PEDIATRIC
NURSING
Practice Exam 1-100 with Answers and Rationale
Practice Exam 1-100 with Answers and Rationale
Situation:
The
school health nurse conducts health education classes to graduating high school
students.
1.
When
teaching an adolescent about the rules for safer sex, which of the following
would you include?
A. Anal sex
carries a little risk in contracting STD’s.
B. Choosing sexual partner is extremely important.
C. Sex during
menstrual flow carries little risk.
D. Always use a
condom when having sexual intercourse
Answer: B
Rationale: Sexual relationships expose both partners
to any diseases of the other partner. Choosing partners carefully reduces the
risk of disease.
(Reference: Pillitteri A.
Maternal and Child Health Nursing, 3rd
Edition, 2003, Vol. 1, p.88)
2.
Responsible
Parenthood means:
A. The couple
must focus on the use of contraception to prevent pregnancy.
B. The parents understands their responsibility and have appropriate
plan for their family based on their capability to support them.
C. The use of
natural family planning and attending seminars before marriage.
D. Both parents
save up for the future of their children
Answer: B
Rationale: Responsible parenthood involves
understanding of couple’s responsibility and having appropriate plan for their
family based on the ability to sustain their needs. It does not solely focus on
the use of contraception or any form of family planning. It includes all the
decisions an individual or couple make about having children. These decisions
usually include if and when to have children, how many children to have, and
how they are spaced.
(Reference: Cuevas F. Public
Health Nursing in the Philippines,10th Edition, 2007)
3.
An
example of methods used in natural family planning includes:
A. Calendar Method and Billings Method
B. Calendar
Method and Condom
C. Contraceptive
pills and Cervical Mucus
D. Tubal
ligation and vasectomy
Rationale: A. Calendar and Billings Method are both
natural family planning methods. Condom and contraceptive pills are artificial
methods whereas Tubal ligation and vasectomy are permanent methods of family
planning.
(Reference: Pillitteri A. Maternal and Child Health Nursing, 3rd Edition,
Vol. 1, 2003, p.101-116)
4.
A 40
year old woman, a heavy smoker, visits your family planning clinic. She told
you that she has a very irregular menstrual cycle. She wants a highly reliable
contraceptives. Assuming that all of the following methods of birth control are
acceptable for her, which of the following would be the best recommendation?
A. The Mini pill
B. A
spermicidal suppository
C. A diaphragm and spermicidal suppository
D. Calendar and
Billings method
Rationale: C. Combined diaphragm and suppository is the
best choice for her considering her age and smoking habits. The combined effect
of two methods is more reliable. Mini-pill contains only progesterone. Without
estrogen content, ovulation may occur, but because the progestins have not
allowed the endometrium to develop fully, implantation will not take place.
When used correctly, they 99.5% effective in preventing conception. Because
women occasionally forget to take them and there are individual differences in
women’s physiology, the typical failure rate is round 3%.
Effectiveness of natural family planning methods such
as calendar and Billings methods vary mainly on couple’s ability to refrain
from having sex on fertile days. Failure rates usually range from 10% to 20%.
(Reference: Pillitteri A.
Maternal and Child Health Nursing, 3rd
Edition, Vol. 1, 2003, p.101-114)
5.
A
young client who has become sexually active asks the nurse. “What is the most
effective way to prevent a pregnancy?” the nurse’s best response would be:
A. “Abstain from sex”
B. “Use birth
control pills”
C. “Have an IUD
inserted
D. “Use condom
and foam”
Rationale: A. Health teaching guidelines for adolescents
regarding sexuality involves saying “no” and being firm about their intentions
to participate in sexual relations. Pregnancy can occur with any sexual
encounter unless you use prevention to avoid it.
(Reference: Pillitteri A.
Maternal and Child Health Nursing, 3rd
Edition, Vol. 1, 2003, p.924)
Situation:
Nurse
Matteo is assigned at the nursery of the National General Medical Center. His
clinical exposure as a novice nurse is proving to be professionally satisfying.
6.
Vitamin
K is administered to all neonates immediately after birth because:
A. their fetal
blood cells are prone to coagulation problems
B. their
immature livers predispose them to low vitamin K levels
C. they lack
intestinal organisms to synthesize vitamin K
D. they all
experience avitaminosis
Answer: C. Neonates have sterile GI tracts at birth and,
therefore, are incapable of synthesizing vitamin K until about 8 days after
birth. At 8 days, the intestinal tract
becomes colonized with organisms.
Reference: Straight A’s in Maternal – Neonatal Nursing © 2004 Lippincott
Williams & Wilkins Companion CD. The
Normal Neonate. Item No. 2.
7.
While
evaluating a neonate in the surgery, you check his hips for signs of
dislocation. Which of the following
signs indicates that the hips are in the normal position?
A. Both legs abduct easily
B. Skin folds
are asymmetrical
C. A click is
heard when hip integrity is assessed
D. The femur
head is felt to slip forward in the acetabulum
Answer: A. Inspection of a neonate’s hips during
assessment should reveal symmetrical skin folds, easy abduction of both legs,
and absence of a click or sense that the femur is moving within the acetabulum.
Reference: Straight A’s in Maternal – Neonatal Nursing © 2004 Lippincott
Williams & Wilkins Companion CD. The
Normal Neonate. Item No. 5.
8.
A new
mother asks you why her neonate is voiding so often. Your best reply is that the:
A. kidneys of the neonate can’t concentrate urine well
B. intestines
of a neonate aren’t yet absorbing fluid
C. fluid
retained during fetal life is being excreted
D. neonate’s
fluid intake is too great for his age
Answer: A. The neonate’s kidneys are immature at birth
and, therefore, unable to properly concentrate urine. This causes the neonate to void
frequently. A neonate’s intestines don’t
regulate the amount of fluid excreted.
Fluid isn’t retained during fetal life; it’s excreted after the kidneys
form. Frequent voiding in neonates isn’t
a sign of excess fluid intake.
Reference: Straight A’s in Maternal – Neonatal Nursing © 2004 Lippincott Williams
& Wilkins Companion CD. The Normal
Neonate. Item No. 6.
9.
Which
characteristic best describes a breast-fed neonate’s stools, as compared with a
formula-fed neonate’s stools?
A. Soft and seedy C. Light yellow in color
B. Dry D. Less frequent
Answer: A. A breast-fed infant passes soft, seedy stools
that have a sweet-and-sour odor and are mustard yellow. Breast milk is easier to digest than formula,
so a breast-fed neonate also has more frequent stools. A formula-fed neonate has less frequent, dry,
light yellow stools.
Reference: Straight A’s in Maternal – Neonatal Nursing © 2004 Lippincott
Williams & Wilkins Companion CD. The
Normal Neonate. Item No. 8.
10. You’re assessing a neonate. Normal assessment findings include:
A. absent
Babinski’s reflex and pale skin
B. heart rate of 130 to 140 beats/minute and acrocyanosis
C. absence of
head control and a relaxed posture while awake
D. respiratory
rate of 60 breaths/minute and expiratory grunting
Answer: B. Heart rate of 130 to 140 beats/minute is
within normal range, and acrocyanosis (cyanosis of the extremities) is normal
in the neonate. Acrocyanosis generally
lasts 7 to 10 days. If Babinski’s reflex
is absent and the skin is pale, the neonate may have central nervous system
damage. Absence of head control and a
relaxed posture while awake are signs of prematurity. A respiratory rate of 60 breaths/minute and
expiratory grunting may indicate a respiratory disorder.
Reference: Straight A’s in Maternal – Neonatal Nursing © 2004 Lippincott Williams
& Wilkins Companion CD. The Normal
Neonate. Item No. 15.
Situation: On her duty to the rural health center,
Jean, a student nurse assist the doctor
on duty in examination of children.
Aaron, a two year old, is hyperactive, negativistic and exhibit tantrums and
mother verbalize that she has difficulty in caring for Aaron. She asks Jean what she can do for him. Jean
then reviewed Aaron’s stage of development and considered this in taking care
of him and in providing health education for Aaron’s mother.
11. Jean reviewed Kohlberg’s theory of
development. According to the theorist, toddlers:
A. Do the right thing because their parent tells him or her to and to
avoid punishment
B. Have moral
judgments that are based on universal human rights
C. Act base on
their value, care and loyalty to others
D. Judge based
on understanding and social order
Rationale: A toddler is considered to be in
preconventional stage of moral development wherein child does right because a
parent tells him or her to and to avoid punishment. Option B pertains to post
conventional stage whereas options C and D pertain to conventional stage.
(Reference: Pillitteri A.
Maternal and Child Health Nursing, 3rd Edition, Vol. 2, 2003, 789)
12. Aaron’s mother asked Jean why her son is
negativistic and has temper tantrums. Which of the following would be the
student nurse’s best response?
A. “Aaron is not
effectively coping with stress“
B. “Aaron’s
need for affection isn’t met.”
C. “This is a normal behavior for his age.”
D. “He is
expressing his need for identity.”
Rationale: Negativism and temper tantrums are common
behaviors exhibited by toddlers. Through these behaviors, they can show degree
of autonomy and independence enough to know what they want, but do not have the
vocabulary or the wisdom to express their feelings in a more socially
acceptable way.
(Reference: Pillitteri A.
Maternal and Child Health Nursing, 3rd Edition, Vol. 2, 2003, 843)
13. When you examine a toddler, you suggest to
his mother that the activity that could foster his developmental task according
to Erickson would be;
A. Spoon feed
him every meal time C.
Allow him push pull toys
B. Read him
story every night D. Have him watch puppet show and TV
Rationale: Toddlers should develop sense of autonomy
or independence. Expression of autonomy can be shown through provision of toys
that exhibits sense of power in manipulation or toys they can play with by
themselves and that require action. These toys include push pull toys, squeaky
frogs they can squeeze, blocks they can stack, and toy telephone they can talk
on.
(Reference: Pillitteri A.
Maternal and Child Health Nursing, 3rd Edition, Vol. 2, 2003, 834)
14. The child’s universal language is:
A. Behavior C. Touching
B. Crying D.
Play
Rationale: According to Pilliterri, urge parents to
encourage language development by naming objects as they play with their child.
Option B pertains to infants. Option A and C are not applicable for toddlers.
(Reference: Pillitteri A.
Maternal and Child Health Nursing, 3rd Edition, Vol. 1,2003, p.863)
15. Which of the following describes the type
of play observed with toddlers?
A. Solitary C. Competitive
B. Parallel D. Fantasy
Rationale: All during toddler period, children play
beside the children next to them or parallel play (side by side play). Option A
is for infants. Competitive play is for school-age. Fantasy is among preschool
(Reference: Pillitteri A.
Maternal and Child Health Nursing, 3rd Edition, Vol. 1,2003, p.865)
16. While
observing a two-year-old girl recently admitted to the hospital, the nurse
becomes concerned by which of the following characteristics?
A. the child is not yet potty trained
B. the child replies “no” to every questions
C. the child cannot share toys
D. the child recognizes 4-6 words
Rationale:
D. A two-year-old should have a 300 word vocabulary. A 4-6 word vocabulary
indicate health problems, such as hearing or motor loss.
17. A
three-year-old girl is brought to the physician’s office with persistent otitis
media. In order to assess factors which may be contributing to the unresolved
illness, the nurse should ask the parents which question?
A. “Is anyone smoking around the child?”
B. “Is the child playing with other children
with otitis media?”
C. “Does the child get water is her ears during
the bath?”
D. “Has the child had a fever recently?”
Rationale:
A. Allergies to common irritants such as smoke can cause congestion and chronic
otitis media.
18. An
18-month-old girl is admitted for a surgical repair of the cleft palate. She
returns from the operating room, supine, with an IV, and a mist tent on room
air. Which is the priority nursing action?
A. medicate for pain
B. check the IV for signs of infiltration
C. turn the child on her side
D. review the postoperative orders
Rationale
C. Airway is always an immediate priority. Turning the child on her side will
protect the child from aspiration.
19. In
planning care for the four-year-old admitted to the hospital, the nurse would
include which toy?
A. a plastic stethoscope
B. a brightly colored mobile
C. a
jigsaw puzzle
D. a
helium balloon
Rationale:
A. Pre-school play centers on imitation of adults. Providing a stethoscope
allows the child to imitate the health personnel and to ease the fear of
unfamiliar equipment.
20. When
the mother of a five-year-old boy expresses concern over her son’s stuttering,
which response by the nurse is least appropriate?
A. vocal hesitancy is common in children younger
than age seven
B. it may help if you stop your son and
encourage him to begin the word over
C. singing songs or nursery rhymes may ease
stuttering
D. look directly at you son while he is speaking
Rationale:
B. Stopping the child mid-word or mid-sentence often draws attention to the
stuttering and may actually worsen it.
21. A
two-year-old girl is admitted to the hospital with croup. She has been placed
in a mist tent with room air. Which statement by the parents indicates
effective client teaching?
A. “The mist will give my child extra fluids.”
B. “My child must remain in the mist tent at all
times.”
C. “My child may have toys inside the mist
tent.”
D. “The mist tent will provide the extra oxygen
my child needs.”
Rationale:
C. The goal is to keep the child quiet and calm to reduce oxygen demand. Toys
may help achieve this goal.
22. A
one-year-old boy is brought to the physician’s office with fever, irritability,
and loss of appetite. A diagnosis of otitis media is made, and the child is
placed on amoxicillin (Augmentin) 150 mg p.o TID for 10 days. Which nursing
instructions must be includes in the child’s plan of care?
A. “Drink clear fluids while in the medication.”
B. “Take an extra nap, since amoxicillin may
cause drowsiness.”
C. “Stay indoors until the medication is
finished.”
D. “Take the medication for the full length of
time.”
Rationale:
D. A full course of an antibiotic must be given to ensure that the medication
is completely effective. Incomplete courses may result in recurrent and/or
resistant infections.
23. A
two-year-old boy is receiving Bleomycin (blenoxane) IV. His mother tells the
nurse that it is time for her son to have his polio immunization. What is the
best response by the nurse?
A. “We will schedule it for next week.”
B. “The cancer drug will delay any possibility
of polio.”
C. “Your son’s immunization will need to be delayed
until a later time.”
D. “I’ll call the doctor later today.”
Rationale:
C. You remembered it was unsafe to give a live virus vaccine while the client
was being treated for cancer. The vaccine will need to be given at a later
date.
24. A
three-year-old boy is admitted with laryngotracheobronchitis. His parents seem
extremely anxious and the child is crying. Which nursing diagnosis has the
highest priority?
A. potential infection
B. ineffective airway clearance
C. altered
parenting
D. impaired
tissue perfusion
Rationale:
B. ABC’s. Laryngotracheobronchitis can result is impaired airway clearance
because of upper airway is of immediate concern.
25. A
four-month-old infant is admitted with a ventricular septal defect, and
undergoes a cardiac catheterization. Post-catheterization, which sign would
alert the nurse to a potential complication?
A. pedal pulses palpable bilaterally
B. apical pulse 140 beats/minute
C. blood pressure 96/40
D. groin dressing intact with small amount of
blood noted
Rationale:
D. Any bleeding from the entry site of the cardiac catheter could indicate
potential hemorrhage.
26. A
12-year-old with a myelomeningocele at L2 is being seen at the clinic. Which
statement by the child would indicate the need for more client teaching?
A. “I always drink three extra glasses of water
every day.”
B. “My teacher says I need remedial reading.”
C. “I only need to catheterize myself twice a
day now.”
D. “I do wheelchair exercises while watching TV.”
Rationale:
C. Infrequent emptying of the bladder can result in stasis and urinary tract
infections. Catheterization should be performed every four hours.
27. In
planning care for a newborn with a surgical repair of a myelomeningocele, the
nurse should be aware that this child is prone to develop which of the
following?
A. osteomyelitis
B. decubitis
C. otitis
media
D. hydrocephalus
Rationale:
D. In the surgical repair of the myelomeningocele, the pathway for the cerebral
spinal fluid has been altered. Therefore, the child is at risk for
hydrocephalus.
28. A
nurse working in an adolescent clinic should know which of the following about
obesity?
A. in teenagers, it is commonly due to
hypothyroidism, hypopituitarism, or other endocrine problem
B. obesity is no more likely to be associated
with emotional conflicts to be associated with emotional conflicts in teenagers
who are not obese, than in teenagers who are obese
C. during adolescence, obesity is highly
correlated with significant psychopathology
D. obesity is often associated with poor
recognition of either hunger or satiation
Rationale:
D. Persons who become obese have poor recognition of feelings of hunger or
satiation after eating. Normal weight persons tend to eat when they feel
hungry, but obese individuals tend to eat when they see food, whether they are
hungry or not.
29. A nurse is caring for four children of
different ages. Which child is showing appropriate cognitive development
according to Piaget’s theory?
A. A 3-year-old who understands the concept of conservation
B. A 4-year-old who believes the intravenous
machine is alive
C. A 2-year-old who is just beginning to
demonstrate object permanence
D. An 11-year-old who thinks bad thoughts caused
his illness
Rationale:
B. The preoperational period of thought occurs from 2–7 years of age. During
this period, a child might think an inanimate object that lights up, such as an
intravenous machine, is alive. This is called animism. Conservation does not
occur until the concrete operational stage-7–11 years. Object permanence begins
at 8–12 months of age, and is fully developed by 24 months. Magical thinking,
such as bad thoughts cause illness, is characteristic of the preoperational
stage, 2–7 years.
30. A nurse plans to offer an infant a pacifier
during the period he is NPO. The
rationale for this intervention is based on which theorist?
A. Erikson
B. Piaget
C. Freud
D. Kohlberg
Rationale:
C. Freud describes the infancy stage as the oral stage. The baby obtains
pleasure and comfort through the mouth; therefore, offering a pacifier while an
infant is NPO can be comforting. Erikson describes the infant stage as a need
to establish trust vs. mistrust. Parent presence would be important for this
theory. Piaget describes infancy as a stage of sensorimotor learning. The baby
learns from movement and sensory input. Kohlberg’s theory relates to moral
development, and the preconventional stage begins at age 4.
31. Sally, age 12 months, weighs 21 pounds. The
nurse reviews the child’s record and finds out that her birth weight was 7
pounds. In planning care, the nurse knows that the child:
A. Has not gained the expected weight related to
the birth weight.
B. Must not be eating enough.
C. Should be referred to Protective Services
immediately for being severely underweight.
D. Falls within normal weight gain related to the
birth weight.
Rationale:
D. An infant should triple her birth weight by 12 months. This child is on
target for weight gain, and does not need any further intervention.
32. A preschool-age client needs a central line
dressing change. The most appropriate technique to use to explain this
procedure is to:
A. show a picture of the procedure in a book
B. explain the procedure with few words
C. let the child perform a dressing change on a
doll
D. explain the procedure to the child’s mother as
the child listens
Rationale:
C. Handling the equipment is the best
method for teaching a preschool-age child. This will help the child to focus
and to not lose interest in the teaching session. Showing pictures of the
procedure, explaining in words, and letting the child listen while explaining
the procedure to the parent will not effectively keep the child’s attention.
33. A parent has understood the teaching for
introducing solid foods to her child if she states:
A. “I can start to feed rice cereal at 2 months
of age.”
B. “I will begin with cereal, then introduce
meats next.”
C. “I will introduce one new food at a time.”
D. “I will begin to wean my baby from the bottle
after I start rice cereal, at 6 months of age.”
Rationale:
C. New foods should be introduced one at a time, so that if a food allergy or
intolerance develops, it will be easy to identify. Rice cereal should not be
started until 4–6 months. Rice cereal is the first solid food, followed by
vegetables, then fruits, and lastly meats, at 8–10 months. The infant should
not be weaned until 1 year of age.
34. The nurse is preparing to assess an infant
under the age of 6 months. The infant is quiet and awake, sucking on a
pacifier. The nurse should start with:
A. An otoscopic exam.
B. A lung, heart, and abdomen exam.
C. An oral exam.
D. An exam for hip dysplasia.
Rationale:
B. The sequence of the exam should be flexible, to capture opportunities for
auscultating the lungs, heart, and abdomen when the infant is quiet or asleep.
The otoscopic, oral, and hip exams are more invasive, and should be done toward
the end of the assessment.
35. The nurse palpates the anterior fontanel of a
12-month-old infant. Identify the area where the nurse is palpating.
A. Anterior fontanel
B. Posterior fontanel
C. Suture lines
D. Lambdoid Suture
Rationale:
A. The anterior fontanel is located at the front of the anterior portion on the
top of the skull. It normally is diamond shaped. It closes between 12–18 months
of age. The posterior fontanel is triangular in shape, and closes between 2–3
months of age. Inaccurate identification would include the posterior fontanel,
or any of the suture line areas.
36. A three-month-old client is being admitted with
pyloric stenosis. She has an IV of D50.2 N/S at 22 cc/h. She is NPO awaiting
surgery. Which nursing assessment takes priority?
A. Urine output 30 cc/2h
B. IV site red
C. Skin
turgor elastic
D. Baby
acts slightly irritable
Rationale:
B. Excellent choice! Because the child is NPO, maintaining IV access is
critical. These children often come into the hospital with fluid and
electrolyte imbalances because of the vomiting. IV fluids are essential.
37. The nurse walked into the room to assess a
four-year-old admitted with croup. The mother says, “He never wets the bed at
home, I am so embarrassed.” The nurse helps the mother and then invites her
into the hall. Which of the following statements is the nurse’s most
appropriate response to the mother’s statement?
A. “I know this can really be embarrassing, but I
don’t have kids myself, so I understand it doesn’t bother me.”
B. “It is uncommon for children to regress
during a hospitalization. His toileting skills will return when he is feeling
better.”
C. “It is probably due to the medication we are
giving him or his infection.”
D. “I plan to discuss your child’s incontinency
with the physician as this may require further investigation.”
Rationale:
B. A recently gained skill such as toilet training is often temporarily lost
due to the stress of hospitalization. It is appropriate to reassure the mother
that this is are expected behavior in young children and the previous
continence will be regained when his health is regained.
38. An ASO titer is drawn on an 11-year-old in the
hospital with acute glomerulonephritis. The mother asks the nurse why the titer
was drawn. Which response by the nurse is most justifiable?
A. “This will tell us if he’s ever had the
measles.”
B. “This will tell us if he’s had a recent strep
infection.”
C. “This lab work is done routinely on all
patients.”
D. “This is done to determine the level of
antibiotic is his blood.”
Rationale:
B. ASO (anti-streptolysin) titer indicates that the child has had a recent
strep infection. In determining a definitive diagnosis for acute
glomerulonephritis, this may be documented as it is usually the result of a
strep infection.
39. A nine-year-old is admitted for surgery for
slipped capital femoral epiphysis. Knowing the main concern of a child of this
age, the nurse would want to plan strategies to do which of the following?
A. arrange for his parents to be with him
continuously
B. obtain a telephone to be at his bedside
C. plan with the physician to obtain Patient
Controlled Analgesia postoperatively
D. provide special hospital pajamas
Rationale:
C. School age children have an extreme fear of needles. They will endure large
amounts of pain just to avoid an injection. Obtaining Patient Controlled
Analgesia will help to avoid some injections, while obtaining pain relief for
this child.
40. A four-year-old who had hydrocephalus as an
infant is admitted with a malfunctioning ventroperitoneal shunt. Following new
shunt placement, the nurse conducts a postoperative check. Which of the
following would demand an immediate response from the nurse?
A. sleepy, very difficult to arouse
B. pupils equal and reactive to light
C. B/P
100/60, apical pulse of 90
D. urine
output 33 cc in 2 hours
Rationale:
A. The child may be sleepy following surgery, but should be easily aroused.
Lethargy could indicate increased intracranial pressure.
41. The nurse is working in a busy pediatric
emergency room. In which of the following cases would she maintain a high index
of suspicion of physical abuse?
A. a three-year-old female with 15% burns in a
splash pattern over the face and chest reportedly sustained when she pulled on
the tablecloth and a teapot fell, spilling over her
B. a 14-year-old male with many bruises on bony
prominences, in various stages of healing. The child is reportedly clumsy
C. a six-year-old with a spiral fracture of the
tibia and fibula which reportedly occurred while riding his bicycle
D. a nine-month-old next drowning, who reportedly
climbed into the tub and turned on the water
Rationale:
D. Maybe a nine-month-old could climb into the tub, but turn the water on? This
should definitely be followed up. The injury does not coincide with the
reported cause of the accident.
42. Upon assessing gestational age of a baby, the
nurse determines that he is 40 weeks gestational age. Which of the following
characteristics are most likely to be found in this baby?
A. lanugo abundant over shoulders and lower
coccyx
B. pinna of ear springs back slowly when folded
C. vernix well distributed over entire body
D. creases covering the entire bottom of both
feet
Rationale:
D. The full term infant should have creases on the soles of their feet.
43. A complete blood count is ordered on a
two-month-old child with cyanotic heart disease. The results are a hemoglobin
of 18 g/dl and a hematocrit of 51%. Which of the following statements reflects
the most appropriate interpretation of this information?
A. the body is compensating for tissue hypoxia by
increasing RBC production
B. the child may be anemic. This is a low
hemoglobin for a two-month-old child and the hematocrit is within normal limits
C. the child is severely dehydrated, and the
loss of vascular fluid has elevated the hematocrit. The hemoglobin is within
normal limits
D. This laboratory data would be considered
within normal limits for a two-month-old child
Rationale:
A. The body is attempting to compensate. Both values are elevated to increase
the oxygen-carrying capacity to the tissues.
44. While making an initial home visit, the community
health nurse notes several bruises and old burns on the 10-month-old child.
Which is the nurse’s priority action?
A. call the child protection hotline and report
possible abuse
B. discuss the family with the physician and
social worker at the next team meeting
C. tell the mother that child protection will be
notified if injuries are noted on the next visit
D. carefully record the visit for follow-up
Rationale:
A. As a mandated reporter the nurse is obligated to report any cases of
suspected abuse. You do not need to prove the case, just report the facts as
you know them. This is a law.
45. A two-year-old is admitted to the hospital with
vomiting and possible dehydration. Which of the following findings would most
concern the nurse?
A. potassium 2.5 mEq/L
B. blood glucose 150 mg/dl
C. weight
loss 10 grams
D. urine
specific gravity 1.020
Rationale:
A. The normal potassium level if 5-5.0 mEq/L. This level indicates hypokalemia,
which could cause arrhythmias or even cardiac arrest.
46. A 12-year-old girl had a ventro-peritoneal
shunt placed to treat hydrocephalus in infancy. In counseling the child about
health management of the ventro-peritoneal shunt, the nurse would consider the
teaching effective if the child states:
A. “I should drink plenty of fluids and stay
rested.”
B. “I may need to wear glasses as a teenager.”
C. “I can take prochlorperazine (Compazine) for
vomiting.”
D. “If I get a really hard headache, I should
call the doctor.”
Rationale:
D. A headache is a sign of increased intracranial pressure. The child correctly
identifies this is an indication to notify the physician.
47. A mother brings her 18-month-old to the
pediatric emergency room. The child has sustained a fractured left femur. Which
statement by the mother might make the nurse suspect a problem of child abuse?
A. “She is so active and gets into everything.”
B. “She was riding her bicycle and her foot got
caught in the spoke.”
C. “My daughter slipped out of her high chair
because the strap was too loose.”
D. “My daughter climbed up on a chair and fell
down.”
Rationale:
B. This statement does not seem reasonable as 18-month-old children are not
developmentally ready to be riding bikes. This should make the nurse suspicious
that the mother may be trying to hide something.
48. At a boy scout camp the nurse encounters a
child who exhibits a high-pitched inspiratory sounds, and cyanosis. Describes
the procedure which the nurse should institute.
A. stand behind the child and apply an upward
thrust below the xiphoid
B. monitor the child; if respirations cease, use
the Heimlich maneuver
C. behind the child forward and deliver back
flows to dislodge the object
D. begin cardiopulmonary resuscitation
Rationale:
A. You have correctly evaluated the data as the child with an inadequate gas
exchange, and then selected the correct procedure for the Heimlich maneuver on
a child.
49. An 18-month-old is being admitted with a
diagnosis of Wilm’s tumor. Which nursing intervention takes priority?
A. checking vital signs every 8 hours for
incidence of hypertension
B. placing a sign over the bed which says “Do
Not Palpate the Abdomen.”
C. raising the head of the bed to ease breathing
D. monitoring the urinary output every 2 hours
Rationale:
B. These tumors are usually encapsulated. It is very important to protect this
encapsulation and help contain the tumor. Decreasing palpation of the abdomen
may protect this encapsulation.
50. The nurse who is assigned to care for a child
with cerebral palsy should obtain information concerning his abilities,
limitations, interest, and habits, because the aim of therapy is to:
A. assess the child’s assets and potentialities
and capitalize on these in the habilitative process, while ignoring limitations
B. reverse abnormal functioning and restore
brain damage through rehabilitation
C. provide a therapeutic program that avoids
subjecting the child to frustrating experiences that decrease his achievement
D. develop an individualized therapeutic program
that utilizes the child’s assets and abilities to provide experiences that
permit him to achieve success as well as help to cope with frustration and
failure
Rationale:
D. This goal statement includes recognizing the client’s assets and helping him
cope with frustrations and failures due to his limitations. This option is a
global response. It states appropriate goals of therapy in general terms, and
it also includes the true part of option A.
51. A mother is
watching her school-age child learn self-care techniques after being recently
diagnosed with type 1 diabetes. Which is a correct statement?
A. “Bandura’s
theory states children learn new behaviors best when imitating others.”
B. “Erikson’s
stages describe school-age children learning by attaining goals.”
C. “Piaget believes
learning will take place more quickly when abstract thinking develops.”
D. “Freud’s
description of personality development affects learning ability.”
Rationale: A. Goal attainment, developing abstract
thinking, and personality development are not as closely related to learning
self-care as is Bandura’s social learning theory, which is described in option
A.
52. During a
developmental assessment, a parent complains that she has a “difficult”
toddler. What advice would the nurse offer to the parent?
A. “Toddlers are
flexible. Accepting new rules will occur quickly.”
B. “Do not
expect the child to adapt quickly to new situations.”
C. “Encourage
associative play and this will get better.”
D. “Spanking
your child will make the difficult behavior improve.”
Rationale: B. Toddlers are not flexible and do not
adapt to anything quickly. Associative play does not occur until preschool age,
and spanking should not be encouraged.
53. A mother who
uses time-out as a method of discipline for her 5-year-old child is asking the
nurse what type of parenting this exemplifies. What is the response that would
be the most appropriate?
A. Indifferent
B.
Authoritative
C.
Authoritarian
D. Permissive
Rationale: B. The authoritative parent sets limits while
establishing an atmosphere of open discussion, thus promoting developmental
integrity and trust. Permissive and indifferent parents do not set limits
whereas authoritarian parents use stricter methods of discipline than do
authoritative parents.
54. Which is the
most important nursing intervention to facilitate communication with a
hospitalized preschool-age child?
A. Provide
detailed explanations of procedures to the child.
B. Encourage
the child to engage in play with dolls, puppets, or safe medical equipment.
C. Ask the
child to write a story about the hospitalization.
D. Keep
visitors to a minimum.
Rationale: B. Play with dolls, puppets, or safe
medical equipment is a developmentally appropriate means by which preschool
children are able to express themselves. Detailed explanations and writing a
story are not developmentally appropriate for a preschool age child. Visitors
are important to children this age. Parents should be allowed to stay at all
times.
55. A nurse is
assessing a 2-year-old boy with the following vital signs: temperature 97.8°F
axillary, apical pulse 100, respirations 28 breaths per minute, blood pressure
125/80. Which action by the nurse would be most appropriate?
A. Reevaluate
the child’s temperature in 1 hour
B. Report the
blood pressure to the physician
C. Assess for
additional signs of respiratory distress in the child
D. Determine
why the child has tachycardia
Rationale: B. All of the vital signs listed are normal
for a 2-year-old child except for the blood pressure. This reading is greater
than the 99th percentile for a 2-year-old child, and should be reported
promptly to the physician.
56. Which
statement indicates nutrition counseling has been effective for the mother of a
6-month-old infant?
A. “I will start
my infant on rice cereal since it is iron fortified and has little chance of
causing allergy.”
B. “I will
start my infant on egg whites since they are high in iron and protein and have
little chance of causing allergy.”
C. “I will
start feeding fruits and vegetables and progress to whole grain cereals as
tolerated.”
D. “I know that
I can start feeding my baby strained meats for the iron and protein and
progress to the more irritating fruits and vegetables.”
Rationale: A. Rice cereal is the recommended first
food for infants since it has a low risk of causing allergy, and it is iron
fortified. Infants should not have egg whites as they can cause severe
allergies. Foods should be introduced one at a time, and the infant should
progress to other single-ingredient cereals, followed by fruits and vegetables.
57. Which
observation during a healthcare visit alerts the nurse to the need for further
developmental assessment in an infant?
A. A
four-month-old has just started to roll from front to back.
B. A nine-month-old
now stands while holding on the furniture.
C. A
nine-month-old is able to sit with support from pillows on each side.
D. A
12-month-old says two words, “dog” and “bottle.”
Rationale: C. The child should sit independently
without support by nine months. Thus, the nine-month-old sitting only with
support indicates the need for more extensive developmental assessment.
58. The nurse
knows that teaching about car seat safety to the parents of a 4-year-old child
has been effective when which statement is made?
A. “Now that our
child is 4 years old, weighs 40 pounds, and is 42 inches tall, we can move to a
forward-facing booster seat.”
B. “Now that
our child is 4 years old, she can sit in the regular car seat and use the seat
belt and shoulder belt like adults.”
C. “Now that
our child is 4 years old, she can sit in her booster seat in the front seat.”
D. “Our
4-year-old must stay in her forward-facing car seat until she is 6 years old.”
Rationale: A. The child can be in a forward-facing
booster seat at this weight and height. The child should continue to use a belt
positioning booster seat until her knees extend to the edge of the seat and the
shoulder belt fits appropriately. Children should not be in the front seat of a
vehicle with passenger side air bags.
59. Which is the
best advice the nurse can give to parents asking for help in handling their
toddler’s temper tantrums?
A. “I think you
should start using time-outs when he throws a temper tantrum.”
B. “Reward him
for good behavior and the temper tantrums will decrease.”
C. “There is
nothing to be done. They are a symptom of emotional instability.”
D. “Temper
tantrums will increase in number through the preschool years.”
Rationale: A. A time-out lets the child know there are
limits and also removes him from the stimulus causing the tantrum. Rewards are
not the best option as they will be interpreted as a reward for the behavior,
which may be repeated in order to get more rewards. Temper tantrums are common
at this age. They do not indicate emotional disturbance. Tantrums should
decrease as the child ages. With age a child is better able to maintain control
and to feel in control of situations.
60. The high
school principal asks the school nurse to provide injury prevention information
to the students. What does the nurse identify as priority for the majority of
students?
A. Driving and
substance abuse
B. CPR and
emergency care
C. Sports
injuries
D. Driving
patterns
Rationale: A.
School dances, social gatherings, and dating increase during high school
along with drug and alcohol experimentation. Cognitive impairment related to
alcohol and drug consumption can cause motor vehicle accidents leading to
injuries. Although learning CPR, avoiding sports injuries, and fire prevention are
important, they are not the priority in this age group.
61. The nurse is
preparing a disaster education plan for school-age children to discuss fire
prevention and fire evacuation planning. What information is priority in the
plan?
A. It is essential
for the child to stay with the family at the time of the fire.
B. The child
and family need to have a definite evacuation plan in place.
C. The child
should stay indoors in the event of a fire.
D. It is
important the child remember to drink more water than usual after a fire.
Rationale: B. Evacuation education is priority. The
child should be instructed to evacuate if indicated, not to find parents and
other family members. As each fire situation is different, the child may be
required to evacuate the building for the outdoors. Finally, while drinking the
water after fire exposure is important, it is not the priority in fire
prevention and evacuation planning.
62. A school
nurse is packing a portable emergency bag for a potential disaster. Which indicates
the need for further education in disaster preparedness?
A. A list of
staff and students and their location
B. A blueprint
of the school and its grounds
C. Handheld
portable radios with batteries
D. A portable
automatic external defibrillator
Rationale: D. An automatic external defibrillator is
not indicated in this population as it is unusual for children to present with
ventricular fibrillation. The blue-print, portable radios, and lists of staff
and students are important to include.
63. Which is the
correct developmental stage at which a child begins to have a more realistic
understanding of death?
A. Preschooler
B. Adolescent
C. School age
D. Preteen
Rationale: C. Cognitively after age 6 or so, children
are able to understand that death is permanent and occurs from varied causes.
Preschoolers have magical thinking and believe death is temporary. Many
preschoolers believe that bad thoughts and/or behavior cause death. The
understanding occurs during the
school-age years. The adolescent understands death much like an adult. There is
no developmental stage by the name of preteen.
64. A nurse
obtains a history from a breastfeeding mother with a small 3-month-old infant
who has been vomiting. Which would give the nurse an indication this infant has
severe dehydration?
A. The infant
is having a seizure
B. The pulse
rate is slightly elevated
C. Skin turgor
is normal
D. Mucous
membranes are dry
Rationale: A. Seizure activity is usually not noted
until the child is severely dehydrated. Slight elevation of pulse rate can be
seen in moderate dehydration. Dry mucous membranes are seen in moderate
dehydration. Normal skin turgor indicates no signs of mild dehydration.
65. The nurse
notes changes in a toddler with heart failure since the shift yesterday. Which
finding is the most significant for extracellular fluid volume overload?
A. Jugular
venous distention
B. Weight gain
of 0.8 kg
C. Weak pulse
D. Presence of
lung crackles
Rationale: B. Rapid weight gain is the most sensitive
index of extracellular fluid volume excess. Assessment of jugular vein
distention is difficult in young children. It is an assessment finding in older
children. A bounding pulse is indicative of fluid excess. Presence of lung crackles
may occur as a sign of pulmonary edema, but it may be a later sign and is not
the most characteristic of pulmonary edema.
66. The parents
of a child who had a tonsillectomy 3 days ago call about concerns with symptoms
they are seeing. Which symptom would alert the nurse that the child may be
having a postoperative problem?
A. The child has
white crusts on the back of the throat
B. The child is
having increased swallowing.
C. The child
will only eat Popsicles.
D. The child
complains of throat pain.
Rationale: B. The child having increased swallowing
could be a sign of increased bleeding from the surgical site. White crusts on
the back of the throat, eating only Popsicles, and complaining of throat pain
are all normal following a tonsillectomy.
67. A child is
brought to the emergency department with an abrupt onset of decreased appetite,
stridor, high fever, and agitation. What information is needed to determine the
nurse’s priority intervention?
A. Determine if
the child has been drooling.
B. Ask if the
child will lie down.
C. Ask if the
child has been around anyone sick.
D. Auscultate
the child’s breath sounds.
Rationale: A. If the child has been drooling,
epiglottitis is a possibility. Since the child is agitated, only interventions
that do not worsen the agitation should be initiated to maintain a patent
airway. Asking the child to lie down may assist in determination of
epiglottitis versus bacterial tracheitis, but is not the most important
assessment and may cause the child’s condition to deteriorate. Asking if the
child has been around anyone sick is not the priority; airway assessment is the
priority in this situation. Since this child is already agitated, listening to
breath sounds may worsen the agitation, causing the airway to become more
reactive if this is epiglottitis.
68. A child is
being treated with dexamethasone in conjunction with other chemotherapy for
treatment of leukemia. On a follow-up visit, the pediatric oncology clinic
nurse expects which as a side effect?
A. Weight gain
B. Decreased
blood pressure
C. Anorexia
D. Improved
mood
Rationale: A. Administration of steroids causes weight
gain. Steroids cause an elevation of blood pressure, an increase in appetite,
and mood instability and irritability.
69. A child with
leukemia has a white blood cell count of 10,000, a red blood cell count of 5,
and platelets of 20,000. The child is also fairly active, visiting the playroom
twice a day. When planning this child’s care, which risk should the nurse
consider most significant?
A. Infection
B. Anemia
C. Hemorrhage
D. Pain
Rationale: C. The platelet count is decreased, thus
putting the child at risk for hemorrhage. The white blood cell count is normal;
however, a differential should be analyzed. The red blood cell count is within
normal limits. Anemia is not a priority; however, hemoglobin and hematocrit
levels should be monitored. Pain should always be considered, but it is not the
focus in this situation.
70. A 3-year-old
female with nephrotic syndrome is being admitted to the general pediatric
floor. Who is the most appropriate roommate for this child?
A. A 2-year-old
female recovering from varicella
B. A 4-year-old
female with a fractured femur
C. A 6-year-old
male postoperative appendectomy
D. A
3-year-old female with cystic fibrosis
Rationale: B. A 4-year-old child with a fractured
femur is a developmentally appropriate roommate for a 3-year-old female. Exposure to this child will not promote
infection. The patients with varicella and cystic fibrosis are not appropriate
roommates due to the risk of infection for the patient on hemodialysis. The
child who is postoperative appendectomy is a male and thus is not the most
appropriate choice.
71. When a child
with type 1 diabetes is sick, which is the most appropriate recommendation?
A. The usual
dose of insulin may need to be decreased or omitted.
B. Test blood
glucose if the urine ketones are positive.
C. Urine
ketones are tested when the glucose level is greater than 200 mg/dL.
D. Maintain
fluid intake, avoiding fluids that contain carbohydrates.
Rationale: C. Urine ketones are tested when the blood
glucose level is greater than 200 mg/dL. Blood glucose levels may need to be
monitored more frequently than is routine. The usual dose of insulin may
actually need to be increased. Higher blood glucose levels may necessitate
increases in insulin doses. The child will need increased fluid intake, greater
than normal demands. If the child cannot eat to maintain food intake, fluids
should have carbohydrates to maintain the usual caloric intake.
72. Identify the
priority nursing diagnosis for an adolescent with hyperthyroidism?
A. Disturbed
Body Image related to changes in appearance caused by process of metabolic
disorder.
B. Imbalanced
Nutrition: More than Body Requirements related to decreased metabolic needs.
C. Risk for
Decreased Fluid Volume related to excess salt excretion.
D. Constipation
related to thyroid medication side effects.
Rationale: A. A teenager is most affected by changes
in body image. Teenagers who are different from their peers or have a change in
appearance may have a difficult time adjusting and need emotional and
psychosocial support. Metabolic needs are higher than usual in hyperthyroidism,
leading to a potential inability to meet the body’s requirements. Fluid volume
deficit is not associated with hyperthyroidism. The child may have increased
appetite, weight loss, diaphoresis, and weakness.
73. The parent of
a child recently diagnosed with viral meningitis is concerned about permanent
effects from the disease. Her neighbor’s child had viral encephalitis with
learning and mobility sequelae as a result. How should the nurse respond to her
concerns?
A. “Let’s wait
and see if this disease becomes viral encephalitis.”
B. “Have they
been playing together?”
C. “Most
children with viral meningitis have future learning problems. You’ll need to
make plans for a special school.”
D. “Children who
have viral meningitis usually have a complete recovery without permanent
effects.”
Rationale: D. Prognosis for viral meningitis is
excellent. Some children with viral encephalitis may also have complete
recoveries but many have intellectual, visual, auditory, or motor deficits.
Viral meningitis is a different disease than viral encephalitis. There is no
connection. Viral encephalitis is not contagious. It occurs as a response to a
virus, specifically herpes simplex type 1.
74. An infant is
brought to the emergency department with assessment findings of failure to
thrive, vomiting, and a decreased level of consciousness. Which should the
nurse suspect?
A. Influenza
B. Reaction to
the dTaP immunization
C. Shaken baby
syndrome
D. A
malabsorption syndrome
Rationale: C. Clinical manifestations of shaken baby
syndrome include seizure, lethargy, failure to thrive, and vomiting. It is
caused by the tearing of the nerve fibers as the brain moves back and forth.
Influenza is an acute illness and should not have accompanying signs of failure
to thrive or a decreased level of consciousness. Response to the DTaP
immunization includes fever and irritability. A malabsorption syndrome can
cause failure to thrive but not a decreased level of consciousness.
75. A 6-year-old
child is having burn care following premedication for pain. The child is not
cooperative for dressing changes and begins screaming and kicking. What is the
best action by the nurse?
A. Inform the
child that cooperation is necessary for proper healing and will shorten the
hospital stay.
B. Allow the
parents to change the dressings with coaching from the nurse.
C. Allow the
child to participate in the dressing change process as much as possible.
D. Inform the
child that restraints will be used if there is no cooperation.
Rationale: C. The school-age child is striving for
feelings of achievement and control. Giving the child the opportunity to help
with the procedure will provide a sense of control and accomplishment.
Effective pain management improves the chance the child will participate. A
shortened hospital stay is no guarantee with or without cooperation and should
never be used as leverage with a child. The parents may not be able to tolerate
the procedure and may not wish to participate. The school-age child will not
respond well to threats and further loss of control.
76. During a routine developmental screening, the
nurse is concerned about the development of a 5-year-old. Which of the following would be recommended?
A. Refer the child to a social worker.
B. Tell the parent to take the child to a physical therapist.
C. Refer the child to a trained specialist to administer developmental testing.
D. Tell the mother that the child should be retested in
a year.
Rationale:
C. If a developmental delay or abnormality is suspected, a specific
developmental screening test is needed. Early intervention is important for
developmental delay. Referring the child to a social worker or other therapist,
or advising about physical therapy, would require further testing.
77. Which of the following assessment questions and
instructions used by the nurse would give information regarding relationship
issues of the child?
A. “Describe your infant’s temperament to me.”
B. “What does your toddler like to do at
school?”
C. “Tell me about your child’s after school
activities.”
D. “How does your infant comfort himself?”
Rationale:
A. Asking what the toddler likes to do at school, asking about after school
activities, and asking how the child comforts himself are not questions
directed towards relationships. Obtaining a description of the infant’s
temperament is directed towards assessing relationships.
78. The nurse is assessing a newborn, and notes all
of the findings. Which of the following nursing assessments would cause the
nurse to be concerned?
A. Baby enjoys sucking on a pacifier and sleeps
16 hours a day.
B. Baby is nursing every 2–2½ hours and has 2
stools daily.
C. Birth weight is 6 pounds, 10 ounces. Present
weight is 5 pounds, 4 ounces.
D. Baby is sleeping in between feedings and is
not babbling.
Rationale:
C. In the first week of life, most babies lose about one-tenth of their birth
weight. Nursing every 2–2½ hours is a normal feeding schedule for a newborn. A
newborn who has lost more than 10% of her birth weight should be evaluated.
Sleeping in between feedings and sucking on a pacifier are normal newborn
responses. Newborns do not vocalize by babbling.
79. A new mother asks the nurse whether
breastfeeding is better than formula for her newborn. Which response by the
nurse is most appropriate?
A. “It often is easier to breastfeed, because you
do not have to prepare bottles.”
B. “Breastfeeding is best for your baby; of
course you should choose this.”
C. “There are no advantages to breastfeeding.
You should do what is best for you.”
D. “There are many benefits to breastfeeding; let
me tell you more about it.”
Rationale:
D. Despite the obvious health and developmental advantages of breastfeeding,
efforts are needed to promote breastfeeding. The nurse’s statement should
respond to the information-seeking question by the mother. Studies have shown
breastfeeding to have obvious health benefits. The nurse never should be
judgmental. There are advantages to breastfeeding. Breastfeeding often is not
easier than bottle-feeding.
80. The father of a 9-month-old infant tells the nurse
that his wife picks up the baby immediately whenever she begins to cry. The
most appropriate response by the nurse is:
A. “It is important for the child to learn to
comfort herself. Does the baby try to calm herself by sucking her thumb?”
B. “It is OK to pick her up often; eventually,
she will stop crying.”
C. “Most infants do not know how to calm
themselves. It is important to be responsive when they cry.”
D. “At 9 months, she is too young to learn to
calm herself. Wait until she is 2 years old before letting her cry longer.”
Rationale:
A. An important indication of infant mental health is the ability to comfort
oneself. The nurse should offer helpful information to the parent. Telling the
father that infants cannot learn to calm themselves is providing false
information.
81. The nurse inquires about the activity level of
a 3-year-old. The mother states that the child loves to play at the park, and
that they go there as much as possible. The nurse encourages the mother to
continue to take the child to the park for play. What important principle is
guiding the nurse’s response?
A. Socialization with other toddlers helps
develop communication skills.
B. Allowing the toddler to walk, run, and hop
enhances the child’s kinaesthesia.
C. Maternal bonding is enhanced through play.
D. Only an emotionally happy child can enjoy the
park.
Rationale:
B. There is no information regarding socialization in the response of the
mother. Kinaesthesia, or the sense of one’s body position and movement,
develops during these years. Maternal bonding is enhanced through play might be
true, but it does not enhance the development of kinaesthesia. The response
“Only an emotionally happy child can enjoy the park” is an unsupported
statement.
82. The father of a 2½ - year-old asks the nurse
how to prevent early-childhood dental cavities. The best response by the nurse
would be:
A. “Your child has only baby teeth; they will
eventually fall out, and so there is no need to worry.”
B. “Make sure your child’s diet is nutritious,
and limit snacks high in sugar.”
C. “Take the child to the dentist to see if he
has any cavities.”
D. “Let the child watch you brush your teeth so
that he can learn how to do it himself.”
Rationale:
B. Early-childhood caries are caused by inadequate preventive care. The nurse’s
best response should be helpful and accurate, should offer advice, and should
address the parents’ concern as to prevention. Telling the parent there is no
need to worry is not supportive and not appropriate. Taking the child to the
dentist diagnoses dental cavities but doesn’t prevent them from occurring.
Letting the child watch how the parent brushes his teeth is fine, but does not
address the client’s needs.
83. The nurse needs to obtain the height of a
3-year-old as part of routine health screening. To obtain an accurate
measurement, the child will:
A. Be measured in a recumbent position.
B. Remove his shoes and stand upright, with head
level.
C. Stand with his feet wide apart.
D. Face the wall as he is measured.
Rationale:
B. Once the child can stand to be measured, sometime between 2–3 years of age,
charts for standing height rather than recumbent length are used. The head
actually is kept level, and feet are kept close together. The child faces away
from the measuring tool.
84. Mother of a 3-year-old tells the nurse that her
child has frequent nightmares. The statement by the mother that indicates the
need for more teaching is:
A. “I usually talk quietly and rub her back to
reassure her.”
B. “I read her a story until she calms down.”
C. “I take her to my bed so she will calm down.”
D. “I stay with her awhile to reassure her.”
Rationale:
C. Nightmares are frightening dreams; parents can reassure the child, rub her
back, and provide some repeat of the bedtime routine. Taking her to the
parents’ bed so she will calm down could cause more problems, as it does not
help the child to calm herself. Talking quietly and rubbing her back to
reassure her would be helpful. Reading a story until she calms down and staying
with her awhile to reassure her are appropriate actions.
85. Most schools include curricula regarding human
sexuality. What is the most appropriate age group for the nurse to include in
her instruction?
A. 12-year-olds
B. 9-year-olds
C. 11-year-olds
D. 15-year-olds
Rationale:
B. Children can receive information in school beginning approximately in the
fourth grade. Nine years old is the age when most children first have the
cognitive ability to comprehend human sexuality. An 11-, 12-, or 15-year-old
already has had the cognitive ability to comprehend human sexuality; teaching
should occur before pubertal changes.
86. A 7-year-old sibling of a child with special
needs is acting out in school. This behavior has been attributed to jealousy
over the attention the special needs child receives. The school nurse should
suggest to the parents that the sibling should:
A. Have a special time or activity with each
parent alone.
B. Be dealt with using behavior modifications.
C. Be asked to participate in the care of the
special needs child to understand why the child needs more attention.
D. Be evaluated by a psychologist to rule out any
mental illness.
Rationale:
A. Siblings need to be recognized with their own personal time with caregivers.
Jealousy and aggression are common with siblings of chronically ill children.
Siblings should not be responsible for any portion of care of the ill child,
due to potential remorse and/or guilt.
87. A 2-year-old with epilepsy is showing signs of
developmental delay. The nurse has been working with the family to support
development. The response from the parents that indicates the need for further
teaching is:
A. “He has a schedule by which we abide at all
times.”
B. “We make sure he is always in a playpen or
enclosed area when he plays.”
C. “He has temper tantrums all the time. We stay
near, but don’t give in to what he gets mad about.”
D. “He gets his Depakote every day at the same
time. He hasn’t shown signs of a seizure since he was 6 months old.”
Rationale:
B. Enclosed areas and overprotection by the parents can affect opportunities
for growth and development. Following a schedule, not giving in to temper
tantrums, and giving medication at the same time all are correct methods to
facilitate safety and normal growth and development.
88. A 6-year-old with a neural tube defect has to
endure daily catheterizations. What is the most appropriate nursing action to
encourage this child to learn self-catheterization?
A. Explain the procedure, and ask the child to
watch how to perform the catheterization.
B. Wait until the child is 8 years old, when
fine motor skills are sufficiently developed to perform the procedure.
C. Allow the child to catheterize an
anatomically correct doll using similar equipment.
D. Have the child’s older sibling of the same sex
assist with catheterizations. Watching the sibling participate might increase
the child’s desire to learn.
Rationale:
C. The school-age years are when you need to begin to identify aspects of the
child’s care for which the child can learn to assume responsibility under the
supervision of the parents. Having the child practice catheterizations on an
anatomically correct doll will help him learn how to catheterize himself in the
near future. This fosters independence and helps with the child’s development.
Children learn through repetitive play, which breeds acceptance and control.
Children at the age of 6 have the skills to perform simple procedures. Allowing
the sibling to participate is inappropriate.
89. The mother of a trainable adolescent with Down
syndrome states to the school nurse, “I don’t know what’s going to happen to my
child when I die. How will he take care of himself?” What is the nurse’s best
response?
A. “There will always be somebody to take care of
him. Don’t worry, everything will be okay.”
B. “Is there a relative who can take care of him
if something happens? You need to develop a plan for the future.”
C. “I am sure there is something we can do. Let
me look into alternative care and see what kind of insurance you have.”
D. “We do have a program that will assist with
vocational learning. I need to get your consent first; then, we can look at
alternatives.”
Rationale:
D. Any disabled client has a right to a vocational plan with the goal of living
an independent life. The types of insurance and relative care are personal
matters that should not influence the vocational plan. It is inappropriate for
the nurse to make promises on issues over which she has no control due to the
unpredictability of life.
90. The nurse needs to administer a medication to a
6-month-old. The most appropriate technique is to:
A. Mix the medication in one ounce of infant
formula, and feed it to the child.
B. Position the child upright, and use an oral
syringe to administer the medication.
C. Pour the medicine from a medication cup into
the inside of the infant’s cheek.
D. Position the infant supine, and squirt the
medicine into the child’s mouth.
Rationale:
B. Oral medication to infants should be administered via an oral syringe into
the inside of the cheek. The infant should be positioned upright to avoid
aspiration. The nurse should avoid mixing medication in more than a very small
amount of food or formula, to ensure that the medicine is taken. Medicine cups
are not appropriate for infants. Administering a medication to a child in the
supine position increases the risk of aspiration.
91. The nurse is teaching a
postpartum client about the normal stooling pattern of a neonate. Which color and consistency best describes
the typical appearance of meconium?
A.
soft,
pale yellow
B.
hard,
pale brown
C. sticky,
green black
D.
loose
golden yellow
92. A mother of a term neonate
asks what the thick, white cheesy coating is on his skin. Which correctly describes this finding?
A.
lanugo
B.
milia
C.
nevus
flammeus
D. vernix
93. Which drug is routinely given
to the neonate within 1 hour of birth?
A. erythromycin
ophthalmic ointment
B.
gentamycin
C.
nystatin
D.
Vitamin A
94. A neonate undergoing
phototherapy treatment needs to monitored for which adverse effect?
A.
hyperglycemia
B. increased
insensible water loss
C.
severe
decrease in platelet count
D.
increased
GI transit time
95. Which immunoglobulin (Ig)
provides immunity against bacterial and viral pathogens through passive
immunity?
A.
IgA
B.
IgE
C. IgG
D.
IgM
96. Which neonatal behavior is
most commonly associated with fetal alcohol syndrome (FAS)?
A.
hypo
activity
B.
high
birth weight
C. poor wake
and sleep patterns
D.
high
threshold of stimulation
97. An initial assessment of a
female neonate shows pink tinged vaginal discharge. Which factor is the probable cause?
A.
cystitis
B.
birth
trauma
C.
neonatal
candidiasis
D. withdrawal
of maternal hormones
98. A woman delivers a 3,250 g
neonate at 42 week’s gestation. Which
physical finding is expected during an examination of this neonate?
A.
absent
lanugo
B.
absence
of sole creases
C.
breast
bud of 1-2 mm in diameter
D. leathery,
cracked and wrinkled skin
99. one minute after birth, a
neonate has a heart rate of 60 beats/minute.
Five minutes after birth, his heart rate is 80 beats/min. Which Apgar heart rate score should he
receive?
A.
0
B. 1
C.
2
D.
3
100. When assessing a male
neonate , the nurse notices that the urinary meatus is located on the ventral
surface of the penis. How should the
nurse document this finding?
A.
as the
normal loation for the urinary meatus
B. as
epispadias
C.
as
hypospadias
D.
as
cryptorchidism
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