1. The parents of a child, age 6, who will begin school in the fall ask the nurse for anticipatory guidance. The nurse should explain that a child of this age: a. b. c. d.
Still depends on the parents Rebels against scheduled activities Is highly sensitive to criticism Loves to tattle
2. While preparing to discharge an 8-monthold infant who is recovering from gastroenteritis and dehydration, the nurse teaches the parents about their infant’s dietary and fluid requirements. The nurse should include which other topic in the teaching session? a. b. c. d.
Nursery schools Toilet Training Safety guidelines Preparation for surgery
3. Nurse Betina should begin screening for lead poisoning when a child reaches which age? a. b. c. d.
6 months 12 months 18 months 24 months
4. When caring for an 11-month-old infant with dehydration and metabolic acidosis, the nurse expects to see which of the following? a. b. c. d.
A reduced white blood cell count A decreased platelet count Shallow respirations Tachypnea
5. After the nurse provides dietary restrictions to the parents of a child with celiac disease, which statement by the parents indicates effective teaching? a. “Well follow these instructions until our child’s symptoms disappear.” b. “Our child must maintain these dietary restrictions until adulthood.” c. “Our child must maintain these dietary restrictions lifelong.” d. “We’ll follow these instructions until until our child has completely grown and developed.”
6. A parent brings a toddler, age 19 months, to the clinic for a regular check-up. When
palpating the toddler’s fontanels, what should the nurse expects to find? a. Closed anterior fontanel and open posterior fontanel b. Open anterior and fontanel and closed posterior fontanel c. Closed anterior and posterior fontanels d. Open anterior and posterior fontanels 7. Patrick, a healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client’s fluid intake because fluid overload may cause: a. b. c. d.
Cerebral edema Dehydration Heart failure Hypovolemic shock
8. An infant is hospitalized for treatment of nonorganic failure to thrive. Which nursing action is most appropriate for this infant? a. Encouraging the infant to hold a bottle b. Keeping the infant on bed rest to conserve energy c. Rotating caregivers to provide more stimulation d. Maintaining a consistent, structured environment 9. The mother of Gian, a preschooler with spina bifida tells the nurse that her daughter sneezes and gets a rash when playing with brightly colored balloons, and that she recently had an allergic reaction after eating kiwifruit and bananas. The nurse would suspect that the child may have an allergy to: a. b. c. d.
Bananas Latex Kiwifruit Color dyes
10. Cristina, a mother of a 4-year-old child tells the nurse that her child is a very poor eater. What’s the nurse’s best recommendation for helping the mother increase her child’s nutritional intake? a. Allow the child to feed herself b. Use specially designed dishes for children – children – for example, a plate with the child’s favorite cartoon character c. Only serve the child’s favorite foods
d. Allow the child to eat at a small table and chair by herself
d. Emptying the trash cans in the assigned client room
11. Nurse Roy is administering total parental nutrition (TPN) through a peripheral I.V. line to a school-age child. What’s the smallest amount of glucose that’s considered safe and not caustic to small veins, while also providing adequate TPN?
16. Nurse Alice is providing cardiopulmonary resuscitation (CPR) to a child, age 4. the nurse should:
a. b. c. d.
5% glucose 10% glucose 15% glucose 17% glucose
12. David, age 15 months, is recovering from surgery to remove Wilms’ tumor. Which findings best indicates that the child is free from pain? a. b. c. d.
Decreased appetite Increased heart rate Decreased urine output Increased interest in play
13. When planning care for a 8-year-old boy with Down syndrome, the nurse should: a. Plan interventions according to the developmental level of a 7-year-old child because that’s the child’s age b. Plan interventions according to the developmental levels of a 5-year-old because the child will have developmental delays c. Assess the child’s current developmental level and plan care accordingly d. Direct all teaching to the parents because the child can’t understand 14. Nurse Victoria is teaching the parents of a school-age child. Which teaching topic should take priority? a. Prevent accidents b. Keeping a night light on to allay fears c. Explaining normalcy of fears about body integrity d. Encouraging the child to dress without help 15. The nurse is finishing her shift on the pediatric unit. Because her shift is ending, which intervention takes top priority? a. Changing the linens on the clients’ beds b. Restocking the bedside supplies needed for a dressing change on the upcoming shift c. Documenting the care provided during her shift
a. Compress the sternum with both hands at a depth of 1½ to 2” (4 to 5 cm) b. Deliver 12 breaths/minute c. Perform only two-person CPR d. Use the heel of one hand for sternal compressions 17. A 4-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority? a. Instituting droplet precautions b. Administering acetaminophen (Tylenol) c. Obtaining history information from the parents d. Orienting the parents to the pediatric unit 18. Sheena, tells the nurse that she wants to begin toilet training her 22-month-old child. The most important factor for the nurse to stress to the mother is: a. b. c. d.
Developmental readiness of the child Consistency in approach The mother’s positive attitude Developmental level of the child’s peers
19. An infant who has been in foster care since birth requires a blood transfusion. Who is authorized to give written, informed consent for the procedure? a. The foster mother b. The social worker who placed the infant in the foster home c. The registered nurse caring for the infant d. The nurse-manager 20. A child is undergoing remission induction therapy to treat leukemia. Allopurinol is included in the regimen. The main reason for administering allopurinol as part of the client’s chemotherapy regimen is to: a. Prevent metabolic breakdown of xanthine to uric acid b. Prevent uric acid from precipitating in the ureters
c. Enhance the production of uric acid to ensure adequate excretion of urine d. Ensure that the chemotherapy doesn’t adversely affect the bone marrow 21. A 10-year-old client contracted severe acute respiratory syndrome (SARS) when traveling abroad with her parents. The nurse knows she must put on personal protective equipment to protect herself while providing care. Based on the mode of SARS transmission, which personal protective should the nurse wear? a. Gloves b. Gown and gloves c. Gown, gloves, and mask d. Gown, gloves, mask, and eye goggles or eye shield 22. A tuberculosis intradermal skin test to detect tuberculosis infection is given to a highrisk adolescent. How long after the test is administered should the result be evaluated? a. b. c. d.
Immediately Within 24 hours In 48 to 72 hours After 5 days
23. Nurse Oliver s teaching a mother who plans to discontinue breast-feeding after 5 months. The nurse should advise her to include which foods in her infant’s diet? a. b. c. d.
Iron-rich formula and baby food Whole milk and baby food Skim milk and baby food Iron-rich formula only
24. Gracie, the mother of a 3-month-old infant calls the clinic and states that her child has a diaper rash. What should the nurse advise? a. “Switch to cloth diapers until the rash is gone” b. “Use baby wipes with each diaper change.” c. “Leave the diaper off while the infant sleeps.” d. “Offer extra fluids to the infant until the rash improves.” 25. Nurse Kelly is teaching the parents of a young child how to handle poisoning. If the child ingests poison, what should the parents do first? a.
Administer ipecac syrup
b. c. d.
Call an ambulance immediately Call the poison control center Punish the child for being bad
26. A child has third-degree burns of the hands, face, and chest. Which nursing diagnosis takes priority? a. Ineffective airway clearance related to edema b. Disturbed body image related to physical appearance c. Impaired urinary elimination related to fluid loss d. Risk for infection related to epidermal disruption 27. A 3-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour. Which sign or symptom suggests excessive I.V. fluid intake? a. b. c. d.
Worsening dyspnea Gastric distension Nausea and vomiting Temperature of 102°F (38.9° C)
28. Which finding would alert a nurse that a hospitalized 6-year-old child is at risk for a severe asthma exacerbation? a. Oxygen saturation of 95% b. Mild work of breathing c. Absence of intercostals or substernal retractions d. History of steroid-dependent asthma
29. Nurse Mariane is caring for an infant with spina bifida. Which technique is most important in recognizing possible hydrocephalus? a. b. c. d.
Measuring head circumference Obtaining skull X-ray Performing a lumbar puncture Magnetic resonance imaging (MRI)
30. An adolescent who sustained a tibia fracture in a motor vehicle accident has a cast. What should the nurse do to help relieve the itching? a. Apply cool air under the cast with a blowdryer b. Use sterile applicators to scratch the itch c. Apply cool water under the cast
d. Apply hydrocortisone cream under the cast using sterile applicator.
symptoms will reappear if the patient eats prohibited foods. 6. Answer C. By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior
1. Answer C. In a 6-year-old child, a
fontanel normally closes between ages 9
precarious sense of self causes
and 18 months. The triangular posterior
overreaction to criticism and a sense of
fontanel normally closes between ages 2
inferiority. By age 6, most children no
and 3 months.
longer depend on the parents for daily
7. Answer A. Because of the inflammation
tasks and love the routine of a schedule.
of the meninges, the client is vulnerable
Tattling is more common at age 4 to 5,
to developing cerebral edema and
by age 6, the child wants to make
increase intracranial pressure. Fluid
friends and be a friend.
overload won’t cause dehydration. It
2. Answer C. The nurse always should
would be unusual for an adolescent to
reinforce safety guidelines when
develop heart failure unless the
teaching parents how to care for their
overhydration is extreme. Hypovolemic
child. By giving anticipatory guidance
shock would occur with an extreme loss
the nurse can help prevent many
of fluid of blood.
accidental injuries. For parents of a 9-
8. Answer D. The nurse caring for an
month-old infant, it is too early to
infant with nonorganic failure to thrive
discuss nursery schools or toilet training.
should maintain a consistent, structured
Because surgery is not used
environment that provides interaction
gastroenteritis, this topic is
with the infant to promote growth and
inappropriate.
development. Encouraging the infant to
3. Answer C. The nurse should start
hold a bottle would reinforce an
screening a child for lead poisoning at
uncaring feeding environment. The
age 18 months and perform repeat
infant should receive social stimulation
screening at age 24, 30, and 36 months.
rather than be confined to bed rest. The
High-risk infants, such as premature
number of caregivers should be
infants and formula-fed infants not
minimized to promote consistency of
receiving iron supplementation, should
care.
be screened for iron-deficiency anemia
9. Answer B. Children with spina bifida
at 6 months. Regular dental visits
often develop an allergy to latex and
should begin at age 24 months.
shouldn’t be exposed to it. If a child is
4. Answer D. The body compensates for
sensitive to bananas, kiwifruit, and
metabolic acidosis via the respiratory
chestnuts, then she’s likely to be allergic
system, which tries to eliminate the
to latex. Some children are allergic to
buffered acids by increasing alveolar
dyes in foods and other products but
ventilation through deep, rapid
dyes aren’t a factor in a latex allergy.
respirations, altered white blood cell or
10. Answer A. The best recommendation is
platelet counts are not specific signs of
to allow the child to feed herself
metabolic imbalance.
because the child’s stage of
5. Answer C. A patient with celiac disease
development is the preschool period of
must maintain dietary restrictions
initiative. Special dishes would enhance
lifelong to avoid recurrence of clinical
the primary recommendation. The child
manifestations of the disease. The other
should be offered new foods and
options are incorrect because signs and
choices, not just served her favorite
foods. Using a small table and chair
1½ “. The nurse should use the heels of
would also enhance the primary
both hands clasped together and
recommendation.
compress the sternum 1½ “to 2” for an
11. Answer B. The amount of glucose that’s
adult. For a small child, two-person
considered safe for peripheral veins
rescue may be inappropriate. For a
while still providing adequate parenteral
child, the nurse should deliver 20
nutrition is 10%. Five percent glucose
breaths/minute instead of 12.
isn’t sufficient nutritional replacement, although it’s sake for peripheral veins. Any amount above 10% must be administered via central venous access. 12. Answer D. One of the most valuable
17. Answer A. Instituting droplet precautions is a priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be prescribed but administering it doesn’t
clues to pain is a behavior change: A
take priority over instituting droplet
child who’s pain-free likes to play. A
precautions. Obtaining history
child in pain is less likely to consume
information and orienting the parents to
food or fluids. An increased heart rate
the unit don’t take priority.
may indicate increased pain; decreased urine output may signify dehydration. 13. Answer C. Nursing care plan should be
18. Answer A. If the child isn’t developmentally ready, child and parent will become frustrated. Consistency is
planned according to the developmental
important once toilet training has
age of a child with Down syndrome, not
already started. The mother’s positive
the chronological age. Because children
attitude is important when the child is
with Down syndrome can vary from
ready. Developmental levels of children
mildly to severely mentally challenged,
are individualized and comparison to
each child should be individually
peers isn’t useful.
assessed. A child with Down syndrome
19. Answer A. When children are minors
is capable of learning, especially a child
and aren’t emancipated, their parents or
with mild limitations.
designated legal guardians are
14. Answer A. Accidents are the major
responsible for providing consent for
cause of death and disability during the
medical procedures. Therefore, the
school-age years. Therefore, accident
foster mother is authorized to give
prevention should take priority when
consent for the blood transfusion. The
teaching parents of school-age children.
social workers, the nurse, and the
Preschool (not school-age) children are
nurse-manager have no legal rights to
afraid of the dark, have fears concerning
give consent in this scenario.
body integrity, and should be
20. Answer A. The massive cell destruction
encouraged to dress without help (with
resulting from chemotherapy may place
the exception of tying shoes).
the client at risk for developing renal
15. Answer C. Documentation should take
calculi; adding allopurinol decreases this
top priority. Documentation is the only
risk by preventing the breakdown of
way the nurse can legally claim that
xanthine to uric acid. Allopurinol doesn’t
interventions were performed. The other
act in the manner described in the other
three options would be appreciated by
options.
the nurses on the oncoming shift but
21. Answer D. The transmission of SARS
aren’t mandatory and don’t tak e priority
isn’t fully understood. Therefore, all
over documentation.
modes of transmission must be
16. Answer D. The nurse should use the heel of one hand and compress 1” to
considered possible, including airborne, droplet, and direct contact with the
virus. For protection from contracting
parts of burn management but aren’t
SARS, any health care worker providing
the first priority.
care for a client with SARS should wear
27. Answer A. Dyspnea and other signs of
a gown, gloves, mask, and eye goggles
respiratory distress signify fluid volume
or an eye shield.
excess (overload), which can occur
22. Answer C. Tuberculin skin tests of
quickly in a child as fluid shifts rapidly
delayed hypersensitivity. If the test
between the intracellular and
results are positive, a reaction should
extracellular compartments. Gastric
appear in 48 to 72 hours. Immediately
distention may suggest excessive oral
after the test and within 24 hours are
fluid intake or infection. Nausea and
both too soon to observe a reaction.
vomiting or an elevated temperature
Waiting more than 5 days to evaluate
may indicate a fluid volume deficit.
the test is too long because any reaction may no longer be visible. 23. Answer D. The American Academy of
28. Answer D. A history of steroiddependent asthma, a contributing factor to this client’s high-risk status, requires
Pediatrics recommends that infants at
the nurse to treat the situation as a
age 5 months receive iron-rich formula
severe exacerbation regardless of the
and that they shouldn’t receive solid
severity of the current episode. An
food – even baby food – until age 6
oxygen saturation of 95%, mild work of
months. The Academy doesn’t
breathing, and absence of intercostals
recommend whole milk until age 12
or substernal retractions are all normal
months, and skim milk until after age 2
findings.
years. 24. Answer C. Leaving the diaper off while
29. Answer A. Measuring head circumference is the most important
the infant sleeps helps to promote air
assessment technique for recognizing
circulation to the area, improving the
possible hydrocephalus, and is a key
condition. Switching to cloth diapers
part of routine infant screening. Skull X-
isn’t necessary; in fact, that may make
rays and MRI may be used to confirm
the rash worse. Baby wipes contain
the diagnosis. A lumber puncture isn’t
alcohol, which may worsen the
appropriate.
condition. Extra fluids won’t make the rash better. 25. Answer C. Before interviewing in any
30. Answer A. Itching underneath a cast can be relieved by directing blow-dyer, set, on the cool setting, toward the itchy
way, the parents should call the poison
area. Skin breakdown can occur if
control center for specific directions.
anything is placed under the cast.
Ipecac syrup is no longer
Therefore, the client should be
recommended. The parents may have to
cautioned not to put any object down
call an ambulance after calling the
the cast in an attempt to scratch.
poison control center. Punishment for being bad isn’t appropriate because the parents are responsible for making the environment safe. 26. Answer A.Initially, when a preschool client is admitted to the hospital for burns, the primary focus is on assessing and managing an effective airway. Body image disturbance, impaired urinary elimination, and infection are all integral
