head
Insert a plastic bite stick into the mouth
Hold the extremities in an extended alignment
Wrap the child’s trunk in a sheet
49. A nurse is caring for a 6-year-old child who suddenly falls to
the floor and begins to have a generalized tonic-clonic
seizure. How can the nurse best insure the child’s safety?
A.
B.
C.
D.
Place a pillow under the head
Insert a plastic bite stick into the mouth
Hold the extremities in an extended alignment
Wrap the child’s trunk in a sheet
A. This will prevent injury to the head and possible skull
fracture during the clonic stage of the seizure.
50. A 6-year-old experienced a grand mal seizure, has been
incontinent of urine, and is difficult to arouse. Identify the
most appropriate nursing action.
A. Ask the child’s parent if the child has a history of urinary
problems
B. Attempt to waken the child completely and assess level of
consciousness
C. Place the child in a side-lying position, stay with the child,
and allow to sleep
D. Perform a complete neurologic check and repeat it every
three to five minutes
50. A 6-year-old experienced a grand mal seizure, has been
incontinent of urine, and is difficult to arouse. Identify the
most appropriate nursing action.
A. Ask the child’s parent if the child has a history of urinary
problems
B. Attempt to waken the child completely and assess level of
consciousness
C. Place the child in a side-lying position, stay with the child,
and allow to sleep
D. Perform a complete neurologic check and repeat it every
three to five minutes
C. Urinary incontinence and sleep are common during and
after a seizure. The child should be allowed to sleep, and
while neurologic status is important, awakening every few
minutes would not be helpful.
51. What should the nurse do prior to bathing a child who has
brain damage, yet is able to respond to touch, sound and
some visual stimuli?
A.
B.
C.
D.
Administer PRN pain medication
Escort the family from the room
Dim the lights in the room
Explain to the child what you are going to do
51. What should the nurse do prior to bathing a child who has
brain damage, yet is able to respond to touch, sound and
some visual stimuli?
A.
B.
C.
D.
Administer PRN pain medication
Escort the family from the room
Dim the lights in the room
Explain to the child what you are going to do
D. When giving care to a client with neurological damage,
always speak to the client before touching and explain in
simple terms what will be done.
52. How should the parent of an infant with hypertonic cerebral
palsy with scissoring of the legs be taught to carry the infant?
A.
B.
C.
D.
Wrap the infant tightly in a blanket
Extend the infant’s extremities
Strap into a flat infant carrier
Straddle on the parent’s hip
52. How should the parent of an infant with hypertonic cerebral
palsy with scissoring of the legs be taught to carry the infant?
A.
B.
C.
D.
Wrap the infant tightly in a blanket
Extend the infant’s extremities
Strap into a flat infant carrier
Straddle on the parent’s hip
D. This helps to control the scissoring of the legs and provides
ease in supporting a child with hypertonicity.
53. The nurse is teaching the parent of a child with hemiplegia
due to cerebral palsy. Which statement by the nurse refers to
the purpose of positioning the child in an upright position and
placing toys on the child's affected side?
A. “This challenges the child to use the affected limb and may
result in increased function.“
B. “Doing this provides a test of the child's visual acuity and
scanning ability.“
C. “Forcing the child to obtain toys from the affected side is
basically a diversional activity.“
D. “This approach is focused on increasing muscle strength in
the affected limb.“
53. The nurse is teaching the parent of a child with hemiplegia
due to cerebral palsy. Which statement by the nurse refers to
the purpose of positioning the child in an upright position and
placing toys on the child's affected side?
A. “This challenges the child to use the affected limb and may
result in increased function.“
B. “Doing this provides a test of the child's visual acuity and
scanning ability.“
C. “Forcing the child to obtain toys from the affected side is
basically a diversional activity.“
D. “This approach is focused on increasing muscle strength in
the affected limb.“
A. The purpose of this type of positioning and placement of
toys is to challenge the child to use the affected limb, which
may eventually lead to improved ability to use that limb.
Physiological Integrity of Children
Developmental Disabilities
54. A newborn has facial features including short palpebral
fissures, hypoplastic philtrum, thin upper lip and hypoplastic
maxilla. Which nursing diagnosis related to the medical
diagnosis would need to be corrected?
A.
B.
C.
D.
Risk for dysfunctional family process: alcoholism
Risk for impaired parent/child attachment
Risk for delayed growth and development
Risk for imbalanced body temperature
54. A newborn has facial features including short palpebral
fissures, hypoplastic philtrum, thin upper lip and hypoplastic
maxilla. Which nursing diagnosis related to the medical
diagnosis would need to be corrected?
A.
B.
C.
D.
Risk for dysfunctional family process: alcoholism
Risk for impaired parent/child attachment
Risk for delayed growth and development
Risk for imbalanced body temperature
D. Fetal alcohol syndrome increases the risk for all but D.
Physiological Integrity of Children
Developmental Disabilities
55. A newborn is displaying symptoms of neonatal abstinence
syndrome (NAS) and the mother is on Methadone. Which is
the most appropriate intervention to plan related to this
syndrome?
A. Neonatal abstinence scoring system will be used to monitor
baby for 1st 24 hours of life
B. Lights and noises will be kept to a minimum
C. Infant will be handled as infrequently as possible
D. Oral opioid will be administered to decrease seizure risk
55. A newborn is displaying symptoms of neonatal abstinence
syndrome (NAS) and the mother is on Methadone. Which is
the most appropriate intervention to plan related to this
syndrome?
A. Neonatal abstinence scoring system will be used to monitor
baby for 1st 24 hours of life
B. Lights and noises will be kept to a minimum
C. Infant will be handled as infrequently as possible
D. Oral opioid will be administered to decrease seizure risk
B. Decreasing stimulation will help to decrease irritability.
Scoring should be done for 2-3 weeks because of the
Methadone. Cuddling the baby helps decrease irritability.
Opioid decreases diarrhea not seizures.
56. A client decides to breast feed her Down Syndrome infant.
During the feeding, the mother requests help because the
infant will not suck. Which action is the most appropriate
nursing action?
A.
B.
C.
D.
Explain the infant's feeding characteristics to the mother
Tell the mother it will be easier to bottle feed
Take the infant to the nursery to be fed
Encourage the mother to keep trying
56. A client decides to breast feed her Down Syndrome infant.
During the feeding, the mother requests help because the
infant will not suck. Which action is the most appropriate
nursing action?
A.
B.
C.
D.
Explain the infant's feeding characteristics to the mother
Tell the mother it will be easier to bottle feed
Take the infant to the nursery to be fed
Encourage the mother to keep trying
A. The infant with Down Syndrome may have
underdeveloped muscles and a large fissured tongue.
These characteristics may make breast feeding more
difficult.
Physiological Integrity of Children
Developmental Disabilities
57. Parents are having difficulty with the behavior of their
hyperkinetic child who is the oldest of four siblings. Both
parents express frustration about managing their child's
behavior. Which health care goal is initially most important in
working with the parents?
A. Providing reference books on the hyperkinetic child and
related problems
B. Helping parents enhance their effectiveness within the
limitations of the home environment
C. Enlisting their assistance in identifying the child's
behavioral problems in school
D. Increasing their opportunities to get away from home so
they can become more objective
57. Parents are having difficulty with the behavior of their
hyperkinetic child who is the oldest of four siblings. Both
parents express frustration about managing their child's
behavior. Which health care goal is initially most important in
working with the parents?
A. Providing reference books on the hyperkinetic child and
related problems
B. Helping parents enhance their effectiveness within the
limitations of the home environment
C. Enlisting their assistance in identifying the child's
behavioral problems in school
D. Increasing their opportunities to get away from home so
they can become more objective
B. Learning to be effective parents involves them in a
constructive task that helps them feel better about their
parenting skills.
58. Parents of a child with Attention Deficit Hyperactivity Disorder
(ADHD) are discussing medication and parenting strategies
with the nurse. Which statement made by the parents would
indicate that further teaching is necessary?
A. “Providing a regular routine for sleeping, eating, working
and playing is very necessary.“
B. “Medication should be given at night so it doesn't decrease
the appetite.“
C. “We will reduce distractions and external stimuli to help
with concentration.“
D. “We will establish firm but reasonable limits on behavior.”
58. Parents of a child with Attention Deficit Hyperactivity Disorder
(ADHD) are discussing medication and parenting strategies
with the nurse. Which statement made by the parents would
indicate that further teaching is necessary?
A. “Providing a regular routine for sleeping, eating, working
and playing is very necessary.“
B. “Medication should be given at night so it doesn't decrease
the appetite.“
C. “We will reduce distractions and external stimuli to help
with concentration.“
D. “We will establish firm but reasonable limits on behavior.”
B. Medications such as methylphenidate (Ritalin), pemoline
(Cylert) or other stimulants may keep the child awake and
should not be given at bedtime (give 6 hrs prior to HS).
59. The nurse is assessing a child with possible acute otitis
media, who is exhibiting a runny nose, fever, cough and
irritability. Which finding would the nurse anticipate when
performing an otoscopic evaluation?
A. A bulging, red tympanic membrane
B. Lack of a red reflex in the affected ear
C. Reddish turbinates covered with purulent drainage
D. Occasional white patches on a reddish pharynx
59. The nurse is assessing a child with possible acute otitis
media, who is exhibiting a runny nose, fever, cough and
irritability. Which finding would the nurse anticipate when
performing an otoscopic evaluation?
A. A bulging, red tympanic membrane
B. Lack of a red reflex in the affected ear
C. Reddish turbinates covered with purulent drainage
D. Occasional white patches on a reddish pharynx
A. With otitis media, the tympanic membrane of the affected
ear, as observed through the otoscope, appears to be
bulging and is reddish in color.
Physiological Integrity of Children
Sensation, Perception, and Protection
60. A child is hit with a snowball in the left eye and complains that
something is in the eye. The eye appears irritated with some
swelling. The child is tearing and complains of acute pain. In
doing an eye examination, the school nurse sees a small
piece of wood that seems to be adherent to the cornea.
Which action should the nurse take immediately?
A. Notify the child's parents to take child to an ophthalmologist
B. Instill normal saline drops and cover the eye with a patch
C. Instill anesthetic ointment to kill the pain
D. Using strict aseptic techniques and a sterile forceps,
remove the piece of wood
60. A child is hit with a snowball in the left eye and complains that
something is in the eye. The eye appears irritated with some
swelling. The child is tearing and complains of acute pain. In
doing an eye examination, the school nurse sees a small
piece of wood that seems to be adherent to the cornea.
Which action should the nurse take immediately?
A.
B.
C.
D.
Notify the child's parents to take child to an ophthalmologist
Instill normal saline drops and cover the eye with a patch
Instill anesthetic ointment to kill the pain
Using strict aseptic techniques and a sterile forceps,
remove the piece of wood
A. It is imperative to get the child to the ophthalmologist as
soon as possible. No treatment should be undertaken until
the doctor sees the child.
61. Acute conjunctivitis is diagnosed in a 3-year-old child with
erythematous conjunctiva, swollen eyelids and purulent
drainage. Which physician order would be questioned by the
RN?
A.
B.
C.
D.
Ilotycin (erythromycin) ophthalmic ointment
Pred G (prednisolone and gentamycin) ophthalmic drops
Notify physician if temperature is over 100.4o F (38o C)
Instill eye medication after crusts are removed with warm,
moist cloth
61. Acute conjunctivitis is diagnosed in a 3-year-old child with
erythematous conjunctiva, swollen eyelids and purulent
drainage. Which physician order would be questioned by the
RN?
A.
B.
C.
D.
Ilotycin (erythromycin) ophthalmic ointment
Pred G (prednisolone and gentamycin) ophthalmic drops
Notify physician if temperature is over 100.4o F (38o C)
Instill eye medication after crusts are removed with warm,
moist cloth
B. No steroidal eye drops are used as they can decrease
ocular resistance to bacteria. Although ointment may blur
the vision, Ilotycin is the better choice.
62. A 5-year-old has just returned from cardiac catheterization.
Which assessment would be most important at this time?
A.
B.
C.
D.
Vital signs
Dressing
Pedal pulses
IV site
62. A 5-year-old has just returned from cardiac catheterization.
Which assessment would be most important at this time?
A.
B.
C.
D.
Vital signs
Dressing
Pedal pulses
IV site
C. Pedal pulses will indicate arterial occlusion distal to the
incision. The other assessments are also important to
identify bleeding or hemorrhage.
63. Which clinical finding is the nurse most likely to assess in the
pediatric client with resolution of heart failure?
A. Increased mucus due to formula
B. Decreased respiratory effort
C. Absence of peripheral edema and increase in periorbital
edema
D. Gallop heart rhythm
63. Which clinical finding is the nurse most likely to assess in the
pediatric client with resolution of heart failure?
A. Increased mucus due to formula
B. Decreased respiratory effort
C. Absence of peripheral edema and increase in periorbital
edema
D. Gallop heart rhythm
B. The stem asks for a finding that indicates the heart failure
has improved, or resolved. C is only partially correct –
there would be no increase in periorbital edema. A and D
are incorrect (D is associated with active heart failure).
64. Before administering digoxin (Lanoxin) to a 4-month-old
infant, the nurse takes the apical pulse and finds it to be 120
beats per minute. Based on this information, what is the
correct nursing action?
A. Administer the medication and record both the
administration and pulse rate
B. Withhold the medication and report this to the charge nurse
at the end of the shift
C. Withhold the medication and call the physician
D. Obtain an EKG and withhold the medication
64. Before administering digoxin (Lanoxin) to a 4-month-old
infant, the nurse takes the apical pulse and finds it to be 120
beats per minute. Based on this information, what is the
correct nursing action?
A. Administer the medication and record both the
administration and pulse rate
B. Withhold the medication and report this to the charge nurse
at the end of the shift
C. Withhold the medication and call the physician
D. Obtain an EKG and withhold the medication
A. A “normal resting” heart rate for children 3 months to 2
years is 70 – 150, so administering the medication is
appropriate.
65. When evaluating the nursing interventions and goal
attainment for an infant with suspected atrial septal defect
(ASD), which finding necessitates further assessment?
A. Child is acyanotic at rest without tachypnea and
tachycardia
B. Child’s O2 saturation is maintained at 92%
C. Child’s parents bring a tape recording of their voices for
the baby to hear
D. Child’s parents handle and touch the baby only briefly to
allow for rest
65. When evaluating the nursing interventions and goal
attainment for an infant with suspected atrial septal defect
(ASD), which finding necessitates further assessment?
A. Child is acyanotic at rest without tachypnea and
tachycardia
B. Child’s O2 saturation is maintained at 92%
C. Child’s parents bring a tape recording of their voices for
the baby to hear
D. Child’s parents handle and touch the baby only briefly to
allow for rest
D. Parents need to hold, touch, talk to and look at the infant to
promote bonding. The prognosis is very good unless
Eisenmenger’s syndrome develops.
Physiological Integrity of Children
Oxygenation (Cardiovascular) Health
66. What nursing information most accurately describes the
cardiac defect of VSD?
A.
B.
C.
D.
Hole in the heart between the right and left atria
Hole in the membrane between the right and left ventricle
Narrowing of the large aorta artery just above the heart
Short tube that connects the aorta to the pulmonary artery
66. What nursing information most accurately describes the
cardiac defect of VSD?
A.
B.
C.
D.
Hole in the heart between the right and left atria
Hole in the membrane between the right and left ventricle
Narrowing of the large aorta artery just above the heart
Short tube that connects the aorta to the pulmonary artery
B. This is the definition of VSD.
Physiological Integrity of Children
Oxygenation (Cardiovascular) Health
67. At a routine pediatrician’s visit, a 4-week-old baby is found to
have a murmur, and on further investigation, bounding pulses
and a widened pulse pressure are discovered. What can the
nurse expect to be done for this child?
A. Coils will be placed in the patient ductus during cardiac
catheterization
B. Child will be watched for a year to see if the cardiac defect
resolves
C. Child will be scheduled for open heart surgery to repair the
atrial defect
D. A prostaglandin inhibitor indomethacin (Indocin) will be
administered
67. At a routine pediatrician’s visit, a 4-week-old baby is found to
have a murmur, and on further investigation, bounding pulses
and a widened pulse pressure are discovered. What can the
nurse expect to be done for this child?
A. Coils will be placed in the patient ductus during cardiac
catheterization
B. Child will be watched for a year to see if the cardiac defect
resolves
C. Child will be scheduled for open heart surgery to repair the
atrial defect
D. A prostaglandin inhibitor indomethacin (Indocin) will be
administered
A. These symptoms are indicative of a patent ductus
arteriosus. At this age, indomethacin will not be effective,
but the child is likely to be treated with insertion of coils to
occlude the opening.
Physiological Integrity of Children
Oxygenation (Cardiovascular) Health
68. Identify the assessment that would lead the nurse to conclude
that an infant has coarctation of the aorta.
A. Loud machinery murmur at the left sternal boarder
B. Growth retardation and lack of energy
C. Stronger upper extremity compared to lower extremity
pulses
D. Widened pulse pressure and increased pulse rate
68. Identify the assessment that would lead the nurse to conclude
that an infant has coarctation of the aorta.
A. Loud machinery murmur at the left sternal boarder
B. Growth retardation and lack of energy
C. Stronger upper extremity compared to lower extremity
pulses
D. Widened pulse pressure and increased pulse rate
C. The stricture in the aorta causes an increased blood supply
to the upper part of the body while reducing the supply to
the lower part of the body.
Physiological Integrity of Children
Oxygenation (Cardiovascular) Health
69. A child with tetralogy of Fallot starts crying, screaming and
visibly shaking when a laboratory technician attempts to draw
blood. The child becomes cyanotic and the respiratory rate
increases to 40 breaths per minute. Choose the priority
action of the nurse.
A.
B.
C.
D.
Ask the physician for a sedative for the child
Explain to the child the importance of the blood tests
Place the child in a knee-to-chest position
Auscultate for an irregular heartbeat
69. A child with tetralogy of Fallot starts crying, screaming and
visibly shaking when a laboratory technician attempts to draw
blood. The child becomes cyanotic and the respiratory rate
increases to 40 breaths per minute. Choose the priority
action of the nurse.
A.
B.
C.
D.
Ask the physician for a sedative for the child
Explain to the child the importance of the blood tests
Place the child in a knee-to-chest position
Auscultate for an irregular heartbeat
C. Flexing the legs reduces venous flow back to the heart,
decreasing the volume of blood moving through the areas
of defect.
Physiological Integrity of Children
Oxygenation (Cardiovascular) Health
Tetralogy of Fallot
70. How would the nurse best respond to a request by a parent to
describe the Blalock-Taussig procedure for tetralogy of Fallot?
A. Ask the physician to give an explanation the next time
rounds are made
B. It is a surgical procedure to increase the blood flow to the
brain
C. The subclavian artery is connected to the pulmonary artery
D. Blood is diverted to the other side of the heart using a
prosthetic material
70. How would the nurse best respond to a request by a parent to
describe the Blalock-Taussig procedure for tetralogy of Fallot?
A. Ask the physician to give an explanation the next time
rounds are made
B. It is a surgical procedure to increase the blood flow to the
brain
C. The subclavian artery is connected to the pulmonary artery
D. Blood is diverted to the other side of the heart using a
prosthetic material
C. This procedure is used palliatively for tetralogy of Fallot to
increase oxygen levels in the blood by circulating more
blood through the lungs.
71. After corrective surgery for tetralogy of Fallot, the nurse
monitors the child for decreased cardiac output. Select the
findings that would indicate low cardiac output.
A. Altered level of consciousness, warm extremities, and
pallor
B. Bounding pulses and mottled skin on extremities
C. Altered level of consciousness, thready pulse, and cool
extremities
D. Capillary refill two seconds and blood pressure 90/60 mm
Hg
71. After corrective surgery for tetralogy of Fallot, the nurse
monitors the child for decreased cardiac output. Select the
findings that would indicate low cardiac output.
A. Altered level of consciousness, warm extremities, and
pallor
B. Bounding pulses and mottled skin on extremities
C. Altered level of consciousness, thready pulse, and cool
extremities
D. Capillary refill two seconds and blood pressure 90/60 mm
Hg
C. Clinical signs of low cardiac output are pale, cool
extremities, weak thready pulses, delayed capillary refill
and altered consciousness.
72. A newborn has been diagnosed with transposition of the
great vessels. What will the parents be told about this
condition?
A. There is very little that can be done for this child at this time
B. The mortality rate following surgery is very high for all
children
C. The child will have surgery to repair the circulation in a
week
D. There will be a high risk of heart failure later in life
72. A newborn has been diagnosed with transposition of the
great vessels. What will the parents be told about this
condition?
A. There is very little that can be done for this child at this time
B. The mortality rate following surgery is very high for all
children
C. The child will have surgery to repair the circulation in a
week
D. There will be a high risk of heart failure later in life
C. The surgical procedure to repair circulation has a mortality
rate of about 5-10% and is done early in life.
Physiological Integrity of Children
Oxygenation (Cardiovascular) Health
73. Which assessment finding is unexpected in a child with
probable Kawasaki Disease?
A.
B.
C.
D.
Temperature 102.0o F (38.89o C)
Conjunctivitis without exudates
Crackles bilaterally lower lobes
Desquamation of hands and feet
73. Which assessment finding is unexpected in a child with
probable Kawasaki Disease?
A.
B.
C.
D.
Temperature 102.0o F (38.89o C)
Conjunctivitis without exudates
Crackles bilaterally lower lobes
Desquamation of hands and feet
C. Lung involvement is not a common characteristic of
Kawasaki Disease.
74. Primary prevention of rheumatic fever includes which
measure?
A. Teaching parents to complete 10-14 day antibiotic therapy
for strep throat
B. Teaching the parents the symptoms of rheumatic fever
C. Encouraging rest when the child has an upper respiratory
infection
D. Encouraging the child to stay in bed
74. Primary prevention of rheumatic fever includes which
measure?
A. Teaching parents to complete 10-14 day antibiotic therapy
for strep throat
B. Teaching the parents the symptoms of rheumatic fever
C. Encouraging rest when the child has an upper respiratory
infection
D. Encouraging the child to stay in bed
A. After a positive culture for hemolytic streptococci, the child
is placed on antibiotics for 10 to 14 days. The full course of
medication is very important.
75. If an infant with prolonged bleeding after circumcision has
hemophilia, which blood test will be abnormal?
A.
B.
C.
D.
Bleeding time
Platelet count
Clot retraction time
Partial thromboplastin time
75. If an infant with prolonged bleeding after circumcision has
hemophilia, which blood test will be abnormal?
A.
B.
C.
D.
Bleeding time
Platelet count
Clot retraction time
Partial thromboplastin time
D. Partial thromboplastin time measures the activity of
thromboplastin which is dependent on intrinsic clotting
factors (like factor VIII). Bleeding time, platelet count and
clot retraction tests measure platelet function and will be
normal in someone with hemophilia.
76. An 8-year-old child with hemophilia A is admitted to a unit with
a severe bleeding episode. What is most important in
planning care with the child?
A. Explore the emotional aspects of this disease with the child
and the parents
B. Make sure the parents and child understand home
management of this disease
C. Help the child keep up with school work
D. Institute measures to control the bleeding episode
76. An 8-year-old child with hemophilia A is admitted to a unit with
a severe bleeding episode. What is most important in
planning care with the child?
A. Explore the emotional aspects of this disease with the child
and the parents
B. Make sure the parents and child understand home
management of this disease
C. Help the child keep up with school work
D. Institute measures to control the bleeding episode
D. The most immediate concern is control of bleeding, which
must be stopped before moving to other aspects of
managing hemophilia.
77. When making rounds, the nurse discovers a client with a
nosebleed. Which intervention is appropriate?
A. Position the client with the head back and apply an ice bag
directly to the nose
B. Have the client lean forward and apply direct pressure to
the nose
C. Position the client in the Fowler’s position and place
packing in the nose
D. Have the client pinch the nares together and spit out any
blood in the mouth
77. When making rounds, the nurse discovers a client with a
nosebleed. Which intervention is appropriate?
A. Position the client with the head back and apply an ice bag
directly to the nose
B. Have the client lean forward and apply direct pressure to
the nose
C. Position the client in the Fowler’s position and place
packing in the nose
D. Have the client pinch the nares together and spit out any
blood in the mouth
B. This is the appropriate first aid treatment for nosebleeds.
Keeping the head downward will prevent swallowing or
aspiration of blood.
78. In considering care planning for the sickle cell crisis client,
what would the nurse anticipate in addition to pain relief
measures?
A.
B.
C.
D.
Antispasmodics and ambulation TID
Cold packs to affected area and oxygen
Gene therapy and Factor VIII replacement
Hydration and electrolyte replacement
78. In considering care planning for the sickle cell crisis client,
what would the nurse anticipate in addition to pain relief
measures?
A.
B.
C.
D.
Antispasmodics and ambulation TID
Cold packs to affected area and oxygen
Gene therapy and Factor VIII replacement
Hydration and electrolyte replacement
D. Bedrest is important to minimize use of oxygen and energy
expenditure. Cold packs promote sickling and
vasoconstriction. Electrolyte replacement is important to
combat metabolic acidosis (from hypoxia) which promotes
more sickling.
79. What should be stressed to help parents decrease the risk of
vaso-occlusive crises in a child with sickle cell disease?
A.
B.
C.
D.
Frequent hand washing
Diet high in iron-rich foods
Avoid use of mothballs in the home
Limit or closely monitor milk intake
79. What should be stressed to help parents decrease the risk of
vaso-occlusive crises in a child with sickle cell disease?
A.
B.
C.
D.
Frequent hand washing
Diet high in iron-rich foods
Avoid use of mothballs in the home
Limit or closely monitor milk intake
A. Crises are often associated with infection, dehydration,
acidosis, or exposure to cold. Many infections, especially
respiratory, are largely spread by fomites, through hand-tonose or eye contact.
80. What is the highest priority for a child with sickle cell disease
admitted with vaso-occlusive crisis?
A.
B.
C.
D.
Pain control and hydration
Psychological and emotional support
Genetic counseling and bedrest
Transfusion of packed red blood cells and Factor VIII
80. What is the highest priority for a child with sickle cell disease
admitted with vaso-occlusive crisis?
A.
B.
C.
D.
Pain control and hydration
Psychological and emotional support
Genetic counseling and bedrest
Transfusion of packed red blood cells and Factor VIII
A. Hydration is absolutely necessary to prevent clumping of
blood cells and pain is a stressor that needs to be
eliminated. These are physiological measures and have
higher priority than emotional measures.
81. What would the nurse include when educating parents of a
child with leukemia about the cause of the anemia?
A.
B.
C.
D.
Inadequate iron intake, which is common in children
Decreased red blood cell production by bone marrow
Increased destruction of red blood cells by lymphocytes
Progressive replacement of bone marrow with inefficient
blood producing cells
81. What would the nurse include when educating parents of a
child with leukemia about the cause of the anemia?
A.
B.
C.
D.
Inadequate iron intake, which is common in children
Decreased red blood cell production by bone marrow
Increased destruction of red blood cells by lymphocytes
Progressive replacement of bone marrow with inefficient
blood producing cells
B. Bone marrow overproduces white blood cells at the
expense of producing red blood cells and platelets.
82. What information does the nurse give a 10-year-old client and
parents prior to a bone morrow aspiration?
A. Will be put to sleep and not feel anything
B. Will need to stay in bed for 24 hours after the procedure
C. Will feel a sharp, stabbing pain at the site for the first 24
hours
D. Will feel pressure at the site during the procedure
82. What information does the nurse give a 10-year-old client and
parents prior to a bone morrow aspiration?
A. Will be put to sleep and not feel anything
B. Will need to stay in bed for 24 hours after the procedure
C. Will feel a sharp, stabbing pain at the site for the first 24
hours
D. Will feel pressure at the site during the procedure
D. It is important for the client to know what type of pain to
expect.
83. When caring for a child with leukemia, the RN notes blood on
the pillowcase and the child’s pajamas. Which parameter of
the child’s laboratory report would the nurse check?
A.
B.
C.
D.
Platelet count
Uric acid level
Prothrombin time
Red blood cell count
83. When caring for a child with leukemia, the RN notes blood on
the pillowcase and the child’s pajamas. Which parameter of
the child’s laboratory report would the nurse check?
A.
B.
C.
D.
Platelet count
Uric acid level
Prothrombin time
Red blood cell count
A. Leukemia causes decreased platelet count. Uric acid level
affects urinary output, not blood clotting. Prothrombin time
is influenced by vitamin K factors, not platelets. RBC would
not explain the cause for bleeding.
84. After a prolonged course of mercaptopurine (Purinethol) and
methotrexate (Amethopterin), an 8-year-old child has an
absolute neutrophil count of 400. What would be the primary
nursing action?
A.
B.
C.
D.
Initiate droplet infection control precautions
Consult with physician
Increase fluid intake
Restrict staff and visitors
84. After a prolonged course of mercaptopurine (Purinethol) and
methotrexate (Amethopterin), an 8-year-old child has an
absolute neutrophil count of 400. What would be the primary
nursing action?
A.
B.
C.
D.
Initiate droplet infection control precautions
Consult with physician
Increase fluid intake
Restrict staff and visitors
D. The child will be placed in protective isolation and staff and
visitors with signs and symptoms of active infection will not
be allowed in the child’s room.
85. At the time of discharge, the sibling of a 7-year-old with
leukemia develops chicken pox. What information does the
nurse give to the family in planning discharge?
A. Chicken pox can be fatal to clients with leukemia
B. Clients receiving prednisone are immune to chicken pox
C. Immunization prior to discharge will protect the child from
acquiring the disease
D. Discharge is planned if the client avoids contact with the
sibling with chicken pox
85. At the time of discharge, the sibling of a 7-year-old with
leukemia develops chicken pox. What information does the
nurse give to the family in planning discharge?
A. Chicken pox can be fatal to clients with leukemia
B. Clients receiving prednisone are immune to chicken pox
C. Immunization prior to discharge will protect the child from
acquiring the disease
D. Discharge is planned if the client avoids contact with the
sibling with chicken pox
A. The virus cannot be combated by the child with leukemia
and might be fatal.
86. Which nursing care measure would the nurse identify as a
teaching priority for the child newly diagnosed with leukemia
and the family?
A.
B.
C.
D.
Comfort measures
Nutritional supplements
Injury prevention
Anticipatory grieving
86. Which nursing care measure would the nurse identify as a
teaching priority for the child newly diagnosed with leukemia
and the family?
A.
B.
C.
D.
Comfort measures
Nutritional supplements
Injury prevention
Anticipatory grieving
D. The family will be overwhelmed by the diagnosis. Other
diagnoses are pertinent but would not be priority with the
new diagnosis.
87. A child with leukemia is being discharged from the hospital on
several antineoplastic medications after intrathecal
administration of methotrexate. What must discharge
instructions to the parents include?
A. Limit contact with friends
B. Schedule routine laboratory testing to evaluate response to
medication
C. Withhold medication when nausea occurs
D. Prepare the child for occasional blood transfusions
87. A child with leukemia is being discharged from the hospital on
several antineoplastic medications after intrathecal
administration of methotrexate. What must discharge
instructions to the parents include?
A. Limit contact with friends
B. Schedule routine laboratory testing to evaluate response to
medication
C. Withhold medication when nausea occurs
D. Prepare the child for occasional blood transfusions
B. If WBC drops dramatically, therapy may be stopped
temporarily. Prolonged therapy contraindicates isolation
from peers, nausea is common and not a cause for
medication discontinuation, and blood transfusions are not
expected.
88. How can the nurse best help a 6-year-old client diagnosed
with acute lymphoblastic leukemia cope with the fear of
dying?
A. Avoid discussions related to the illness
B. Distract the child by playing games and watching television
C. Refer the child’s questions to the physician or to the
parents
D. Answer the questions in an open and honest manner
88. How can the nurse best help a 6-year-old client diagnosed
with acute lymphoblastic leukemia cope with the fear of
dying?
A. Avoid discussions related to the illness
B. Distract the child by playing games and watching television
C. Refer the child’s questions to the physician or to the
parents
D. Answer the questions in an open and honest manner
D. This helps the client deal directly and realistically with the
problem. A and B ignore the problem and C shifts
responsibility.
89. Which child should be evaluated first?
A. A 20-month-old with bronchiiolitis who has crackles
bilaterally and has been in 23% oxygen all night
B. A 6-month-old who has a croupy cough and some
inspiratory stridor with activity
C. A 4-year-old with bronchial asthma who required PRN
respiratory treatment of albuterol (Ventolin) for wheezes
two hours ago
D. A 3-year-old with cystic fibrosis with right lower lobe
pneumonia, crackles bilaterally, and in 21% oxygen
89. Which child should be evaluated first?
A. A 20-month-old with bronchiiolitis who has crackles
bilaterally and has been in 23% oxygen all night
B. A 6-month-old who has a croupy cough and some
inspiratory stridor with activity
C. A 4-year-old with bronchial asthma who required PRN
respiratory treatment of albuterol (Ventolin) for wheezes
two hours ago
D. A 3-year-old with cystic fibrosis with right lower lobe
pneumonia, crackles bilaterally, and in 21% oxygen
C. This client’s respiratory status is the most unstable and
needs to be re-evaluated first since the child required a
PRN respiratory treatment 2 hours ago.
90. A 2-week-old infant is admitted with symptoms of respiratory
distress related to upper respiratory infection. Which nursing
diagnosis has the highest priority?
A.
B.
C.
D.
Activity intolerance related to fatigue
Ineffective airway clearance related to secretions
Ineffective breathing pattern related to respiratory distress
Risk for altered parenting related to hospitalization
90. A 2-week-old infant is admitted with symptoms of respiratory
distress related to upper respiratory infection. Which nursing
diagnosis has the highest priority?
A.
B.
C.
D.
Activity intolerance related to fatigue
Ineffective airway clearance related to secretions
Ineffective breathing pattern related to respiratory distress
Risk for altered parenting related to hospitalization
B. Airway clearance comes before breathing.
91. A couple who has recently lost a child to sudden infant death
syndrome (SIDS) suddenly joins the SIDS Foundation.
Which explanation shows the best understanding regarding
their action?
A.
B.
C.
D.
The desire to obtain answers regarding why SIDS occurred
Using the organization to obtain education regarding SIDS
Providing information that will prevent SIDS in others
Seeking the support of others who have experienced SIDS
91. A couple who has recently lost a child to sudden infant death
syndrome (SIDS) suddenly joins the SIDS Foundation.
Which explanation shows the best understanding regarding
their action?
A.
B.
C.
D.
The desire to obtain answers regarding why SIDS occurred
Using the organization to obtain education regarding SIDS
Providing information that will prevent SIDS in others
Seeking the support of others who have experienced SIDS
D. Losing a child, particularly when death is unexplainable,
e.g. SIDS, requires a lot of emotional support. Only
another person who has experienced the same
phenomenon can truly understand and give the needed
support.
92. Which child has signs and symptoms most suggestive of
bronchiolitis?
A. A 2-month-old with a respiratory rate of 68, heart rate of
175, and expiratory wheeze
B. A 12-month-old with a respiratory rate of 50, heart rate of
140, and mild expiratory stridor
C. A 6-month-old with a respiratory rate of 70, heart rate of
180, and a prolonged inspiratory phase
D. An 8-month-old with a respiratory rate of 50, heart rate of
140, and inspiratory wheeze
92. Which child has signs and symptoms most suggestive of
bronchiolitis?
A. A 2-month-old with a respiratory rate of 68, heart rate of
175, and expiratory wheeze
B. A 12-month-old with a respiratory rate of 50, heart rate of
140, and mild expiratory stridor
C. A 6-month-old with a respiratory rate of 70, heart rate of
180, and a prolonged inspiratory phase
D. An 8-month-old with a respiratory rate of 50, heart rate of
140, and inspiratory wheeze
A. Bronchiolitis results in a narrowing of the bronchial
passages on expiration which results in expiratory wheezes.
Tachycardia and respiratory rate greater than 50 per minute
are common with bronchiolitis.
93. A hospitalized infant with acute bronchiolitis is NPO and
receiving IV fluids. Which statement explains the rationale for
eliminating feedings?
A. “The baby doesn’t need as many calories right now.”
B. “There is an increased risk of fluid overload.”
C. “Feeding would be too much of an effort for the baby right
now.”
D. “The baby’s digestive system is sluggish because of the
infection.”
93. A hospitalized infant with acute bronchiolitis is NPO and
receiving IV fluids. Which statement explains the rationale for
eliminating feedings?
A. “The baby doesn’t need as many calories right now.”
B. “There is an increased risk of fluid overload.”
C. “Feeding would be too much of an effort for the baby right
now.”
D. “The baby’s digestive system is sluggish because of the
infection.”
C. Oral feeding during the acute phase of the illness will
increase hypoxemia and the effort expended during feeding
may result in tachypnea, weakness and fatigue. Caloric
needs will increase because of accelerated metabolism,
over hydrating is not the reason why the child is NPO, and
there is no reason why peristalsis should decrease.
94. A 2 ½ -year-old child with acute asthma is short of breath,
has a pulse of 100 and a respiratory rate of 54. What blood
gas values will the nurse expect to find?
A.
B.
C.
D.
pH of 7.32
PO2 of 95 mm Hg
HCO3 of 26 mEq/L
PCO2 of 40 mm Hg
94. A 2 ½ -year-old child with acute asthma is short of breath,
has a pulse of 100 and a respiratory rate of 54. What blood
gas values will the nurse expect to find?
A.
B.
C.
D.
pH of 7.32
PO2 of 95 mm Hg
HCO3 of 26 mEq/L
PCO2 of 40 mm Hg
A. Hypoxia causes hypercapnia which leads to a decreased
pH (normal 7.35-7.45). B is within normal range (80-100),
C is within normal range (21-28), and D is within normal
range (35-45).
95. A 7-year-old child is brought to the clinic with an acute
asthma attack. The parent states the child has had an upper
respiratory infection with a frequent dry cough for several
days. What is the priority nursing action?
A.
B.
C.
D.
Obtain a complete history from the parent
Obtain STAT arterial blood gases
Determine what medications the child takes regularly
Auscultate lung bases for air movement
95. A 7-year-old child is brought to the clinic with an acute
asthma attack. The parent states the child has had an upper
respiratory infection with a frequent dry cough for several
days. What is the priority nursing action?
A.
B.
C.
D.
Obtain a complete history from the parent
Obtain STAT arterial blood gases
Determine what medications the child takes regularly
Auscultate lung bases for air movement
D. Since an acute asthma attack results in airway obstruction,
the nurse needs to ascultate the lungs to evaluate the
severity of the obstruction and degree of airflow
compromise.
96. Which suggestion by the nurse would be most appropriate
when discussing with parents measures to prevent their
child's asthma attacks?
A. Maintain a high humidity (>70%) environment inside the
house
B. Encourage the child to sleep with the window open at night
C. Use an antimold agent in cleaning showers and tile areas
D. Spray an aerosol disinfectant in the child's bedroom
96. Which suggestion by the nurse would be most appropriate
when discussing with parents measures to prevent their
child's asthma attacks?
A. Maintain a high humidity (>70%) environment inside the
house
B. Encourage the child to sleep with the window open at night
C. Use an antimold agent in cleaning showers and tile areas
D. Spray an aerosol disinfectant in the child's bedroom
C. Exposure to mold, aerosolized chemicals, and substances
inhaled through an open window can all be triggers for
asthma attacks. Also, it's best to maintain a low humidity
environment (under 50%) to discourage house dust mites.
97. A 10-year-old client with asthma suddenly stops breathing.
What is the priority nursing action?
A.
B.
C.
D.
Call 911
Initiate rescue breathing with 2 breaths
Begin cardiopulmonary resuscitation
Check for a carotid pulse
97. A 10-year-old client with asthma suddenly stops breathing.
What is the priority nursing action?
A.
B.
C.
D.
Call 911
Initiate rescue breathing with 2 breaths
Begin cardiopulmonary resuscitation
Check for a carotid pulse
B. The nurse should initiate rescue breathing with 2 breaths
and continue at a rate of 12 breaths per minute.
98. An 8-year-old child is receiving both intravenous aminophylline
(Aminophyllin) and hydrocortisone (Solu-Medrol). During the
morning assessment, the child vomits breakfast and is very irritable.
Assessment reveals a heart rate of 116 beats per minute, but other
vital signs are within normal ranges. Breath sounds are equal with
a faint expiratory wheeze. What should be the priority nursing
action?
A. Re-evaluate vital signs and irritability again in 30 minutes and
document results
B. Notify the physician immediately as these are signs of
theophylline toxicity
C. Call the physician to increase the aminophylline dose since
wheezes are still present
D. Continue with the prescribed dosages as these are normal side
effects of the medication
98. An 8-year-old child is receiving both intravenous aminophylline
(Aminophyllin) and hydrocortisone (Solu-Medrol). During the
morning assessment, the child vomits breakfast and is very irritable.
Assessment reveals a heart rate of 116 beats per minute, but other
vital signs are within normal ranges. Breath sounds are equal with
a faint expiratory wheeze. What should be the priority nursing
action?
A. Re-evaluate vital signs and irritability again in 30 minutes and
document results
B. Notify the physician immediately as these are signs of
theophylline toxicity
C. Call the physician to increase the aminophylline dose since
wheezes are still present
D. Continue with the prescribed dosages as these are normal side
effects of the medication
B. Vomiting, irritability and elevated heart rate are signs of
theophylline toxicity.
99. What is the first action the nurse should take when a child is
admitted with status asthmaticus?
A.
B.
C.
D.
Monitor vital signs every two to four hours
Place upright in a sitting position
Administer large amounts of IV fluids for hydration
Perform chest physiotherapy and postural drainage
99. What is the first action the nurse should take when a child is
admitted with status asthmaticus?
A.
B.
C.
D.
Monitor vital signs every two to four hours
Place upright in a sitting position
Administer large amounts of IV fluids for hydration
Perform chest physiotherapy and postural drainage
B. This position will make breathing easier and help increase
oxygenation.
100. Which diagnosis suggests that a nurse may obtain
inaccurate readings from a pulse oximeter that is attached to
the finger of a 5-year-old with croup?
A.
B.
C.
D.
Activity intolerance
Decreased tissue perfusion
Fluid volume excess
Ineffective airway clearance
100. Which diagnosis suggests that a nurse may obtain
inaccurate readings from a pulse oximeter that is attached to
the finger of a 5-year-old with croup?
A.
B.
C.
D.
Activity intolerance
Decreased tissue perfusion
Fluid volume excess
Ineffective airway clearance
B. Poor tissue perfusion will decrease circulation to the finger
and interfere with accurate readings. Ineffective airway
clearance would make the pulse oximetry readings low, but
they would be accurate.
101. What intervention is most important when providing care to
a 4-year-old child with croup?
A. Monitor respiratory function to maintain a patent airway
B. Force non-caffeinated fluids to liquefy pulmonary
secretions
C. Maintain a semi-Fowler’s position to decrease chest pain
D. Increase oxygen supply to prevent subcutaneous skin
breakdown
101. What intervention is most important when providing care to
a 4-year-old child with croup?
A. Monitor respiratory function to maintain a patent airway
B. Force non-caffeinated fluids to liquefy pulmonary
secretions
C. Maintain a semi-Fowler’s position to decrease chest pain
D. Increase oxygen supply to prevent subcutaneous skin
breakdown
A. Maintaining an airway is the most important of the
respiratory interventions listed.
102. The client with which symptoms needs the most immediate
attention?
A. Barking cough, oxygen saturation of 93 in room air, and
occasional inspiratory stridor
B. Tympanic temperature of 102.2o F (39o C), green nasal
drainage, and pulling at the ears
C. Harsh paroxysmal cough, audible expiratory wheeze and
mild retractions
D. Sore throat, tongue slightly protruding, drooling, expiratory
stridor and tachypnea
102. The client with which symptoms needs the most immediate
attention?
A. Barking cough, oxygen saturation of 93 in room air, and
occasional inspiratory stridor
B. Tympanic temperature of 102.2o F (39o C), green nasal
drainage, and pulling at the ears
C. Harsh paroxysmal cough, audible expiratory wheeze and
mild retractions
D. Sore throat, tongue slightly protruding, drooling, expiratory
stridor and tachypnea
D. The assessment data suggest this child is experiencing
acute epiglottitis which can result in acute respiratory
distress secondary to airway obstruction.
103. A 5-year-old child is found to have a cough, fever, and chest
pain following an upper respiratory infection. A chest X-ray
indicates pneumonia is likely. What will the nurse expect to
happen next?
A.
B.
C.
D.
An IV with intense antibiotic therapy
Supportive care with oxygen and cool mist
Antipyretics and IV fluid administration
Sputum culture to determine causative organism
103. A 5-year-old child is found to have a cough, fever, and chest
pain following an upper respiratory infection. A chest X-ray
indicates pneumonia is likely. What will the nurse expect to
happen next?
A.
B.
C.
D.
An IV with intense antibiotic therapy
Supportive care with oxygen and cool mist
Antipyretics and IV fluid administration
Sputum culture to determine causative organism
D. While all of the listed treatments may be done, the first
thing is to determine whether the pneumonia is viral or
bacterial so appropriate treatment can be started.
104. An adolescent has had a “cold” for a week and suddenly
develops a high fever, cough, chest pain, and difficulty
breathing. The diagnosis is staphylococcal pneumonia. What
is the complication likely to occur with this diagnosis?
A.
B.
C.
D.
Empyema
Otitis media
Appendicitis
Tonsillitis
104. An adolescent has had a “cold” for a week and suddenly
develops a high fever, cough, chest pain, and difficulty
breathing. The diagnosis is staphylococcal pneumonia. What
is the complication likely to occur with this diagnosis?
A.
B.
C.
D.
Empyema
Otitis media
Appendicitis
Tonsillitis
A. This type of pneumonia is likely to cause empyema if not
treated early and aggressively. Otitis media is more
common in young children with other types of bacteria.
105. A 4-year-old child is admitted with a diagnosis of
bronchopneumonia. Select the most appropriate expected
client outcome related to the priority nursing diagnosis,
“Ineffective Breathing Pattern, related to infection.”
A.
B.
C.
D.
Able to tolerate food without gagging
Have no symptoms of chills or coughing
Able to engage in normal activities for age
Exhibit no symptoms of respiratory distress
105. A 4-year-old child is admitted with a diagnosis of
bronchopneumonia. Select the most appropriate expected
client outcome related to the priority nursing diagnosis,
“Ineffective Breathing Pattern, related to infection.”
A.
B.
C.
D.
Able to tolerate food without gagging
Have no symptoms of chills or coughing
Able to engage in normal activities for age
Exhibit no symptoms of respiratory distress
D. Others may be pertinent but do not relate directly to the
diagnosis.
106. The initial assessment of a 5-year-old child returning to the unit
from a tonsillectomy and adenoidectomy was T-98.2o F (36.8o C),
P-80, R-20, and B/P-100/60, pain rating of a 4 and some
hesitancy in swallowing. Six hours later, the assessment is T98.6o F (37o C), P-100, R-18, and B/P-90/50, pain rating of 7,
and frequent swallowing noted. What should be the nurse’s
priority action?
A. Evaluate the operative site for increased postop bleeding
B. Medicate child with Tylenol with Codeine Elixir for pain
C. Re-evaluate vital signs and pain rating again in 15 minutes
D. Notify the physician immediately of the changes in
assessment
106. The initial assessment of a 5-year-old child returning to the unit
from a tonsillectomy and adenoidectomy was T-98.2o F (36.8o C),
P-80, R-20, and B/P-100/60, pain rating of a 4 and some
hesitancy in swallowing. Six hours later, the assessment is T98.6o F (37o C), P-100, R-18, and B/P-90/50, pain rating of 7,
and frequent swallowing noted. What should be the nurse’s
priority action?
A. Evaluate the operative site for increased postop bleeding
B. Medicate child with Tylenol with Codeine Elixir for pain
C. Re-evaluate vital signs and pain rating again in 15 minutes
D. Notify the physician immediately of the changes in
assessment
A. Frequent swallowing following a tonsillectomy/adenoidectomy
is a sign of increased postop bleeding. This child went from
hesitancy in swallowing to frequent swallowing which warrants
further assessment of the operative site for increased
bleeding.
107. An 8-year-old child has just had a tonsillectomy. The client
is awake, restless, and frequently swallowing and clearing the
throat. Which nursing action is most appropriate?
A. Carefully insert a tongue depressor to directly observe the
throat for bleeding
B. Give an analgesic to promote comfort and allay
restlessness
C. Encourage oral intake of cool fluids such as water, crushed
ice, or popsicle
D. Instruct child to lie on stomach, and offer reassurance to
calm child
107. An 8-year-old child has just had a tonsillectomy. The client
is awake, restless, and frequently swallowing and clearing the
throat. Which nursing action is most appropriate?
A. Carefully insert a tongue depressor to directly observe the
throat for bleeding
B. Give an analgesic to promote comfort and allay
restlessness
C. Encourage oral intake of cool fluids such as water, crushed
ice, or popsicle
D. Instruct child to lie on stomach, and offer reassurance to
calm child
A. This child is manifesting signs of postoperative
hemorrhage, and direct observation of the throat can
determine the extent of bleeding
108. Of the problems listed, which makes the nurse suspect an
infant has cystic fibrosis?
A.
B.
C.
D.
Pneumonia
Imperforate anus
Meconium ileus
Feeding intolerance
108. Of the problems listed, which makes the nurse suspect an
infant has cystic fibrosis?
A.
B.
C.
D.
Pneumonia
Imperforate anus
Meconium ileus
Feeding intolerance
C. Thick meconium blocks the lumen of the intestine and may
be one of the first signs of cystic fibrosis.
109. Which rationale is the primary reason the RN includes
“Decreased risk of infection exposure” in the plan of care for
a child with cystic fibrosis?
A. Repeated infections increase damage to the respiratory
tract
B. Pulmonary therapy is less effective during acute infections
C. Immunocompromise caused by decreased pancreatic
function increases the child’s risk of secondary infection
D. Usual childhood immunizations are contraindicated in a
child with cystic fibrosis
109. Which rationale is the primary reason the RN includes
“Decreased risk of infection exposure” in the plan of care for
a child with cystic fibrosis?
A. Repeated infections increase damage to the respiratory
tract
B. Pulmonary therapy is less effective during acute infections
C. Immunocompromise caused by decreased pancreatic
function increases the child’s risk of secondary infection
D. Usual childhood immunizations are contraindicated in a
child with cystic fibrosis
A. Pulmonary therapy is effective during infections,
immunocompromise is not caused by decreased
pancreatic function, and immunizations are not
contraindicated in children with cystic fibrosis.
110. What factor would the nurse emphasize in discussing the
administration of exogenous pancreatic enzymes with the
parent of a child who has cystic fibrosis?
A.
B.
C.
D.
The enzymes should be taken between meals
The enzymes should be taken only at bedtime
The enzymes should be taken after each loose stool
The enzymes should be taken with meals and snacks
110. What factor would the nurse emphasize in discussing the
administration of exogenous pancreatic enzymes with the
parent of a child who has cystic fibrosis?
A.
B.
C.
D.
The enzymes should be taken between meals
The enzymes should be taken only at bedtime
The enzymes should be taken after each loose stool
The enzymes should be taken with meals and snacks
D. Pancreatic enzymes should be taken every time the child
eats.
111. Which meal is appropriate for an 8-year-old with cystic
fibrosis?
A.
B.
C.
D.
Peanut butter and jelly sandwich
Hamburger and milk shake
Spaghetti and meatballs
Egg salad sandwich and milk
111. Which meal is appropriate for an 8-year-old with cystic
fibrosis?
A.
B.
C.
D.
Peanut butter and jelly sandwich
Hamburger and milk shake
Spaghetti and meatballs
Egg salad sandwich and milk
C. Fat should be reduced, however, the client should receive
increased amounts of calories and protein. Peanut butter
sandwich is appropriate for this age but contains too much
fat. The milk and milk products are mucus-producing
foods.
112. The nurse administers digestive replacement enzymes for
the client with cystic fibrosis. What change indicates the
enzyme is effective?
A.
B.
C.
D.
Increased mucus excretion in stools
Decreased fat excretion in stools
Increased expectoration of mucus
Weight loss
112. The nurse administers digestive replacement enzymes for
the client with cystic fibrosis. What change indicates the
enzyme is effective?
A.
B.
C.
D.
Increased mucus excretion in stools
Decreased fat excretion in stools
Increased expectoration of mucus
Weight loss
B. This indicates the enzymes are aiding in digestion of fats
and protein.
113. Parents should be taught to avoid exposing their child with
cystic fibrosis to which situation to minimize the risk of
complications?
A.
B.
C.
D.
A dog that is shedding hair
A kitten born 3 days ago
A neighborhood child who has the flu
A relative who has hepatitis B
113. Parents should be taught to avoid exposing their child with
cystic fibrosis to which situation to minimize the risk of
complications?
A.
B.
C.
D.
A dog that is shedding hair
A kitten born 3 days ago
A neighborhood child who has the flu
A relative who has hepatitis B
C. Children with cystic fibrosis are very susceptible to
respiratory infections. Parents should be taught to guard
against exposing the child to infections to the greatest
extent possible.
114. A priority for an infant born with cleft lip and palate is to
receive adequate nutrition. Which intervention would need to
be rewritten before the plan of care was implemented?
A.
B.
C.
D.
Encourage breastfeeding if the mother chooses
Use a soft bottle that can be squeezed if bottle feeding
Place baby prone after feeding to help prevent aspiration
If infant refuses bottle, spoon feed with rice cerealthickened formula
114. A priority for an infant born with cleft lip and palate is to
receive adequate nutrition. Which intervention would need to
be rewritten before the plan of care was implemented?
A.
B.
C.
D.
Encourage breastfeeding if the mother chooses
Use a soft bottle that can be squeezed if bottle feeding
Place baby prone after feeding to help prevent aspiration
If infant refuses bottle, spoon feed with rice cerealthickened formula
C. Babies should not be placed on the abdomen but supine or
side-lying with few exceptions. This includes babies with
cleft lip and palate prior to surgery.
Physiological Integrity of Children
Nutritional and Metabolic Health
Cleft lip and
Palate
Physiological Integrity of Children
Nutritional and Metabolic Health
Cleft lip and Palate
Physiological Integrity of Children
Nutritional and Metabolic Health
Pre-operative Care
115. After surgery, the child with a cleft palate repair is placed on
the abdomen. Why is this position the best choice?
A.
B.
C.
D.
Protects the suture line
Enhances cleansing procedures
Facilitates drainage of secretions
Decreases the infant's tendency to suck
115. After surgery, the child with a cleft palate repair is placed on
the abdomen. Why is this position the best choice?
A.
B.
C.
D.
Protects the suture line
Enhances cleansing procedures
Facilitates drainage of secretions
Decreases the infant's tendency to suck
C. Postoperative positioning of the infant on the abdomen is
helpful in the immediate postoperative period to facilitate
drainage of secretions
116. After surgery for a cleft lip repair, an infant is having difficulty
breathing. Which nursing action would be most helpful in
bringing relief?
A.
B.
C.
D.
Raise the baby’s head
Turn the baby onto the abdomen
Administer oxygen per mask
Exert downward pressure on the infant’s chin
116. After surgery for a cleft lip repair, an infant is having difficulty
breathing. Which nursing action would be most helpful in
bringing relief?
A.
B.
C.
D.
Raise the baby’s head
Turn the baby onto the abdomen
Administer oxygen per mask
Exert downward pressure on the infant’s chin
D. After cleft lip repair, the infant must become accustomed to
nasal breathing. If the infant is having difficulty breathing,
the first thing that should be done is open the mouth.
Abdominal positioning and raising the baby’s head may
aggravate the breathing problem and abdominal
positioning may damage the suture line. Oxygen is not
necessary if opening the mouth is successful and a mask
might damage the suture line.
117. An infant, born with a cleft lip and palate, is ready for
discharge. Which behavior would indicate the parents are
ready for the infant's homecoming?
A.
B.
C.
D.
Parents appear angry about the infant's condition
During infant feedings, the parents talk to the infant
Mother asks the nurse to feed the infant
Father refuses to touch the infant
117. An infant, born with a cleft lip and palate, is ready for
discharge. Which behavior would indicate the parents are
ready for the infant's homecoming?
A.
B.
C.
D.
Parents appear angry about the infant's condition
During infant feedings, the parents talk to the infant
Mother asks the nurse to feed the infant
Father refuses to touch the infant
B. Talking to and stroking the infant are signs of attachment
and readiness to care for the infant
118. Which physician order for a child with gastroesophageal
reflux would the RN question?
A.
B.
C.
D.
Small, frequent, thickened formula feedings
Tagamet (cimetidine) PO
Reglan (megoclopramide) PO
Position supine after feedings
118. Which physician order for a child with gastroesophageal
reflux would the RN question?
A.
B.
C.
D.
Small, frequent, thickened formula feedings
Tagamet (cimetidine) PO
Reglan (megoclopramide) PO
Position supine after feedings
D. The child should be placed in an upright position after
feedings, not flat.
119. A child with lactose intolerance is placed on a lactose-free
diet and the parents are being taught about this condition.
Which parent statement indicates understanding of the
condition?
A. “If my child has severe constipation, I will notify the
physician.”
B. “I should notice symptoms within 30 minutes to a few hours
after eating.”
C. “One common, hidden source of lactose is gluten.”
D. “If my child drinks soy milk, that will contain plenty of
calcium and Vitamin D.”
119. A child with lactose intolerance is placed on a lactose-free
diet and the parents are being taught about this condition.
Which parent statement indicates understanding of the
condition?
A. “If my child has severe constipation, I will notify the
physician.”
B. “I should notice symptoms within 30 minutes to a few hours
after eating.”
C. “One common, hidden source of lactose is gluten.”
D. “If my child drinks soy milk, that will contain plenty of
calcium and Vitamin D.”
B. Constipation is not a common symptom. Soy milk contains
½ the calcium of milk and may not be fortified with Vitamin
D.
120. A child with celiac disease is recovering from an
appendectomy and is ready to eat regular food. Which food
should be removed from the menu?
A.
B.
C.
D.
Chicken rice soup
Fresh fruit cup
Hamburger patty
Crackers
120. A child with celiac disease is recovering from an
appendectomy and is ready to eat regular food. Which food
should be removed from the menu?
A.
B.
C.
D.
Chicken rice soup
Fresh fruit cup
Hamburger patty
Crackers
D. The diet for children with celiac disease is gluten-free and
crackers contain gluten; the other listed foods do not.
121. What clinical assessment is most likely to be seen in an
infant with pyloric stenosis?
A. Visible peristaltic waves that move right to left in lower
abdomen
B. Rebound tenderness
C. Palpable mass in the epigastrium to the right of the
umbilicus
D. Tenderness over epigastric area not relieved by heat
application
121. What clinical assessment is most likely to be seen in an
infant with pyloric stenosis?
A. Visible peristaltic waves that move right to left in lower
abdomen
B. Rebound tenderness
C. Palpable mass in the epigastrium to the right of the
umbilicus
D. Tenderness over epigastric area not relieved by heat
application
C. Typical sign due to the obstruction caused by pyloric
stenosis. The waves typically move from left to right in the
upper abdomen.
122. Identify the most classic sign of pyloric stenosis in a 6-weekold infant.
A.
B.
C.
D.
Projectile vomiting after feeding
Prolonged crying after feeding
Persistent watery fecal discharge
Painful episodes with constipation
122. Identify the most classic sign of pyloric stenosis in a 6-weekold infant.
A.
B.
C.
D.
Projectile vomiting after feeding
Prolonged crying after feeding
Persistent watery fecal discharge
Painful episodes with constipation
A. Pyloric stenosis causes an obstruction at the gastric outlet.
Any food which has been consumed cannot proceed into
the small intestine and is usually forcefully ejected from the
stomach.
123. An infant was returned to the unit about 4 hours ago after
surgery to correct pyloric stenosis. Select the most important
nursing intervention.
A. Feed small amounts frequently and assess emesis
B. Keep the infant NPO and encourage parent to perform oral
care
C. Monitor intake and output and administer medications
D. Monitor hydration status and encourage parent to rest
123. An infant was returned to the unit about 4 hours ago after
surgery to correct pyloric stenosis. Select the most important
nursing intervention.
A. Feed small amounts frequently and assess emesis
B. Keep the infant NPO and encourage parent to perform oral
care
C. Monitor intake and output and administer medications
D. Monitor hydration status and encourage parent to rest
A. Small frequent feedings are resumed at 4-6 hours
postoperatively. C and D are not as important as A.
Physiological Integrity of Children
Nutritional and Metabolic Health
124. An hour after admission to the nursery, the nurse observes
the infant’s respirations to be 70 breaths/minute along with
excessive drooling. Which action should the nurse take first?
A. Continue to observe the infant closely for other symptoms
B. Reposition to side-lying position and call the physician
C. Suction the infant’s mouth and place in supine position
with HOB elevated
D. Provide supplemental oxygen when the respirations
exceed 70 breaths/minute
124. An hour after admission to the nursery, the nurse observes
the infant’s respirations to be 70 breaths/minute along with
excessive drooling. Which action should the nurse take first?
A. Continue to observe the infant closely for other symptoms
B. Reposition to side-lying position and call the physician
C. Suction the infant’s mouth and place in supine position
with HOB elevated
D. Provide supplemental oxygen when the respirations
exceed 70 breaths/minute
C. The data support the possibility of a tracheoesophageal
fistula and placing the infant in this position decreases the
risk of aspiration. With the excessive drooling, suctioning
would be necessary to maintain the airway.
125. What is the reason for positioning an infant with
tracheoesophageal fistula supine with head and shoulders
elevated prior to surgery?
A. Reduce respiratory and cardiac workload
B. Alleviate pressure of distended abdominal contents on the
diaphragm
C. Increase pooling of secretions in bottom of upper
esophageal pouch
D. Reduce gastric distention by allowing air bubbles from the
fistula to escape
125. What is the reason for positioning an infant with
tracheoesophageal fistula supine with head and shoulders
elevated prior to surgery?
A. Reduce respiratory and cardiac workload
B. Alleviate pressure of distended abdominal contents on the
diaphragm
C. Increase pooling of secretions in bottom of upper
esophageal pouch
D. Reduce gastric distention by allowing air bubbles from the
fistula to escape
C. Gravity encourages the flow of secretions with pooling in
the bottom of the upper pouch where more effective
removal of secretions can be accomplished by placing a
catheter in this pool. Abdominal distention is a very late
manifestation of TEF and there is no increased respiratory
or cardiac workload caused by TEF.
Physiological Integrity of Children
Nutritional and Metabolic Health
126. The nurse is caring for a client diagnosed with a suspected
intussusception. Which test should the nurse anticipate being
ordered for this client?
A.
B.
C.
D.
MRI of the abdomen
Water-soluble contrast enema
Upper GI series
Colonoscopy
126. The nurse is caring for a client diagnosed with a suspected
intussusception. Which test should the nurse anticipate being
ordered for this client?
A.
B.
C.
D.
MRI of the abdomen
Water-soluble contrast enema
Upper GI series
Colonoscopy
B. First, an abdominal X-ray to detect intraperitoneal air from
a bowel perforation is obtained. If the X-ray is negative,
water-soluble contrast and air pressure may be used to
attempt to reduce the intussusception.
Physiological Integrity of Children
Nutritional and Metabolic Health
127. Which statement by a parent would be pertinent to a
diagnosis of Hirschsprung’s disease?
A.
B.
C.
D.
“He is constipated often.”
“He sometimes gets colds.”
“He sometimes spits up.”
“He has a rectal temperature of 99.6o F (37.6o C).”
127. Which statement by a parent would be pertinent to a
diagnosis of Hirschsprung’s disease?
A.
B.
C.
D.
“He is constipated often.”
“He sometimes gets colds.”
“He sometimes spits up.”
“He has a rectal temperature of 99.6o F (37.6o C).”
A. Chronic constipation is the most consistent symptom.
128. A 4-year-old who has a colostomy due to Hirschsprung’s
disease is admitted because of poor weight gain. While
teaching the parents about proper diet, which food should the
nurse recommend be avoided?
A.
B.
C.
D.
Ripe bananas
Spaghetti
Cheese
Apples
128. A 4-year-old who has a colostomy due to Hirschsprung’s
disease is admitted because of poor weight gain. While
teaching the parents about proper diet, which food should the
nurse recommend be avoided?
A.
B.
C.
D.
Ripe bananas
Spaghetti
Cheese
Apples
D. Colostomy clients should be on a low-residue, low-fiber
diet. Raw apples contain a lot of fiber and residue.
Physiological Integrity of Children
Nutritional and Metabolic Health
129. Which assessment information would provide the nurse with
the most accurate indication of the impact of fluid loss in an
infant with gastroenteritis and diarrhea?
A.
B.
C.
D.
Weight change from pre-illness to current
Moistness of oral mucous membranes
Hematocrit level
Skin turgor
129. Which assessment information would provide the nurse with
the most accurate indication of the impact of fluid loss in an
infant with gastroenteritis and diarrhea?
A.
B.
C.
D.
Weight change from pre-illness to current
Moistness of oral mucous membranes
Hematocrit level
Skin turgor
A. Infants are more vulnerable to fluid and electrolyte
imbalances than older children or adults. Depending on
the severity of the dehydration, the infant can experience a
weight loss of up to 15%.
130. Select the most accurate expected client outcome related to
the diagnosis of “Fluid Volume Deficit related to fluid loss
caused by severe diarrhea”.
A.
B.
C.
D.
Has normal bowel movements
Does not have diarrhea stools for four hours
Tolerates intravenous fluids well
Exhibits moist mucous membranes
130. Select the most accurate expected client outcome related to
the diagnosis of “Fluid Volume Deficit related to fluid loss
caused by severe diarrhea”.
A.
B.
C.
D.
Has normal bowel movements
Does not have diarrhea stools for four hours
Tolerates intravenous fluids well
Exhibits moist mucous membranes
D. It is the only answer that specifically focuses on the
diagnosis. All other answer choices are good signs, but
not specific enough.
Physiological Integrity of Children
Nutritional and Metabolic Health
Physiological Integrity of Children
Nutritional and Metabolic Health
131. A 6-year-old child is admitted with RLQ pain, nausea and
vomiting for six hours. Which positive assessment is most
indicative of appendicitis?
A.
B.
C.
D.
Sunset sign
Trousseau’s sign
Ladin’s sign
Rovsing’s sign
131. A 6-year-old child is admitted with RLQ pain, nausea and
vomiting for six hours. Which positive assessment is most
indicative of appendicitis?
A.
B.
C.
D.
Sunset sign
Trousseau’s sign
Ladin’s sign
Rovsing’s sign
D. Rovsing’s is rebound tenderness, abdominal pain
particular to appendicitis. Sunset indicates hydrocephalus,
Trousseau’s indicates hypocalcemia, and Ladin’s is a sign
of pregnancy.
132. A 13-year-old is admitted with the diagnosis of appendicitis
and complains of “feeling funny” all over. Which sign or
symptom would be related to something other than the
sympathetic effects caused by the acute abdominal pain?
A.
B.
C.
D.
Chills
Tachycardia
Dilated pupils
Rapid breathing
132. A 13-year-old is admitted with the diagnosis of appendicitis
and complains of “feeling funny” all over. Which sign or
symptom would be related to something other than the
sympathetic effects caused by the acute abdominal pain?
A.
B.
C.
D.
Chills
Tachycardia
Dilated pupils
Rapid breathing
A. Chills are a normal physiologic response to infection and
not a response of the sympathetic nervous system to pain.
All other choices are sympathetic responses to pain.
133. A 9-year-old child is admitted with a tentative diagnosis of
appendicitis. Which laboratory test result is most indicative
that the condition is worsening?
A.
B.
C.
D.
Negative C-reactive protein
Hemoglobin 14.2 g/100 mL of blood
Increasing erythrocyte sedimentation rate
White blood cell count of 19,500/cu mm of blood
133. A 9-year-old child is admitted with a tentative diagnosis of
appendicitis. Which laboratory test result is most indicative
that the condition is worsening?
A.
B.
C.
D.
Negative C-reactive protein
Hemoglobin 14.2 g/100 mL of blood
Increasing erythrocyte sedimentation rate
White blood cell count of 19,500/cu mm of blood
C. The sedimentation rate is another non-specific test for
inflammatory disease; situation states it has been taken
earlier and is now increasing; (the client is worse).
134. Which assessment would the RN do first when a child
returns to the unit after an emergency appendectomy?
A.
B.
C.
D.
Bladder
Intravenous fluid infusion site
Nasogastric tube function
Dressing
134. Which assessment would the RN do first when a child
returns to the unit after an emergency appendectomy?
A.
B.
C.
D.
Bladder
Intravenous fluid infusion site
Nasogastric tube function
Dressing
D. Initial assessment should focus on the surgical site, then
the nurse would check the IV site and determine if the child
needs to urinate. There is seldom an NG tube unless there
is a ruptured appendix.
135. Which symptoms would be unexpected in a client with
pinworms?
A.
B.
C.
D.
Rebound tenderness
No symptoms
Diarrhea
Perianal pruritis
135. Which symptoms would be unexpected in a client with
pinworms?
A.
B.
C.
D.
Rebound tenderness
No symptoms
Diarrhea
Perianal pruritis
A. Rebound tenderness is associated with appendicitis, not
pinworms.
136. A child is seen in the clinic with symptoms of intestinal
parasite infestation. Which symptom would alert the RN that
the infestation was by ascaris lumbricoides (roundworms)?
A.
B.
C.
D.
Thread-like worms noted at anus
Large 10-14 inch worms noted in diaper
Large pale mucous stools
Few symptoms except eosinophilia
136. A child is seen in the clinic with symptoms of intestinal
parasite infestation. Which symptom would alert the RN that
the infestation was by ascaris lumbricoides (roundworms)?
A.
B.
C.
D.
Thread-like worms noted at anus
Large 10-14 inch worms noted in diaper
Large pale mucous stools
Few symptoms except eosinophilia
B. Ascaris is the largest of the intestinal helminthes, can lead
to bowel perforation, obstructive jaundice, and pneumonia.
Most frequently seen in children 1-4 years old and is
treated with chewable Vermox (mebendazole).
137. A school-age child is seen in clinic for nocturnal enuresis.
Tests for UTI and diabetes were negative. If the parent
responds with punitive measures, which nursing diagnosis
would be anticipated?
A.
B.
C.
D.
Body Image Disturbance
Ineffective Family Coping
Self-esteem Disturbance
Noncompliance
137. A school-age child is seen in clinic for nocturnal enuresis.
Tests for UTI and diabetes were negative. If the parent
responds with punitive measures, which nursing diagnosis
would be anticipated?
A.
B.
C.
D.
Body Image Disturbance
Ineffective Family Coping
Self-esteem Disturbance
Noncompliance
C. Self-esteem often is disturbed if parental response is harsh
or punitive.
138. Which hospital roommate assignment would be most
appropriate for a 3-year-old girl with nephrotic syndrome?
A.
B.
C.
D.
2-year-old girl with croup
3-year-old girl with impetigo
4-year-old boy with tonsillitis
4-year-old boy with a fractured femur
138. Which hospital roommate assignment would be most
appropriate for a 3-year-old girl with nephrotic syndrome?
A.
B.
C.
D.
2-year-old girl with croup
3-year-old girl with impetigo
4-year-old boy with tonsillitis
4-year-old boy with a fractured femur
D. First, the roommate must not be contagious then the
developmental level is assessed.
139. A child with nephrotic syndrome is taking prednisone. What
would the nurse tell the parents about the expected effects of
the medication?
A.
B.
C.
D.
Decreases blood pressure
Decreases protein in the urine
Increases sodium reabsorption
Increases epithelial immunity
139. A child with nephrotic syndrome is taking prednisone. What
would the nurse tell the parents about the expected effects of
the medication?
A.
B.
C.
D.
Decreases blood pressure
Decreases protein in the urine
Increases sodium reabsorption
Increases epithelial immunity
B. The purpose of taking prednisone is to decrease the
excretion of protein from the kidney.
140. One of the nursing diagnoses included by the nurse in a
care plan for a child with nephrotic syndrome is "Fluid volume
excess." Choose the most appropriate intervention for this
diagnosis.
A. Observing strict bedrest
B. Testing urine specific gravity every shift
C. Monitoring hourly intake and output
D. Weighing the child before breakfast
140. One of the nursing diagnoses included by the nurse in a
care plan for a child with nephrotic syndrome is "Fluid volume
excess." Choose the most appropriate intervention for this
diagnosis.
A. Observing strict bedrest
B. Testing urine specific gravity every shift
C. Monitoring hourly intake and output
D. Weighing the child before breakfast
D. Weight changes are important indicators of fluid status,
especially in children. Hourly I and O is not necessary.
Urine protein levels are more significant for nephrotic
syndrome than specific gravity.
141. The nurse provides discharge teaching to the parents of a 4year-old with nephrotic syndrome. Which statement by a
parent indicates the nurse’s teaching has been effective?
A. “We will notify the physician if the protein increases in the
urine.”
B. “Our child can learn to check his/her own urine.”
C. “We realize that cloudy urine will show a false positive.”
D. “We will collect a clean catch specimen for analysis.”
141. The nurse provides discharge teaching to the parents of a 4year-old with nephrotic syndrome. Which statement by a
parent indicates the nurse’s teaching has been effective?
A. “We will notify the physician if the protein increases in the
urine.”
B. “Our child can learn to check his/her own urine.”
C. “We realize that cloudy urine will show a false positive.”
D. “We will collect a clean catch specimen for analysis.”
A. This is an early sign of re-occurring nephrosis. Urine
should be checked daily for protein with a dipstick.
142. When assessing a 4-year-old child with glomerulonephritis,
which physical finding should be expected?
A.
B.
C.
D.
Decreased joint mobility
White lines on the nails
Periorbital edema
Hypotension
142. When assessing a 4-year-old child with glomerulonephritis,
which physical finding should be expected?
A.
B.
C.
D.
Decreased joint mobility
White lines on the nails
Periorbital edema
Hypotension
C. Excessive water accumulation and sodium retention lead
to edema. A does not occur with nephritis and B and D
occur more commonly in nephrotic syndrome.
143. A 14-year-old client with chronic glomerulonephritis is
displaying signs of renal failure.The client is being taught to
monitor daily fluid status. Which finding would probably be
the first indication the client is retaining fluid?
A.
B.
C.
D.
Decreased urine output
Sudden weight gain
Severe ankle edema
Periorbital edema
143. A 14-year-old client with chronic glomerulonephritis is
displaying signs of renal failure.The client is being taught to
monitor daily fluid status. Which finding would probably be
the first indication the client is retaining fluid?
A.
B.
C.
D.
Decreased urine output
Sudden weight gain
Severe ankle edema
Periorbital edema
B. When clients are dealing with this disease in the home
setting, they should be taught by the nurse to weigh
themselves daily and to notify the doctor if an increase
exceeds 2 lbs/day
144. Which nursing intervention has the highest priority in caring
for a client with acute glomerulonephritis?
A.
B.
C.
D.
Assess for dysuria
Monitor blood pressure
Monitor temperature
Assess for jaundice
144. Which nursing intervention has the highest priority in caring
for a client with acute glomerulonephritis?
A.
B.
C.
D.
Assess for dysuria
Monitor blood pressure
Monitor temperature
Assess for jaundice
B. Increased blood pressure is a serious problem associated
with this disorder.
145. A child with glomerulonephritis is placed on a low sodium
diet. The parent has been taught the rationale for the diet
and foods that can be included on the diet. The parent's
selection of which food for a snack would indicate a clear
understanding of the diet restrictions?
A.
B.
C.
D.
Potato chips
Ginger ale
Plain popcorn
Graham crackers
145. A child with glomerulonephritis is placed on a low sodium
diet. The parent has been taught the rationale for the diet
and foods that can be included on the diet. The parent's
selection of which food for a snack would indicate a clear
understanding of the diet restrictions?
A.
B.
C.
D.
Potato chips
Ginger ale
Plain popcorn
Graham crackers
C. Unsalted, plain popcorn is commonly suggested as a snack
for children on low sodium diets.
146. A 3-year-old child presents with an abdominal mass. A
diagnosis of Wilms tumor is made. From knowledge of this
tumor, which aspect of care does the nurse know must be
enforced by the family and all who care for the child?
A.
B.
C.
D.
Strict bed rest
Forcing fluids
Minimal handling of the abdomen
Vigorous bathing in preparation for surgery
146. A 3-year-old child presents with an abdominal mass. A
diagnosis of Wilms tumor is made. From knowledge of this
tumor, which aspect of care does the nurse know must be
enforced by the family and all who care for the child?
A.
B.
C.
D.
Strict bed rest
Forcing fluids
Minimal handling of the abdomen
Vigorous bathing in preparation for surgery
C. In Wilms tumor it is important to avoid excessive handling
of the abdomen to prevent rupture of the tumor capsule
and possible spread of the tumor
147. The goal of care for a 6-year-old child with vesicoureteral
reflux is to comply with preventive measures. Which is
appropriate to make the goal measurable?
A.
B.
C.
D.
Child will be encouraged to void every 2-3 hours
Child will maintain appropriate hygiene
Medications will be taken as ordered
Child will have adequate fluid intake
147. The goal of care for a 6-year-old child with vesicoureteral
reflux is to comply with preventive measures. Which is
appropriate to make the goal measurable?
A.
B.
C.
D.
Child will be encouraged to void every 2-3 hours
Child will maintain appropriate hygiene
Medications will be taken as ordered
Child will have adequate fluid intake
A. This is the most specific and most easily measurable.
148. The physician and parents have agreed to correct the
congenital clubfoot using conservative treatment rather than
surgery. Which intervention would be inappropriate?
A. Teach warning signs to report (pain, edema, decreased
capillary refill)
B. Prepare for serial casting every few days for several weeks
C. Teach parents to check capillary refill following cast
application
D. Reinforce that total treatment time is approximately 4-5
months
148. The physician and parents have agreed to correct the
congenital clubfoot using conservative treatment rather than
surgery. Which intervention would be inappropriate?
A. Teach warning signs to report (pain, edema, decreased
capillary refill)
B. Prepare for serial casting every few days for several weeks
C. Teach parents to check capillary refill following cast
application
D. Reinforce that total treatment time is approximately 4-5
months
D. If not aligned by 8-12 weeks by X-ray evaluation, surgery
would likely be indicated.
Physiological Integrity of Children
Mobility (Musculoskeletal) Health
Physiological Integrity of Children
Mobility (Musculoskeletal) Health
149. The nurse detects a positive Ortolani’s sign in a newborn.
What is the nurse assessing?
A.
B.
C.
D.
Broadening of the perineum
Shortening of one leg
Audible click on hip manipulation
Unilateral droop of the hip
149. The nurse detects a positive Ortolani’s sign in a newborn.
What is the nurse assessing?
A.
B.
C.
D.
Broadening of the perineum
Shortening of one leg
Audible click on hip manipulation
Unilateral droop of the hip
C. This is the definition of Ortolani’s sign where there is an
audible click and indicates hip dysplasia.
Physiological Integrity of Children
Mobility (Musculoskeletal) Health
Physiological Integrity of Children
Mobility (Musculoskeletal) Health
150. An assessment on a 2-day-old infant finds the presence of
asymmetrical buttock folds. What does this indicate?
A.
B.
C.
D.
Normal in a neonate
Suspicious for fracture
Breech delivery
Developmental hip dysplasia
150. An assessment on a 2-day-old infant finds the presence of
asymmetrical buttock folds. What does this indicate?
A.
B.
C.
D.
Normal in a neonate
Suspicious for fracture
Breech delivery
Developmental hip dysplasia
D. This is a clinical sign of developmental dysplasia of the hip
and includes unequal gluteal folds, restricted abduction and
positive Ortolani’s sign.
Physiological Integrity of Children
Mobility (Musculoskeletal) Health
Congenital
Hip
151. A nurse would anticipate the presence of which finding in
assessing a 2-month-old infant with developmental dysplasia
of the hip?
A. Ortolani's sign
B. Positive Barlow's test
C. Limited hip abduction
D. Positive Trendelenburg sign
151. A nurse would anticipate the presence of which finding in
assessing a 2-month-old infant with developmental dysplasia
of the hip?
A. Ortolani's sign
B. Positive Barlow's test
C. Limited hip abduction
D. Positive Trendelenburg sign
C. Ortolani's sign and a positive Barlow's test are seen in the
newborn period of life. A positive Trendelenburg sign is
seen in the weight-bearing or walking child.
Physiological Integrity of Children
Mobility (Musculoskeletal) Health
Pavlik
Harness
152. Which nursing action would be the most important for the
successful treatment of acute hematogenous osteomyelitis in
an 11-year-old child?
A.
B.
C.
D.
Diversional activities based on interests
Maintenance of the client's intravenous infusion site
Adequate preparation for surgery when fever subsides
Relief of the severe pain that accompanies this disease
152. Which nursing action would be the most important for the
successful treatment of acute hematogenous osteomyelitis in
an 11-year-old child?
A.
B.
C.
D.
Diversional activities based on interests
Maintenance of the client's intravenous infusion site
Adequate preparation for surgery when fever subsides
Relief of the severe pain that accompanies this disease
B. Vigorous intravenous antibiotic therapy to ensure high
blood levels is paramount to reduce the infection and
prevent amputation.
153. When parents of a preschooler, diagnosed with juvenile
rheumatoid arthritis, ask for information about the disease
progression, what should the nurse tell them?
A. The disease will go into permanent remission in most
children
B. Many children have long remissions, but have severe
deformities
C. The disease typically progresses gradually and will become
crippling as the child reaches adulthood
D. Most children recover completely within a few years of
diagnosis and treatment
153. When parents of a preschooler, diagnosed with juvenile
rheumatoid arthritis, ask for information about the disease
progression, what should the nurse tell them?
A. The disease will go into permanent remission in most
children
B. Many children have long remissions, but have severe
deformities
C. The disease typically progresses gradually and will become
crippling as the child reaches adulthood
D. Most children recover completely within a few years of
diagnosis and treatment
A. A majority of children achieve remission by adolescence.
154. Which statement by the parent of a child with juvenile
rheumatoid arthritis indicates teaching by the nurse has been
successful?
A. “By putting cool compresses on the joints that hurt, I can
help relieve my child's pain.“
B. “If my child performs vigorous weight-bearing exercises
four times a day, that will help.“
C. “It's important to be sure my child sleeps on a soft mattress,
to facilitate rest.“
D. “The use of moist heat on the painful joints will help ease
my child's discomfort.“
154. Which statement by the parent of a child with juvenile
rheumatoid arthritis indicates teaching by the nurse has been
successful?
A. “By putting cool compresses on the joints that hurt, I can
help relieve my child's pain.“
B. “If my child performs vigorous weight-bearing exercises
four times a day, that will help.“
C. “It's important to be sure my child sleeps on a soft mattress,
to facilitate rest.“
D. “The use of moist heat on the painful joints will help ease
my child's discomfort.“
D. Moist heat on affected joints will increase circulation,
resulting in decreased pain and facilitation of joint
movement.
Physiological Integrity of Children
Mobility (Musculoskeletal) Health
155. When caring for a client with a compound fracture, the nurse
is most concerned about the client’s increased risk for which
occurrence?
A.
B.
C.
D.
Immobility
Infection
Arthritis
Callus formation
155. When caring for a client with a compound fracture, the nurse
is most concerned about the client’s increased risk for which
occurrence?
A.
B.
C.
D.
Immobility
Infection
Arthritis
Callus formation
B. With a compound fracture, the skin (the body’s first line of
defense) has been broken. This increases the client’s risk
for infection.
Physiological Integrity of Children
Mobility (Musculoskeletal) Health
156. Two days following a long bone fracture, the client
complains of sudden onset of difficulty breathing. Select the
nurse’s priority, from a list of physician orders.
A.
B.
C.
D.
Obtain arterial blood gases
Obtain a chest X-ray
Initiate an IV of 0.45% normal saline
Administer oxygen
156. Two days following a long bone fracture, the client
complains of sudden onset of difficulty breathing. Select the
nurse’s priority, from a list of physician orders.
A.
B.
C.
D.
Obtain arterial blood gases
Obtain a chest X-ray
Initiate an IV of 0.45% normal saline
Administer oxygen
D. Oxygen should be initiated immediately to treat hypoxia
and the client’s “difficulty breathing.” It is possible that the
client has a fat embolism and will need appropriate
treatment.
157. The RN is evaluating a 3-year-old client’s outcomes related
to 90 degree-90 degree skeletal traction. Which chart entry
would alert the RN to the need to adjust the plan of care?
A.
B.
C.
D.
Child actively resists pin care
Weights are hanging freely
Child uses trapeze independently
Skin clear with no signs of redness or ecchymosis
157. The RN is evaluating a 3-year-old client’s outcomes related
to 90 degree-90 degree skeletal traction. Which chart entry
would alert the RN to the need to adjust the plan of care?
A.
B.
C.
D.
Child actively resists pin care
Weights are hanging freely
Child uses trapeze independently
Skin clear with no signs of redness or ecchymosis
A. It is important that pin care be done as prescribed to
prevent infection. Covering the pin sites may help
decrease the child’s distress.
158. The nursing assistant is assigned to care for a client in
Buck’s traction for a fractured hip. Which statement by the
nursing assistant would indicate the RN needs to further
clarify the instructions?
A.
B.
C.
D.
“I need to monitor the client’s intake and output.”
“I will remove the traction during meal times.”
“I will encourage the client to cough and deep breathe.”
“If the client has a productive cough, I need to note the
color of the sputum.”
158. The nursing assistant is assigned to care for a client in
Buck’s traction for a fractured hip. Which statement by the
nursing assistant would indicate the RN needs to further
clarify the instructions?
A.
B.
C.
D.
“I need to monitor the client’s intake and output.”
“I will remove the traction during meal times.”
“I will encourage the client to cough and deep breathe.”
“If the client has a productive cough, I need to note the
color of the sputum.”
B. Buck’s traction reduces muscle spasms and should remain
on at all times. Traction should never be removed without
a physician’s order.
159. The hips of a child in Bryant’s traction should be maintained
in which position?
A.
B.
C.
D.
45o
60o
90o
180o
159. The hips of a child in Bryant’s traction should be maintained
in which position?
A.
B.
C.
D.
45o
60o
90o
180o
C. This is the proper alignment needed for proper healing.
160. The nurse is caring for a client in Crutchfield tongs for the
treatment of a cervical vertebral fracture. Which independent
nursing intervention would be effective in preventing
constipation?
A. Elevation of the head of the bed to 45 degrees during
bedpan use
B. Encouraging selections of bulk-building foods into the diet
C. Administering a laxative for bowel stimulation
D. Ambulating the client to increase peristalsis
160. The nurse is caring for a client in Crutchfield tongs for the
treatment of a cervical vertebral fracture. Which independent
nursing intervention would be effective in preventing
constipation?
A. Elevation of the head of the bed to 45 degrees during
bedpan use
B. Encouraging selections of bulk-building foods into the diet
C. Administering a laxative for bowel stimulation
D. Ambulating the client to increase peristalsis
B. The nurse could independently provide dietary instructions
as listed. A laxative could not be given without a
physician’s order. Movement of the client in tongs is
minimal without a halo vest, and requires physician order.
Crutchfield Tongs
Halo Traction
161. When providing care for a postoperative client who has had
an open reduction of a fractured femur, the nurse observes a
small amount of bloody drainage on the cast. What action
should be taken by the nurse?
A.
B.
C.
D.
Split the cast to minimize circulatory complications
Circle the area of drainage and note the time
Elevate the leg higher and apply an ice bag
Report the drainage immediately to the physician
161. When providing care for a postoperative client who has had
an open reduction of a fractured femur, the nurse observes a
small amount of bloody drainage on the cast. What action
should be taken by the nurse?
A.
B.
C.
D.
Split the cast to minimize circulatory complications
Circle the area of drainage and note the time
Elevate the leg higher and apply an ice bag
Report the drainage immediately to the physician
B. Since the bloody drainage is described as a “small
amount,” this would not be unusual for a “fresh”
postoperative client. Continued observation for extension
of the drainage beyond the circle would be most logical at
this time.
162. What nursing intervention is appropriate for the care of a
client with pruritus from a cast on the leg?
A.
B.
C.
D.
Insert long slender object under the cast interface
Direct cool air from hair dryer down the cast
Pour water into the cast to cool the skin
Attach toothbrush to wire hanger to stimulate skin under
the cast
162. What nursing intervention is appropriate for the care of a
client with pruritus from a cast on the leg?
A.
B.
C.
D.
Insert long slender object under the cast interface
Direct cool air from hair dryer down the cast
Pour water into the cast to cool the skin
Attach toothbrush to wire hanger to stimulate skin under
the cast
B. Cool air promotes drying and relieves itching. Scratching
with a foreign object can cause infection.
163. The nurse is providing care for a client who has a casted left
leg. Which observation would the nurse report to the
physician immediately?
A.
B.
C.
D.
Client complaints of pain in the left leg
Edema of the left foot with inability to wear shoe
Loss of appetite with constipation
Client inability to feel toes of left foot
163. The nurse is providing care for a client who has a casted left
leg. Which observation would the nurse report to the
physician immediately?
A.
B.
C.
D.
Client complaints of pain in the left leg
Edema of the left foot with inability to wear shoe
Loss of appetite with constipation
Client inability to feel toes of left foot
D. This could indicate insufficient perfusion to the left foot and,
if left unreported and untreated (e.g. bivalving of plaster
cast), might lead to necrosis of tissue and loss of part or all
of the limb.
164. Choose the most appropriate roommate for a 16-year-old
client who is in a full body cast.
A.
B.
C.
D.
12-year-old with an inguinal hernia repair
9-year-old with gastroenteritis
6-year-old with a fractured femur
15-year-old with pneumonia
164. Choose the most appropriate roommate for a 16-year-old
client who is in a full body cast.
A.
B.
C.
D.
12-year-old with an inguinal hernia repair
9-year-old with gastroenteritis
6-year-old with a fractured femur
15-year-old with pneumonia
A. Although this child is not the closest in age to the client in a
full body cast, it is the closest choice without an active
disease process present.
165. Which is likely to be associated with the most common type
of scoliosis?
A.
B.
C.
D.
Male client with 25% lateral curvature
Client presents with severe pain
Severity decreases with growth
Develops after 10 years of age
165. Which is likely to be associated with the most common type
of scoliosis?
A.
B.
C.
D.
Male client with 25% lateral curvature
Client presents with severe pain
Severity decreases with growth
Develops after 10 years of age
D. Idiopathic scoliosis usually has onset after 10 years old
through skeletal maturity. It is mostly in females, pain is
not usually severe and severity does not usually increases
with age if untreated.
Physiological Integrity of Children
Mobility (Musculoskeletal) Health
Scoliosis
Physiological Integrity of Children
Mobility (Musculoskeletal) Health
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