1
Q
the RN observes the child walk up and down steps. THe nurse notes the child has a steady gait and can use short sentences. The RN estimates the child’s age to be how many months?
A
Ans: 24 months
Goes up and odwn stairs alone, runs well w/ wide stance, builds tower of 6-7 blocks, has a vocab of about 300 words
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2
Q
the young child diagnosed with autism is admitted to the ped unit w/ a tracheotomy after swallowing a small toy. The unlicensed assistant personnel reports to the nurse that the child doesn’t maintain eye contact. Which response by the nurse is best?
A
Ans: “The inability to maintain eye contact is a characteristic of autism”
This response offers the staff member an explanation about the lack of eye contact. While in the hospital, parents should be encouraged to stay w/ child; decrease stimulation; physical contact may upset child with autism; establish trust
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3
Q
the nurse performs assessments in the well-baby clinic. The RN identifies which finding is a warning sign of cerebral palsy?
A
Ans: The infant has poor head control after 3 months.
-The earliest indication of CP is delayed gross motor development; signs include stiff or rigid arms or legs, arching back, floppy or limp body posture.
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4
Q
The parent brings the 6 month old baby to the clinic for a check up. The parent reports the baby had a check up at 2 months and received the first DTaP. Which action by the nurse is most appropriate?
A
Ans: Give the second DTaP.
-by the age of 6 months, the child should be ready for her 3rd immunization; when the schedule has been interrupted, it’s appropriate to simply continue w/ the schedule; she is due for her 2nd DTap vaccine
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5
Q
which implementation is the BEST way for the RN to maintain an adequate fluid intake for a toddler with nausea, diarrhea and vomiting?
A
Ans: Offer oral rehydration solutions (ORS) to rehydrate
ORS contain sodium, potassium, chloride, citrate, and glucose. Amt given depends on amt of dehydration & child’s weight; if child vomiting, give small amt at frequent intervals
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6
Q
the RN observes the 5 yo child playing w/ several other children about the same age. The RN identifies which play activity as the one in which the child would MOST LIKELY engage in?
A
Ans: Children at 5 yo are involved in imitative play; will play house, play doctor, or pretend to be engaged in the occupational roles of adults around them.
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7
Q
the RN performs a home care visit for the child diagnosed w/ cystic fibrosis. The RN should intervene if which finding is observed?
A
Ans: the child takes the pancreatic enzymes 1hr after eating
-enzymes should be taken at beginning of meal or with a snack or within 30 min of eating. Chewing or crushing beads destroys enteric coating
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8
Q
the 4 week old infant is brought to a HCP by the parent. The infant is vomiting and has abdominal distention. The infant is diagnosed as having pyloric stenosis and is admitted to the hospita. The RN should expect the infant’s emesis to have which of these qualities?
A
Ans: be projectile.
-infant w/ pyloric stenosis will present w/ projectile vomiting & abdominal distention; other symptoms include weight loss, constipation, dehydration, visible peristaltic waves. Pyloric stenosis has unknown etiology & usu develops during 1st 3 weeks post firth
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9
Q
which intervention shoud the RN recognize as most important to promote maximum mobility in infants?
A
Ans: provide a safe play are
-be aware of danger of aspirating foreign objects, poisoning, burns, and falls from infant seats, high chairs, walkers and swings.
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10
Q
The nurse knows DTaP vaccine protects against which diseases?
A
Ans: diphtheria, pertussis and tetanus
-Note: pertussis is not given to kids over age of 7
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11
Q
the nurse cares for the newborn diagnosed with developmental dysplasia of the hip (DDH). The nurse expects which method of Tx to be used for the newborn?
A
Ans: Pavlik harness.
-during the early newborn period, a harness is applied to hold the hips in wide abduction; if the Tx does not acheive the correction in a few months, then surgery is indicated and a postoperative spica hip bandage or body cast is applied. Harness should be worn full time for 3-6 months until hip is stable.
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12
Q
the nurse instructs the 10 yo pt about how to collect a 24 hour urine specimen at home using a clean, empty jar. The nurse should recommend that the client use which jar?
A
Ans: 48 ounce jar
-expected amt of urine output for a 10 yo child is ~1,200 ml; since 30ml=1ounce, 1,200ml=40ounces & a 48ounce jar is needed.
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13
Q
a brace is ordered for the adolescent to correct a scoliosis deformity. Which statement, if made by the parent to the nurse, indicates teaching is successful?
A
Ans: the brace should be worn 23 hours a day
-Should be worn 23 hrs per day; nurse should assess home environment for safety hazards; teach child how to prevent falls using handrails and avoiding slippery surfaces
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14
Q
to prevent parent-child disturbances, the nurse should complete which action?
A
Ans: Discuss w/ parents any problems or fears abt childrearing that they may have
-important that parents ecome active listeners, become actively involved in kid’s educations, & look at things from the kids’ point of view
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15
Q
The home care nurse visits the 3 yo child diagnosed at birth w/ phenylketonuria. The nurse assesses the child’s intake for the previous week. The nurse is MOST concerned if the child’s parent makes which statement?
A
Ans: my child’s favorite lunch is a peanut butter and jelly sandwich.
-PB not allowed on diet; can have a jelly sandwich made w/ low-protein bread
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16
Q
the nurse plans care for the infant diagnosed w/ a myelomeningocele. Which principle of nursing care is most important to apply when caring for this infant?
A
Ans: asepsis
-infection may cause meningitis and damage the brain; the CNS is very delicate; asepsis is extremely important
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17
Q
The woman delivers a healthy 8-lb, 2-oz infant. She mentions to th eRN that her baby’s “soft spot” seems very large. Which statement by the nurse is most appropriate?
A
Ans: the baby’s anterior “soft spot” will remain for approx 1-1.5yrs
-it takes the anterior fontanel 12 to 18 months to close. Posterior fontanel closes at 2 months
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18
Q
The home care nurse monitors the pediatric client diagnosed w/ a chronic seizure disorder. The nurse should intervene if which finding is observed?
A
Ans:The parent takes the child’s temperature using an oral electronic thermometer
-Seizures can occur w/o warning; it’s dangerous to have a thermometer in the mouth bc the child may start seizing
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19
Q
the 18 month old child drinks some drain cleaner and is brought to the ER. Which piece of equipment is most essential for the nurse to have on hand?
a. intubation tray
b. EKG machine
c. dialysis machine
d. gastric lavage tube
A
Ans: intubation tray
-intubation tray most essential piece of equipment for the nurse to have on hand; w/ this caustic substance, there’s a potential for massive swelling, which would compromise respirations; intubation tray should be immediately available so that airway is protected
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20
Q
the 1 week old child is diagnosed with hemophilia A. Neither the mother nor the father has the disease. Which statement by the RN to the parents correctly describes the hemophilia trait?
A
Ans: It is an X-linked recessive trait found primarily in males
-this trait very rarely shows itself in females, since their second sex chromosome is also X they would need to have the disease linked to both chromosomes in order to show the disease; since males’ 2nd sex chrom is Y, they show disease more frequently. A woman with the trait linked to one X chromosome and not the other is called a “carrier”
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21
Q
which guideline is appropriate for the RN to give a mother concerning the developmental age of her 7 yo child?
A
Ans: the child’s periods of shyness should be tolerated
-a 7 yo girl may become shy at times bc she experiences a conflict re: her independence from her mother; to allow the daughter to become independent, the mother should allow these episodes of shyness
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22
Q
the RN teaches the parent how to care for a child with impetigo. The RN knows that the greatest danger associated with an impetigo infection is the risk of which complication?
A
Ans: Developing glomerulonephritis secondary to streptococcus infection
-can be caused by beta hemolytic streptococcus, the same organism responsible for glomerulonephritis
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23
Q
the school RN assesses children enrolled in the kindergarten class. The RN is most concerned if which finding is observed?
a. child throws and catches a ball
b. child is able to neatly tie shoelaces
c. child eats with fingers
d. child walks down stairs by placing both feet on one step
A
Ans: d. child walks down stairs by placing both feet on one step
- should be able to walk down stairs using alternating feet by age 4; indicates a delay.
- this age group is more aware of hands as a tool; not unusual that 5 yo kids revert to finger feeding
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24
Q
The child with ADHD is taking methylphenidate. THe RN knows that methylphenidate is prescribed for this child for which effect?
a. CNS depressant
b. antianxiety
c. sedative
d. CNS stimulant
A
Ans: d. CNS stimulant
-pharmacological therapy is useful in mngt of ADD; CNS stimulants improve concentration and adaptive behavior
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25
Q
antidote for acetaminophen (Tylenol)?
A
mucomyst
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26
Q
MMR vaccine is for:
A
measles, mumps, rubella
-needs to be given at age 12-15 months and again at 4 to 6 years
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27
Q
the 7 yo child is admitted to the hospital w/ a Dx of idiopathis hypopituitarism. Which clinical manifestation is the nurse most likely to observe?
a. abnormal body proportions
b. early sexual maturation
c. delicate features
d. coarse, dry skin
A
Ans: c. delicate features
-clients characteristically have fine skin and delicate features; also have increased insulin sensitivity and premature aging common later
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28
Q
the child is admitted w/ lead poisoning. Which Sx does the RN expect to see?
a. anemia, hearing impairment, and distractibility
b. tinnitus, confusion, hyperthermia
c. polycythemia, hypoactivity, impaired liver functioning
d. SOB, dependent edema, bounding pulse
A
Ans: a. anemia, hearing impairment, and distractibility
- a. CORRECT - also includes irritability, sleepiness, nausea, vomiting, ab pain, increased intracranial pressure; Tx includes chelation
b. indicates aspirin poisonign
c. chelating agents are excreted through kidneys; nurse should monitor renal system
d. indicates congestive heart failure
note: lead toxicity is also known as “plumbism”
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29
Q
Cerebral Palsy
A
group of nonprogressive, PERMANENT but changing motor impairment syndromes; may be spastic, hypotonic, dystonic, or a combo of all; indications include poor head control after 3 months, stiff or rigid arms/legs, pushing away or arching the back, limp body posture. It’s important to maximize the child’s functioning.
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30
Q
What is cystic fibrosis?
A
hereditary dysfunction of exocrine glands, causing obstructions bc of flow of thick mucus; involves dysfunction in sweat glands, respiratory, and GI systems (particularly pancreas); voracious appetite early in disease and loss of appetite later; difficulties w/ eating d/t respiratory difficulties; Tx includes postural drainage, chest physiotherapy, breathing exercises, expectorants, mucolytic agents, replacement of pancreatic enzymes, aerosol therapy w/ bronchodilators, & mucolytics assists in loosening secretions so they may be removed, relief of bronchospasm, decreases edema of the mucosa, & liquefies bronchial secretions
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31
Q
developmental milestones for 3 yo:
A
copies a circle, builds bridge w/ 3 cubes, less negative than toddler, decreased tantrums, learns from experience, rides triclycle, walks backward and downstairs w/o assistance, undresses w/o help; has 900 word vocab, may invent imaginary friend
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32
Q
Developmental milestones for 4 yo:
A
climbs and jumps well, laces shoes, brushes teeth, has 1,500 word vocab, skips and hops on one foot, throws overhead
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33
Q
Developmental milestones for 5 yo:
A
runs well, jumps rope, dresses w/o help, 2,100 word vocab, tolerates increasing periods of separation from parents, beginning of cooperative play, gender-specific behavior, skips on alternate feet, ties shoes
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34
Q
the 6 month old baby has a cyanotic congenital heart defect. The nurse knows that a cyanotic heart defect is associated with which symptom?
a. pedal edema
b. clubbing of the fingers
c. obligate nose breathing
d. warm, dry skin
A
Ans: b. clubbing of the fingers
- Add’l symptoms that occur in pts w/ congenital heart defects include costal retractions and failure to thrive. Cyanotic congenital heart disease includes tetralogy of Fallot, transposition of the great vessels, truncus arteriosis, tricuspid Atresia, hypoplastic left heart
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35
Q
A 5 1/2 year old child comes to the clinic for a routine exam. The parent reports that the child likes to jump and climb, questions everything, and is often observed interacting w/ an “imaginary” best friend. The nurse should advise the parent to take which action?
a. encourage child to play more often w/ other children
b. tell child that the playmate is not real
c. allow child to engage in imaginary play
d. never leave the child alone
A
Ans: c. allow child to engage in imaginary play
-having imaginary friends is a normal and common occurrence in kids btwn ages 4-6; usu by the time the child is 6, s/he outgrows the imaginary friend
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36
Q
The home care RN visits the home of the toddler diagnosed w/ nonorganic failure to thrive (NFTT). The RN instructs the toddler’s mother about mealtime. Which suggestion by the nurse is most appropriate?
a. give toddler 10 min to eat meal
b. insist toddler eat certain foods
c. develop structured routine for bathing, sleeping, and playing
d. invite other children to eat w/ toddler
A
Ans: c. develop structured routine for bathing, sleeping, and playing
-children respond better if ADLs are structured; unstructured lifestyle will be reflected in child’s unwillingness to eat. NFTT is d/t causes unrelated to disease, e.g. parents’ inadequate nutrition info, disturbances in maternal-child attachment, or an inability by the kid to separate from parents; feed child in same way each meal and allow about 30 min for eating. Never force feed!
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37
Q
The 5 month old infand is brought to the clinic by a parent for a well-baby check up. The RN expects to make which observation?
a. the infant sits w/o support
b. infant transfers an object from hand to hand
c. infant puts their feet to their mouth when lying supine
d. infant appears afraid of strangers
A
Ans: c. infant puts their feet to their mouth when lying supine
-can also roll over from abdomen onto back, able to hold head erect and steady when in sitting position; able to grasp objects voluntarily, takes objects directly to mouth
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38
Q
The RN cares for pts in a ped clinic. The RN should investigate which child for a possible speech impairment?
a. 3 month old who babbles
b. 8 month old who laughs
c. 4 year old who shows an understanding of speech
d. 5 year old who uses single words
A
Ans: d. 5 year old who uses single words
-should have vocab of 2,100-3,000 words and use complete sentences containing 5-7 words
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39
Q
The nurse recognizes that which child is at greatest risk for poisoning?
a. 5-month old
b. 2 yr old
c. 5 year old
d. 7 year old
A
Ans: b. 2 yr old
-2 yo kid is very interested in oral activity and exploration and doesn’t have the judgement necessary to avoid dangerous substances
40
Q
Which action should the RN take to minimize separation anxiety experienced by a toddler?
a. provide a diff RN each shift til child responds warmly to one
b. reassure parents that child is getting along fine w/o them
c. bring other kids in to visit w/ child
d. keep toys from home in bed w/ child
A
Ans: d. keep toys from home in bed w/ child
-provides a familiar environment that will help comfort child
41
Q
The nurse is asked to explain the major difference btwn a clubfoot and a positional deformity to a student nurse. Which statement is appropriate by the nurse?
a. a clubfoot can be passively corrected but a positional deformity must be corrected w/ surgery & casting
b. a clubfoot is corrected w/ surgery & casting but a positional deformity can be passively corrected
c. a clubfoot is not correctable, but a positional deformity is correctable
d. a clubfoot is correctable but a positional deformity is not correctable
A
Ans: b. a clubfoot is corrected w/ surgery & casting but a positional deformity can be passively corrected
-clubfoot is a deformity that can’t be moved into proper alignment w/ manipulation; treated by a series of casts that allow for gradual stretching of structures
42
Q
The parent of the child diagnosed w/ frequent acute otitis media asks the RN why this keeps happening to the child. The nurse’s response should be based on which explanation?
A
Ans: Children have a shorter auditory, or eustachian, tube
-eustachian tubes of children are shorter, wider, and straighter than that of adults; infection travels from the pharynx via the eustachian tube to the middle ear
43
Q
The nurse knows which signs or Sx of rubeola are exhibited before the appearance of the rash?
a. diarrhea, intestinal cramps, and lack of appetite
b. runny nose, sneezing, and coughing
c. itching, fever, and cold sores
d. sore throat and swollen lymph nodes
A
Ans: b. runny nose, sneezing, and coughing
-these are all respiratory Sx that occur before the rash; rubeola is communicable during prodromal phase. Isolate until 5th day after rash appears; maintain bedrest during first 3-4 days; dim lights if complaining of photophobia
44
Q
The nurse instructs the parent about the appropriate way to instill ear drops in the right ear of the 2 yo child. The RN determines teaching is effective if the parent makes which statement?
a. I should pull my child’s ear down and back
b. i will have my child stand next to me
c. i will place a dry cotton pledget in my child’s ear
d. my child should lie on the right side after I instill the drops
A
Ans: a. I should pull my child’s ear down and back
-in children 3yrs, pull pinna up and back
45
Q
The nurse understands that, according to Erikson, adolescence is regarded as the period associated w/ establishment of which developmental goal?
a. sense of trust
b. sense of autonomy
c. sense of identity and intimacy
d. sense of initiative
A
Ans: c. sense of identity and intimacy
-according to Erickson, there’s an overlap of late adolescence and early adulthood in which the individual tries to develop intimate relationships
46
Q
The 4 month old infant is seen in the well-child clinic. The nurse is most concerned if which finding is observed?
a. infant’s head turns to the side when a sound is made at the level of the ear
b. infant’s head lags when pulled from a lying to a sitting position
c. the infant is drooling
d. the infant smiles spontaneously
A
Ans: b. infant’s head lags when pulled from a lying to a sitting position
-should observe almost no head lag at 4 months
47
Q
The 18 month old toddler diagnosed w/ cystic fibrosis is admitted to the hospital w/ a respiratory infection. The nurse should expect to see which characteristic feature of cystic fibrosis?
a. an absence of gastric enzymes
b. an altered viscosity of mucus
c. an absence of liver enzymes
d. poor ventilatory functioning
A
Ans: b. an altered viscosity of mucus
-Cystic fibrosis is an autosomal recessive trait with generalized involvement of the exocrine glands, resulting in altered viscosity of mucus-secreting glands (causes obstruction d/t thick mucus)
48
Q
The nurse anticipates that the child w/ a diagnosis of idiopathic hypopituitarism will be given which hormone?
a. estrogen
b. parathormone
c. growth hormone
d. thyroxine
A
Ans: c. growth hormone
-promotes growth of bone and soft tissues, affects linear growth, conserves carbohydrate utilization
49
Q
The 3 day old infant is born w/ a myelomeningocele. The nurse caring for the neonate should place the infant in which position?
a. prone
b. fowler’s
c. trendelenburg’s
d. side-lying
A
Ans: a. prone
-neural tube fails to close and fuse during development; sac usually encased in fine membrane that is prone to tearing, which causes leaking of CSF; prone position helps prevent pressure on the fatlike protrusion on the back; pressure on the area may result in increased intracranial pressure, and may also cause a rupture of the sac, leading to infection
50
Q
The 18 month old child is admitted to the hospital. When the parents leave, the child starts to cry loudly, and the nurses attempt to console the child. After a while, the child stops crying and becomes quiet and withdrawn. The nurse thinks that the child has accepted the situation and has adjusted well to the separation. Which statement is TRUE?
a. RN is correct and has acted appropriately
b. RN fails to see that the child has entered the second stage of separation anxiety
c. RN fails to see that the child has entered the 3rd stat of separation anxiety
d. the nurse is falsely interpreting undesirable behavior
A
Ans: the nurse fails to see that the child has entered the 2nd stage of separation anxiety
-2nd stage is despair; at this time the crying stops and child becomes depressed, apathetic, and withdrawn
51
Q
The RN in the well-child clinic receives a phone call from the parent of the 6 month old who received the DTaP vaccine 3 days ago. The nurse is most concerned if the parent makes which statement?
a. there’s redness and swelling at the injection site
b. my baby is crying continuously
c. my baby’s temp is 101F (38.3C)
d. my baby seems to be eating less
A
Ans: b. my baby is crying continuously
-Other serious side effects include convulsions, high fever, loss of consciousness
52
Q
The nurse visits the family w/ three small children who live in a 3 bedroom home built in 1952. The RN counsels the family about how to avoid lead poisoning. The RN determines that teaching is effective if the parents make which statement?
A
Ans: I wet mop all of my floors and wash all of the window sills weekly
-homes w/ lead paint should be cleaned weekly by wet cleaning all hard surfaces to remove dust that may contain lead; do not dry sweep
53
Q
The nurse observes parents interacting w/ their newborn shortly after birth. It’s MOST important for the RN to make which assessment during this observation?
a. proper parenting skills
b. healthy or pathologic relationships
c. normal neurologic functioning of the infant
d. parental knowledge of the infant’s behavioral responses
A
Ans: b. healthy or pathologic relationships
-observing the parents’ behavioral responses to their newborn, including holding and interacting with the infant, gives some indication of a healthy or pathological response to the child; early observations by the nurse may also be used to identify infants at risk d/t parental isolation, financial stress, or parental illness; referral to appropriate follow-up service may help to the establishment of a healthy parent-child relationship.
54
Q
The RN in the well-child clinic counsels teh parent of the newborn about normal growth and development. The nurse determines teaching is effective if the parent makes which statements?
A
Ans: my baby will double his birth weight at 5 months
55
Q
The nurse counsels the mom of the child diagnosed with ADD> Which statement by the nurse is most appropriate?
a. you must consider your child’s chronological age when setting goals
b. don’t expect your child to succeed if faced w/ a difficult task
c. limit the # of toys and materials that you offer your child
d. hug your child after a task is correctly performed
A
Ans: d. Hug your child after a task is correctly performed
-kids with ADD are often underachievers in school and may display impulsive, aggressive, and hostile behavior; child responds to positive reinforcement
56
Q
The adolescent is evaluated for scoliosis. The pt asks the nurse, “what’s scoliosis?” Which statement by the RN best describes scoliosis?
A
Ans: it is a lateral curvature of a portion of the spine
-if a pt wears brace, good skin care under pressure areas is necessary; brace is worn 23hrs per day
57
Q
The 15 month old kid crawls but is not yet able to walk. THe parent are concerned and ask the RN if this is normal. Which is the BEST initial response by the RN?
A
Ans: “children often set their own pace”
-important for nurse to explain to parents that teh child will set his own pace in achieving certain developmental tasks such as walking; many children don’t walk until later on, while others walk earlier; there’s no need for concern
58
Q
The RN counsels the parent of a 12 year old diagnosed with chickenpox about when the child can return to school. The RN determines that teaching is effective if the parent makes which statement?
A
Ans: my child can return to school when the lesions are crusted
-abt 1 week after onset of disease; also communicable 2 days BEFORE rash appears
59
Q
The RN cares for the infant diagnosed w/ a cyanotic congenital heart defect. The RN understands that chronic hypoxia from this disorder can result in which finding?
a. intellectual disability
b. polycythemia
c. respiratory infections
d. fluid retention
A
Ans: b. polycythemia
-in chronic hypoxia, the body tries to compensate by producing more red blood cells to carry the limited amt of oxygen available to the tissues
60
Q
The 4 yo child was crying near the fireplace when the clothing caught fire and enveloped the child in flames. THe RN was in the home. Which action should the nurse take FIRST?
a. obtain child’s respirations
b. transport the child to hospital
c. push child to ground and make child roll
d. remove child’s clothing as quickly as possible
A
Ans: c. push child to ground and make child roll
-smother flames; do not let child run bc it will fan the flames
61
Q
Which lab test is most imoprtant for the nurse to follow when monitoring the care of the pt w/ an acetaminophen overdose?
a. liver function test
b. chest x-ray
c. bleeding time
d. WBC count
A
Ans: a. liver function test
-monitor AST and ALT bc liver damage is potential problem
62
Q
The RN knows that which type of feeding is most commonly used with infants who are intolerant of cow’s milk?
A
Ans: soy-based formula
-soybeans are used as the protein source in formulas for children with allergies to cow’s milk’ this protein is less likely to induce allergies in infants
63
Q
A parent calls the clinic to report that the child has been exposed to varicella zoster (chickenpox). The RN should tell the parent that the incubation period for chickenpox is which length of time?
a. 1 day
b. 2-4 days
c. 1 week
d. 2-3 weeks
A
Ans: d. 2-3 weeks
-incubation period for chickenpox is abt 10-21 days, approximately 2-3 weeks
64
Q
The infant is able to assume a sitting position, plays “peek-a-boo” and is starting to say “mama” and “dada”. The nurse identifies that these behaviors are characteristic of which age?
a. 5 months
b. 6 months
c. 9 months
d. 1 year
A
Ans: c. 9 months
-at 9 months, the infant is able to pull himself up and assume a sitting position as well as say words such as “dada” and “mama”
65
Q
When assessing the 9 month old child, the nurse expects which reflex to be present?
a. babinski
b. moro’s
c. tonic neck
d. grasp
A
Ans: a. babinski
-Babinski reflex disappears at 12 months; stroking the outer sole of the foot upward from the heel across the ball of the foot causes the big toe to dorsiflex and toes to hyperextend
66
Q
Typical developmental milestones for a 15-month-old
A
weight about 24lbs and height of 31 inches; walks alone and crawls up stairs, still loses balance easily; likes to throw things, esp down; holds spoon and cup, but difficulty feeding self; places objects in holes appropriately, builds two blocks; looks at books with big pictures; beginning to say words; shakes head “no” in response to most questions; imitates parents w/ tasks; kisses and hugs, has temper tantrums
67
Q
The 8 month old child is about to receive an immunization injection when the child begins to cry. Which comment by the RN is MOST appropriate?
A
Ans: “I know you are frightened. It will be over with soon.”
-this is the best response bc it doesn’t minimize child’s Rx; responds to the child’s feeling tone and says that it will all be over soon
68
Q
The nurse talks with a group of adolescents about their nutritional needs. Which statement is BEST?
A
Ans: you have an increased need for most nutrients.
-adolescents have an increased need for nearly all nutrients d/t their rapid growth and high activity levels
69
Q
The RN performs an assessment on the child admitted with a diagnosis of acute asthma. The RN determines that which observation by the parents is significant to determine the cause of the acute asthma attack?
A
Ans: My child slept on a new pillow last night.
-asthma is chronic inflammatory disorder of the airways; allergies is one of the predominant factors causing asthma; bedding often triggers childhood allergies, which could have precipitated the attack; pillows should be stuffed with either foam rubber or Dacron and either placed in a zippered allergen-impermeable cover or washed in hot water weekly
70
Q
The school RN assesses the physical development of school-age children. Which is the MOST valuable tool for this assessment?
A
Ans: the wight and height compared to standard tables
-growth charts are the basic tool of nutritional assessment of a school-aged child
71
Q
The nurse instructs the parents of a 7-year-old child diagnosed with cystic fibrosis about required dietary modifications. Which adjustment is likely to be made in a normal diet?
A
Ans: increased protein
-children w/ cystic fibrosis tend to need add’l protein for growth since they have increased metabolic needs d/t high incidence of infection
72
Q
The RN supervises the family caring for the child diagnosed with cerebral palsy. The RN should intervene if which finding is observed?
A
Ans: The older sister places a toy in the child’s hands
-important to offer child w/ cerebral palsy incentives to move; place toy out of the immediate reach of the child
73
Q
An 8-month old child presents with stunted growth, and chromosomal studies show that the child has only 45 chromosomes. The RN should identify that the child’s condition is d/t which diagnosis?
A
Ans: Turner’s syndrome
-genetic abnormally resulting from a female’s having only one X chromosome; clinical manifestations include short stature, webbed neck, low posterior hairline, and shield-shaped chest
74
Q
the 17 month old child sucks a thumb, especially at night when quieting for sleep. Which suggestion by the nurse is best?
A
Ans: Don’t intervene, it will subside. The behavior usually peaks at 24 months
-this behavior usu peaks at 24 months; thumb sucking is normal and expected behavior in the toddler period
75
Q
The neighbor of the nurse comes running to the nurse’s house saying, “i just found my 2 yo in the kitchen surrounded by several bottles of cleaning solutions and the bottles are all open!” Which action by the nurse is best?
A
Ans: call the poison control center
-assess the child, initiate steps to stop the exposure (empty the mouth of pills, plants, etc) and call the poison control center for instruction
76
Q
The RN counsels the parent of an infant diagnosed with nonorganic failure to thrive (NFTT). THe RN notes that the mother appears depressed and is expressing feelings of inadequacy and resentment toward her infant. Which approach by the RN is most appropriate?
A
Ans: Structure environment so that the mother feels accepted
-help parents increase self-esteem by making them feel accepted; nurse should empathize with parents about the difficulty of childrearing
77
Q
The 2 yo child is brought to the clinic for extensive facial burns. The child’s parent states that they resulted from the child’s running into a lighted cigarette. The child is holding on to the parent and doesn’t want to let go to be examined. Which is the best rationale for the RN to suspect this parent is abusing the child?
A
Ans: There is little relationship btwn the extent of the child’s burns and the Hx
-most important criterion is incompatibility btwn Hx and presenting injury
78
Q
The RN knows vit E (alpha-tocopherol) is given to premature infants to prevent which condition?
A
Ans: oxidation of RBCs
-fragile cells break apart since the cell walls are weakened in the absence of sufficient vitamin E
79
Q
After an aspirin overdose, it is most important for the nurse to assess for which condition?
A
Ans: bleeding
-aspirin has a potent platelet-inhibiting action that leads to an increased risk for bleeding, such as gastrointestinal hemorrhage; this would be the most life-threatening complication
80
Q
The nurse cares for the infant immediately after insertion of a shunt d/t hydrocephalus. Which observation by the nurse should be reported to the health care provider immediately?
A
Ans: the infant’s pupils are dilated
-indicates increased ICP
81
Q
The 1 yo child is admitted to the hospital for evaluation and a bone marrow aspiration is performed. The nurse expects the test to be performed using which site?
A
Ans: tibia
-the tibia is used in children up to 2 yo to obtain bone marrow aspirations; analgesia or anesthesia is used
82
Q
A 4 yo child is brought to the ER w/ a Dx of acute epiglottitis. Which assessment finding, if made by the nurse, is most significant?
A
Ans: Drooling of saliva
-drooling, agitation, and absence of spontaneous cough are predictive of epiglotitis; do not attempt throat inspection unless immediate intubation can be performed
83
Q
The RN understands that which principle should serve as the basis for managing childhood weight problems?
A
Ans: allow for slower weight gain compared to linear growth
-encourage diet high in complex carbohydrates and fresh fruits and vegetables; encourage physical activity
84
Q
The nurse counsels the parents of a child with Down’s syndrome. Which statement, if made by parents to the RN, indicates further teaching is necessary?
A
Ans: My child’s development will become more rapid in time
-usually mildly to moderately retarded; socially may be 2-3 years beyond mental age
85
Q
The RN considers the developmental stage of a child before choosing a toy. A push-pull toy is appropriate for which age group?
A
Ans: 18-20 months
-child able to walk and learns to coordinate walking with pushing or pulling a toy
86
Q
Which artery should the nurse use to assess the pulse rate of an infant during cardiopulmonary resuscitation?
A
Ans: brachial artery
-brachial artery near the axilla in the infant; infant’s arteries are naturally small; femoral, carotid, and apical pulses may be difficult to palpate; gently palpating just under the axilla can provide the rescuer with an accurate assessment of the circulation to leg
87
Q
The 4 yo child sustains a deep partial-thickness burn. Based on an understanding of growth and development, the nurse anticipates which hospital experiences will probably be the most upsetting to the child?
A
Ans: IM injections
-a 4 yo child has many fears, particularly fear of mutilation; injections would probably be the most upsetting experience for a 4 yo; encourage understanding by playing with puppets, dolls; demonstrate equipment; talk at child’s eye level; edminister medication IV
88
Q
The nurse interviews a 15 year old client. The nurse is most concerned if the adolescent makes which statement?
A
Ans: I don’t perspire like the other kids
-with adolescence there is an increase, not a decrease, in sweat production
89
Q
The nurse identifies which reaction as an adverse effect most often identified w/ the measles, mumps, and rubella (MMR) immunizations?
A
Ans: arthritis
-arthritis is a worrisome adverse effect taht can occur following the MMR immunization; other side effects include rash and fever
90
Q
The RN understands that which food is most likely to cause an allergy in a 6 month old infant?
a. cereals
b. vegetables
c. fruits
d. eggs
A
Ans: eggs
-egg and meat proteins are highly allergenic compared w/ vegetable and grain proteins; introduce meat and eggs only when a child is close to 9 months of age, when child is less likely to develop an allergy to them
91
Q
Surgical repair of a congenital heart defect is performed on the 5 month old infant. Which measure is most important for the nurse to include in the postoperative care plan?
A
Ans: elevate the client’s head to reduce respiratory effort
-elevating the HOB assists w/ respiratory effort, and is an essential component of postoperative care
92
Q
Prior to surgery for myelomeningocele, which action should the RN perform to care for the area of the defect?
A
Ans: apply a moist, sterile dressing
-before a surgical correction, it’s critical to protect the area of a myelomeningocele from puncture; a myelomeningocele is an outpocketing of spinal cord contents through a defect in the vertebral column; skin over the area is thin and friable; preoperatively, the infant should be positioned on his side w/ a moist, sterile dressing over the defect to prevent infection
93
Q
Which statement, if made to the nurse by the parent of an 8 month old child, indicates a possible delay in the child’s development?
A
Ans: my child has almost double the birth weight
-an infant’s birth weight should double by 5-6 months. Since this infant is 8 months, this could indicate a possible delay in development
94
Q
The 3 yo child is brought to the ER with a history of vomiting and diarrhea for the past 3 days. Which finding is the nurse most likely to see?
A
Ans: sunken eyes
-a 3 year old child who has had vomiting and diarrhea for three days will exhibit signs of fluid volume deficit
95
Q
The 3 yo child is seen in the local clinic for croup. The child’s parent asks the nurse what to do for the child at home to alleviate Sx. Which suggestion by the nurse is most appropriate?
A
Ans: stand w/ your child in front of an open freezer
-cool air will constrict edematous blood vessels; use a cold-water vaporizer or take child to cool basem*nt or garage; offer fluids that child likes
96
Q
An infant is found to have an excessive amount of oral secretions after birth. During the first feeding the infant has a choking episode accompanied by cyanosis. The nurse knows that these Sx are indicative of which problem?
A
Ans: tracheoesophageal defect
-tracheoesophageal defects are a group of congenital anomalies in which the esophagus ends in a blind pouch, and teh trachea is attached to the esophagus via a fistula; infant will exhibit respiratory difficulty from birth, and experience choking with first feeding
97
Q
What is acute epiglotitis?
A
a serious obstructive inflammatory process caused by H. influenzae that can be life-threatening; Sx include fever, sore throat and pain on swallowing; children are sicker than they look
