Peds Exam 3 Questions with Answers all 100% Correctly Verified updates 2024, Exams of Nursing

Download Peds Exam 3 Questions with Answers all 100% Correctly Verified updates 2024 and more Exams Nursing in PDF only on Docsity! Peds Exam 3 Questions with Answers all 100% Correctly Verified updates 2024 1- A 5 y.o male diagnosed with mild dehydration should be given Oral Rehydration Solution (ORS) by the nurse or parent with which of the following rehydration therapy? (Mild ORS, 50 Ml/Kg within 4 hrs, Moderate 100 ml/Kg within 4 hr, Severe 40 mL/kg/hr IV until pulse and states of consciousness return to norm; then 50-100 mL/kg ) 50 ml/kg/ 4 hrs 2- The nurse is planning care for a school-age child with bacterial meningitis. What intervention should be included? -Assess for signs of increased intracranial pressure 3- A child with pyloric stenosis is having excessive vomiting. Which of the following is a potential complication? -Metabolic alkalosis 4- A 2-year-old is brought the peds ER following a generalized tonic clonic seizure that lasted 2 minutes. It terminated without any treatment. Her temperature was measured as 39.5°C. She has a two-day history of feeling unwell. She has never had such a seizure before. What is the most appropriate management plan for this child? (Select all that apply) -Reassure parents, discharge home and safety teaching -Child will probably be discharged home with anti-pyretic medication 5- A newborn female infant in the NICU has signs of ambiguous genitalia, and hyponatremia. Which of the following is the infant's likely diagnosis? -Congenital Adrenal Hyperplasia 6- A young girl has just injured her ankle at school. After notifying the child's parents and applying ice to the area, what is the next most appropriate action by school nurse? -Elevate the extremity to reduce edema formation 7- A child with a fracture of the humerus has a long arm cast. Which of the following signs are assessed to determine tissue ischemia or compartment syndrome? -Pulselessness 8- The nurse is assessing an infant with intussusception. Which of the following clinical findings should the nurse expect? (Select all that apply) -Stool mixed with blood and mucus -Palpable sausage shaped abdominal mass -Acute abdominal pain 9- The nurse is teaching the parents of a 1-month-old infant with developmental dysplasia of the hip about preventing skin breakdown under the Pavlik harness. What statement by the parent would indicate a correct understanding of the teaching? - “I should gently massage the skin under the straps once a day to stimulate circulation." 10- In teaching the parent of a newly diagnosed 2-year-old child with pyelonephritis related to vesicoureteral reflux (VUR), the nurse should include which information? -Have siblings examined for VUR 11- What statement is true concerning osteogenesis imperfecta (OI)? -Disease characterized by fractures and bone deformity 12- Which of the following conditions has the clinical manifestation of Exophthalmos (protruding eyeballs)? -Hyperthyroidism 13- A 12 yr old child is admitted to the PICU in acute renal failure (ARF). The nurse prepares to administer which of the following medication to rapidly provoke of urine? -Mannitol (osmitrol)/Furosemide (Lasix) or both 14- The nurse is assisting with application of a synthetic cast on a child with a fractured humerus. What is an advantages of a synthetic cast over a plaster of Paris cast? -Lightweight, and less bulky/Drying time is faster/permits regular clothing to be worn/can be cleaned with small amount of soap and water 15- An adolescent with diabetes is admitted to the ER for treatment of hyperglycemia and pneumonia. What are clinical manifestations of diabetic hyperglycemia? -Increased appetite, fatigue, thirst/frequent urination(Polyuria, Polyphagia, Polydipsia) 16- A child with juvenile idiopathic arthritis (JIA) is started on a non-steroidal anti-inflammatory drug (NSAID). What nursing consideration should be included? -Check for abdominal pain and bloody stools 17- A 5 year old male is diagnosed with diarrhea and mild dehydration. Which of the following Oral Rehydration Solution (ORS) should be given by the nurse or parent to replace the stool losses? (Mild/Moderate/Severe all same 150-250 ml each stool, Infant 10ml/kg) -150-250 ml each stool (MILD) 18- Which of the following urine tests would be considered abnormal? (Norm 1.001-1.035) -Specific gravity 1.040 19- After a pyloromyotomy, a week old infant is prescribed feedings of 1 to 2 oz of Pedialyte every 3 hours then advance to breastmilk as tolerated postoperatively. The nurse should advance the feeding if which occurs? -The infant is taking the Pedialyte without vomiting or distention 20- Children with steroid induced Cushing syndrome should receive their medication at which of the following times to lessen the Cushingoid features? Give the drug: -Early in the morning upon awakening 21- Alport Syndrome is a X linked hereditary disease characterized by which of the following? (Select all that apply)(Hematuria, high-frequency deafness, ocular disorders, chronic renal failure, & proteinuria) -High tone sensorineural deafness -Chronic kidney disease -Ocular disorders 22- What statement is an advantage of peritoneal dialysis compared with hemodialysis? -It is easy to learn and can be done at home 23- A child, age 3 years, has cerebral palsy (CP) and is hospitalized for orthopedic surgery. His mother says he has difficulty swallowing and cannot hold a utensil to feed himself. He is slightly underweight for his height. Which of the following is the most appropriate nursing action related to feeding Jason? -Stabilize his jaw with caregiver's hand to facilitate swallowing 24- A 10 yr old child is admitted with a hx of Crohn disease. The child's plan of care should include a diet that has which of the following component? -Increased calories/(Increased protein) 25- A 6-month-old infant with Hirschsprung disease is scheduled for a temporary colostomy. What should postoperative teaching to the parents include? -Skin and stoma care 26- A nurse is teaching clients in an outpatient facility about the use of insulin to treat type 1 diabetes mellitus. For which of the following types of insulin should the nurse tell the clients to expect a peak effect 2 to 4 hr after administration: -Short acting Regular 52- Surgery is performed on a child to correct cryptorchidism. The parents understand the reason for the surgery if they tell the nurse this was done to do what? -“Maintaining future fertility opportunity” 53- An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Postoperative nursing care would include what? -Monitor closely for signs of infection. 54- What clinical manifestations of developmental dysplasia of the hip would be assessed in a newborn? -Ortolani sign 55- A 3-month-old with developmental dysplasia of the hip (DDH) is being fitted for a Pavlik harness. Which statement made by the parent indicates a need for further instruction? -I will adjust the harness straps every 3-5 days Peds 106 Final Exam 1- The doctor has ordered Ampicillin 500 mg IV TID for a child weighing 28kg. The normal pediatric dose is 50- 200mg/kg/day in divided doses. What is the therapeutic dose range for this medication? Answers A-D A min 1400-max 5600 B min 1000-max 5000 C min 500-max 4000 D min 800-max 4800 2- An infant, brought to the US from another country, is diagnosed with congenital hypothyroidism. The nursing student is aware the infant is at risk for which symptoms? (Select all that apply) Answers A-E A Delayed Growth B Hearing and Speech disorders C Excessive weight loss D Cognitive impairment E Frequent urinary tract infections 3- The parents of a child diagnosed with an autosomal recessive condition consult the nurse, stating they want to have more children but are worried about subsequent children also inheriting the disease. Which information should the nurse provide to the parents? Answers A-D A You should consult with a geneticist to determine who is the carrier B "Each child has a 1 in 4 risk of inheriting the disease C "There is a way to predict if the child will have the disease D "The disease is carried on the mother's chromosome'’ 4- A 10 month old female is diagnosed with UTI and Vesicoureteral Reflux (VUR). As a result of these diagnoses, this child is at risk for which of the following complications? Answers A-D A Hematuria B Pyelonephritis C Bladder cancer D Glomerulonephritis F Proteinuria 5- A concerned mother brings her 1-year-old son to the peds ER. She explains her son has been having sudden bouts of crying during which he draws up his legs, for the past 12 hours. He is also not feeding and appears pale but is afebrile. This morning he passed stool that appeared red in color. These symptoms describes which of the following conditions? Answers A-D A Pyloric Stenosis B Gastroesophageal Reflux C Intussusception D Hirschsprung Disease A toddler with symptoms of sudden inconsolable screaming or crying, drawing up of the knees to the chest, vomiting, and a tender distended abdomen will probably be diagnosed with which of the following diseases? Ans. Intussusception 6- Which immunizations should the nurse plan to administer to normal healthy children between the ages of 1 and 5 years? (Select all that apply) Answers A-E A Diphtheria, tetanus, pertussis (DTAP) B Meningococcal (MCV) C Pneumococcal (PCV-13) D Measles, mumps, rubella (MMR) E Human Papillomavirus (HPV) F IPV G Hib H Hep A &B I varicella 7- Which is the leading cause of death in infants younger than 1 year in the United States? Answers A-D A Maternal complications specific to the perinatal period B Congenital anomalies C Disorders related to short gestation and low birth weight D Sudden infant death syndrome 8- An 18-month-old child has been diagnosed with pediculosis capitis (head lice). The drug of choice for infants and children to treat head lice is? Answers A-D A Pyrethrin with piperonyl butoxide (RID) B Benzyl alcohol 5% lotion C Malathion (Ovide) D Permethrin 1% (Nix) 9- Which of the following conditions is Intranasal desmopressin acetate (DDAVP) used to treat? Answers A-D A Hypopituitarism B Acute adrenocortical insufficiency C Syndrome of inappropriate antidiuretic hormone (SIADH) D Diabetes insipidus (DI) (Drug of choice—DDAVP, Nasal spray or IM or SQ administration, Requires treatment for life) 10- The health care provider has prescribed ondansetron (Zofran) 0.1 mg/kg as needed for nausea for a child admitted for vomiting. The child weighs 55 lb. Calculate the correct dose of Zofran in milligrams. Answers A-D A 0.5 mg B 2.5 mg C 1.0 mg D 1.5 mg 11- Which nursing intervention is priority for the pediatric intensive care nurse to implement when caring for a 15 year old client diagnosed with diabetic ketoacidosis (DKA)? Answers A-D A Maintain the regular insulin IV rate on an infusion pump, B Check blood glucose levels once per day C Monitor the client’s pulse oximeter readings D Assess for a fruity breath odor 12- A school nurse is educating a room full of 12-14 yr old females on health and hygiene issues. She included the following symptoms: high fever, vomiting, diarrhea, oliguria, & hypotension to best describe which illness? Answers A-D 25- Give Regular insulin by continuous IV. infusion at 20 units/hr. The solution is 250 mL NS with 100 units of Regular insulin. What rate on the infusion pump will deliver the correct dose? Answers A-D A 50 ml/hr B 25 ml/hr C 35 ml/hr D 75 ml/hr 26- Tetralogy of fallot consists of pulmonic stenosis, overriding aorta, ventricular septal defect, and which of the following? Answers A-D A Atrial septal defect B Patent Ductus Arteriosus C Aortic stenosis D Right ventricular hypertrophy 27- Which of the following is the most common period when Nephrotic Syndrome usually occurs in a child? Answers A-D A School age B Preschool C Adolescence D Infancy 28- Select the developmental milestones usually seen in children during the Preschool stage (3-6 years) (Select all that apply) Answers A-D A Ride a tricycle B Learns colors and shapes C Child learns to run jump, skip and hop D Dress self completely E Loss of primary teeth Select the developmental milestones usually seen in children during the toddler stage (1-3 years). (Select all) Appears to be bowlegged and potbellied, Kicks a ball by 24 mon Feeds self w spoon and cup @ 2 yrs Daytime toilet training can start @ 2 yrs 2-3 word sentences by 2 yrs 3-4 word sentences by 3 yrs Own first and last name by 2.5 -3 yrs Temper tantrums are common Select the developmental milestones usually seen in children during the toddler stage (6-12 years). (Select all) Gains 4-6 lbs/yr- 2 inches in height/yr Girls may experience menarche Loss of primary teeth/gain of permanent teeth Fine and gross motor skills mature Able to write script @ 8 yrs Dress self completely Egocentrism replaced by social awareness Learns to tell time Understands past, present & future Learns cause & effect Socialization with peers important Molars erupt 29- The potential effects of chronic illness or disability on a child's development vary at different ages. Which of the following is a threat to a toddler's normal development? Answers A-D A Hindered mobility B Limited opportunities for socialization C Child's sense of guilt that he or she caused the illness or disability D Limited opportunities for success in mastering toilet training 30- A 7 yr old child with Acute Lymphocytic Leukemia (ALL) is on steroids. A common side effect of corticosteroid (prednisone) therapy is? Answers A-D A Anorexia B Alopecia C Weight gain D Nausea and vomiting 31- Which of the following legally allows a young adult under the age of majority to be considered an emancipated minor, and allows them to give informed health care consent? (Select all that apply) Answers A-E A Minor that is sexually active B Minor in the foster care system C Marriage D Military service E High School graduation (pregnancy, marriage, high school graduation, independent living, or military service) 32- A 10 yr old sustained a full thickness 3rd degree burn on his left arm during a barbecue. What will be required for healing from this injury? Answers A-D A Desquamation B Escarotomy C Amputation D Autografting 33- A 4 week old infant has a femoral shaft fracture. The nurse recognizes that the approximate healing time for this infant's fracture is how long? Answers A-D A 8-12 weeks B 6-7 weeks С 4-5 weeks D 2-3 weeks Neonatal period—2 to 3 weeks Early childhood—4 weeks Later childhood—6 to 8 weeks Adolescence—8 to 12 weeks 34- A child has been diagnosed with scabies. Which statement by the parent indicates understanding of the nurse's teaching about scabies? Answer A-D A 'We will complete extensive aggressive housecleaning" B "The itching will stop after the cream is applied C ‘'Everyone who has been in close contact with my child will need to be treated D "We will apply the cream to only the affected areas as directed” 35- A newborn is suspected of having esophageal atresia with a tracheal esophageal fistula. What nursing assessment information would assist in validating the presence of a fistula? Answers A.D A Chin tug and circumoral pallor B Clammy skin and croup cough C Crying and chest retractions D Choking and coughing with frothy saliva Clinical manifestation- Frothy saliva, drooling, coughing, choking 36- A child with a fracture of the humerus has a long arm cast. Which of the following signs are assessed to determine tissue ischemia or compartment syndrome? Answers A-D A Paralysis B Physiologic C Proliferation D Position Pain and point of tenderness Pulse— distal to the fracture site Pallor Paresthesia—sensation distal to the fracture site Paralysis—movement distal to the fracture site Pallor 37- The nurse is teaching the family of a child, age 8 years, with moderate hemophilia about home care. What should the nurse tell the family to do to stop the bleeding? Answers A-D А Administer DDAVP (synthetic vasopressin) B Provide intravenous (IV) infusion of factor Vill concentrates С Administer nonsteroidal anti-inflammatory drugs (NSAIDs). D Encourage elevation and application of ice to the involved joint DDAVP through IV -Causes 2 to 4 times increase in factor VIII activity -Used for mild to moderate hemophilia -Replace missing clotting factors -Transfusions- At home with prompt intervention to decrease complications Following major or minor hemorrhages 38- The nurse notes that a 12-month-old infant who weighed 6.5 pounds at birth now weighs 25.5 pounds. What is the nurse's evaluation of the infant's current weight? Answers A-D A The child is consuming more calories than needed B Infant's weight is appropriate for the age C The infant should be evaluated for malnutrition D The nurse should assess the infant for symptoms of colic The nurse notes that a 12 month old infant who weighed 6.5 lbs at birth now weighs 20.5 lbs. What is the nurse’s evaluation of the infant’s current weight? Infant’s weight is appropriate for the age 39- The physician has ordered Rocephin 200 mg IM b.id, for a child who weighs 5000 g. The Rocephin vial contains 1 g of medication that must be reconstituted with 3.6 ml of diluent to yield 1 g/4ml Answers A-D 53- During a respiratory assessment, the nurse notes a sinking in of soft tissues relative to the cartilaginous and bony thorax. What is the term for this finding? Answers A-D A Grunting B Tachypnea С Retractions D Nasal Flaring 54- A 12-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than which rate? Answers A-D А 90 beats/min B 100 beats/min С 70 beats/min D 120 beats/min A 2 y.o child is receiving digoxin(Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than which rate? 90 beats/min 55- The nurse is doing a prehospitalization orientation for a girl, age 7 years, who is scheduled for cardiac surgery. As part of the preparation, the nurse explains that after the surgery, the child will be in the intensive care unit. How might the explanation by the nurse be viewed? Answers A-D A The surgeon's responsibility B Unnecessary C An appropriate part of the child's preparation D Too stressful for a young child E Necessary information for the child and parents 56- What statement is an advantage of peritoneal dialysis compared with hemodialysis? Answers A-D A Dietary limitations are not necessary B Protein loss is less extensive С it is needed less frequently than hemodialysis D It is easy to learn and can be done at home 57- A parent requests info on her infant's hearing. Which of the following should the nurse say is a clinical manifestation of hearing impairment in an infant less than 12 months old? Answers A-D A Absence of babbling by 4 months B Occasionally turns head towards sounds C Responds to loud noises as opposed to voice D Failure to look parent in the eye 58- A 3-year-old with a Wilms tumor is returning to the unit after surgery to remove the tumor. Which of the following is the highest post-op priority for the nurse? Answers A-D A Administering pain medication every 4 hours B Maintaining NPO C Turning every 4 hours D Monitor vital signs especially blood pressure 59- The nurse is assessing a 4 year old boy in the pediatric clinic Which behaviors by the client would concern the nurse for possible Duchenne muscular dystrophy? (Select all that apply) Answers A-E A Has painful knees and elbows in the morning B Suddenly rigidly extends arms and legs C Places hands on the thighs to push up to stand D Frequent trips and falls at home E Has disproportionately large calves, and a waddling gait -Frequent trips and falls at home -Places hands on thighs to push up to stand -Walks on tiptoes and has disproportionately large calves 60- A 6 yr old male in the peds ER has a history of fluid loss and dehydration over the past 12 hours. The nursing assessment should include close monitoring for the possibility of which of the following? Answers A-D A Impending shock B Hyperkalemia C Hypercalcemia D Metabolic Alkalosis 61- A school-age child with celiac disease asks for guidance about snacks that will not exacerbate the disease. What snack should the nurse suggest? Answers A-D A Rice cakes B Pizza C Oatmeal cookies D Pretzels -Creamed corn, Popcorn, Corn on the cob with butter, Grilled chicken, baked potato, and strawberry yogurt, Mexican corn tacos with ground beef and cheese, Rice noodles with chicken and broccoli, potato chips Which of the following statements made by the mother of a child recently diagnosed with celiac disease indicates a need for further teaching? “My child can have small amounts of foods containing wheat as long as she remains symptoms free” 62- A 12-year-old boy is brought to the emergency department by his father as he has not been able to weight bear on his right leg for the last 12 hours. There is no history of trauma on physical examination, the child complains of pain during passive movement of the right hip joint, and the child has a limp. These symptoms describe which of the following conditions? Answers A-D A Osteogenesis Imperfecta (0I) B Slipped Capital Femoral Epiphysis (SCFE) С Juvenile Arthritis (JA) D Club Foot (Tapiles Equinovarus) 63- Which of the following toys are appropriate for a hospitalized preschooler? Answers A-D A Video games, board games, puzzles B Rattles, squeaking toys, mobile toys C Push pull toys, telephones, stuffed animals D Coloring books, building blocks, clay 64- Which of the following concepts provides a rational approach to decision making that facilitates best practice in nursing care? Answers A-D A Family Centered Care B Evidence Based Practice C Critical Thinking Skills D Atraumatic Care *Evidence-Based Practice (EBP) -Based on valid, important, and applicable patient-reported, nurse-observed, and research-derived information -Combines knowledge with clinical experience and intuition -Provides a rational approach to decision making that facilitates best practice 65- A school age child is admitted in vasooclusive sickle cell crisis (pain episode). The child’s care should include which therapeutic interventions? Select all that apply) Answers A-E A Pain management B Factor V1111 replacement C Correction of Alkalosis D Hydration E Electrolyte Replacement 66- The nurse is evaluating the laboratory results of a stool sample. What is a normal finding? Answers A-D A The laboratory reports a stool pH of 7.0 B The laboratory reports reducing substances present C The laboratory reports low levels of enzymes. D The laboratory reports a positive guaiac E The laboratory reports a negative guaiac An acidic pH (5–5.5) indicates malabsorption, which occurs with lactose intolerance. The normal pH of the stool is (7.0 to 7.5). A finding of 8 would be alkaline. 67- The nurse is preparing to administer a unit of packed red blood cells to a hospitalized child. What are appropriate actions that applies to administering blood? (Select all that Apply) Answers A-E A Administer blood through an appropriate filter B Administer the blood with 5% glucose in a piggyback setup C Infuse blood within 4 hours D Administer the first 50 ml of blood slowly and stay with the child E Use blood within 30 min of its arrival from the blood bank 68- A 1 week old infant is evaluated in pediatric renal clinic, with a narrowing of the opening of his foreskin. What is this condition called? Answers A-D А Phimosis B Hypospadias C Chordee D Epispadias 69- The nurse notes that a child has lost 3.6 kg (8 lb) after 4 days of hospitalization for acute glomerulonephritis. What is the most likely cause of this weight loss? Answers A-D A increased potassium intake B Restriction to bed rest C Poor appetite D Reduction of edema 7. A 3-month-old with gastrointestinal reflux has been placed on enteral feedings. Which action should the nurse include in the infant’s plan of care? a. Speak with the HCP about instituting physical therapy b. Give the infant a pacifier during the feedings c. Use sterile technique during the feedings d. Refer to abdominal x-ray to ensure placement of the nasogastric tube 8. A 4-year-old child is admitted to the hospital after experiencing a febrile seizure with a two- day history of a fever above 103 degrees F. The nurse observes the child is fearful with rapid deep respirations. Which acid base imbalance should the nurse anticipate the child developing? a. Respiratory alkalosis b. Metabolic alkalosis c. Metabolic acidosis d. Respiratory Acidosis 9. A 12-year-old boy with hemophilia is hospitalized for hemarthrosis of his right knee. He is complaining of severe knee pain. Which intervention should the nurse implement? a. Perform range of motion exercises to the right knee b. Evaluate and immobilize right knee in a flexed position c. Give ibuprofen for pain d. Apply hot packs to the right knee 10. A toddler is hospitalized with Kawasaki’s disease. Pharmacological management includes aspiration therapy. Which is the primary benefit of the aspirin? a. Reduce joint swelling b. Manage irritability c. Control high fever d. Minimize vascular inflammation 11. A mother brings her 10-year-old boy who is holding his abdomen to the clinic because of fever, vomiting and abdominal pain for the past 12 hours. Which assessment data is most important for the nurse to obtain? a. Activity history 24 hours prior to the onset of pain b. His description of the quantity and nature of the pain c. A complete blood count, including differential count d. His typical pattern and type of bowel movements 12. The nurse is discharging a school-aged child who is newly diagnosed with congenital adrenal hyperplasia. Which information should the nurse instruct the parents to report to the HCP immediately? a. Persistent vomiting b. Weakness when walking c. Fatigue during the day d. Constipation 13. A 3-year-old male child is seen in the outpatient clinic with reddish vesicles on his legs. The medical diagnosis is impetigo contagiosa. The child’s mother is concerned about the long-term effects of the condition. The nurse should inform the mother of which probable outcome? a. Deep pitted scarring b. Pigmented scarring c. Slightly reddened scarring d. No scarring 14. The nurse is assessing an adolescent who arrived at the clinic for a physical examination before high school starts. The adolescent reports trouble hearing and a constant ringing in the ears. Which action should the nurse implement first? a. View the oropharynx and obtain an oral temperature b. Perform an otoscopic ear examination c. Ask about frequent use of earbuds to listen to music d. Evaluate lying and standing blood pressures 15. A 2-year-old girl is brought to the clinic by her 17-year-old mother. When the nurse observes that the child is drinking sweetened soda from her bottle, what information should the nurse discuss with his mother? (Select all that apply) a. Drinking soda is related to childhood obesity b. Toddlers should be drinking from a cup by age 2 c. Dental caries are associated with drinking soda d. Toddlers should be sleeping 10 hours a right e. A 2-year-old should be speaking in 2 word phrases 16. The nurse is examining an infant for possible cryptorchidism. Which exam technique should be used? a. Place the infant in a warm room and use a calm approach b. Cleanse the penis with an antiseptic-soaked pad c. Hold the penis and retract the foreskin gently d. Placed the infant in side-lying position to facilitate the exam 17. A 6-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child? a. List of achievement timeline for developmental milestones b. Mother’s use of alcohol, drugs, or cigarettes during pregnancy c. A history or rubella, rubeola, or chicken pox d. Reactions to any previous hospitalizations 18. Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. Which instructions should the nurse give the parents if their child becomes pale, cool and lethargic? a. Provide a quiet time by holding or rocking the toddler b. Encourage oral electrolyte solution intake c. Contact their healthcare provider immediately d. Assist the child to a recumbent position 19. Which nutritional information should the nurse plan to provide the mother of a 6-month-old regarding introduction of solid foods? a. Foods are best introduced by mixing them with formula and feeding them to the infant with a feeder bottle b. Introduce fruits and vegetables simultaneously into the diet c. Foods should be introduced into a diet one at a time, at 4 to 7 day intervals d. Begin introducing solid foods into the child’s diet after the child reaches one year of age child’s 20. The nurse is teaching the parents of a child with cystic fibrosis about homecare. Which intervention should the nurse ensure the parents understand about managing the child’s respiratory secretions? a. Percussion and postural drainage b. Vitamin supplementation c. Inhaled hypotonic saline d. Prophylactic antibiotics 21. A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticaria, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take? a. Change the latex-free gloves when handling infant b. Apply zinc oxide to perineum with each diaper change c. Draw blood to analyze for streptococcal infection d. Auscultate the lungs for respiratory pneumonia 22. The heart rate for a 3 year old child with a congenital heart defect has steadily decreased over the last few hours, and is now at 76 beats/minute. The previous reading 4 hours ago was 110 beats/minute. Which additional clinical finding should be reported immediately to the healthcare provider? a. Oxygen saturation of 94% b. Respiratory rate of 25 breaths/minute c. Urine output of 20 ml/hour d. Blood pressure of 70/40 mmHg 23. A mother brings her 3 year old son to the emergency room and tells the nurse that he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102 F (38.9 C). He is drooling and becoming increasingly more restless. What action should the nurse take first? A. Listen to lung sounds and place him in a mist tent B. Assist the child to lie down and examine his throat C. Put a cold cloth on his head and administer acetaminophen D. Notify the healthcare provider and obtain a tracheostomy tray 24. Parents bring their 8 month old daughter to the clinic because they are concerned that she is not developing as her older brother did. Which developmental characteristic should the nurse expect an 8 month old to exhibit? a. Sits alone unsupported b. Pulls self to sitting position c. Takes a first step alone d. Can feed self finger food 25. Several children at a day camp return from playing in a tick infested field. Which action should the camp nurse take first? a. Assess the children for the presence of a bull’s eye rash b. Ask the children if they were using tick repellant c. Assess for the use of illicit drugs d. Evaluate vital signs and lab findings 39. A 9 year old boy is diagnosed with diabetes mellitus type 1. Which stage of Erikson’s theory of psychosocial development is the nurse addressing when teaching this client about insulin injections? a. Identity b. Autonomy c. Industry d. Initiative 40. A child receives a prescription for clarithromycin 215 mg by mouth four times a day with food. The drug is available as an oral suspension labeled “125mg/5 mL”. How many mL per dose should the nurse administer? Ans. 8.6 mL 41. Albumin 25 % IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect? a. Reduction of edema b. Reduction of fever c. Weight gain d. Improved caloric intake 42. A child with possible duchenne muscular dystrophy (MD) undergoes an electromyogram (EMG). following the procedure, the child’s parents tell the nurse that the child is complaining of sore muscles. How should the nurse respond? a. Encourage the parents to monitor b. Advise the parents that children with chronic disease may seek attention by reporting pain or other unpleasant symptoms c. Explain that muscle aches and pain are commonly experienced by children with this form of muscular dystrophy d. Offer reassurance that muscle soreness following this procedure is temporary and does not indicate a problem 43. The parents of a 14-year-old child who is hospitalized due to febrile seizures tell the nurse that they fear their child will have lifelong seizures. Which information should the nurse convey to their parents? a. Ibuprofen should be used prophylactically to prevent febrile seizures. b. Avoid excessive visual stimuli because it can precipitate seizure activity. c. Provide the child with a sponge bath for temperature over 100.6 F̊ (38.1 C).̊ d. Reassure the parents that febrile seizures decrease as the child grows older. 44. The nurse is teaching the parents about important dietary changes for their child who is newly diagnosed with celiac disease. Which foods should the nurse include in the list of allowed foods for the child? a. Oats. b. Barley. c. Rye. d. Rice. 45. The mother of an infant born with hypospadias is concerned because she has been told that her child cannot be circumcised according to her Jewish faith tradition. Which response is best for the nurse to provide? a. “Circumcising the penis can contribute to frequent urinary infections b. “During the surgery part of the foreskin is used to repair the meatus.” c. “Your faith is important, but correcting this problem is priority for your son.” d. “I understand your concern. Would you like to talk to the pediatrician?” 46. When inspecting the spine of a 10-year-old, the nurse notes a concave curvature at the back of the neck. How should this finding be classified? a. Indicative of skeletal immaturity b. Minor deviation. c. Normal d. Abnormal 47. A child is admitted to the hospital with diarrhea. The nurse can expect this child to exhibit which finding? a. Hypercalcemia. b. Hyperkalemia. c. Metabolic acidosis. d. Metabolic alkalosis. 48. An adolescent with pelvic-inflammatory disease (PID) is admitted to the hospital after 14 days of taking levofloxacin 500 mg orally once daily and metronidazole 500 mg twice daily. She asks the nurse, “Why do I have to be in the hospital?” Which purpose should the nurse provide that supports an effective outcome? a. Collection of serial anaerobic cultures of vaginal discharge. b. Administration of a supervised parenteral antibiotic protocol. c. Detection of early symptoms of Jarisch-Herxheimer reaction. d. Implementation of contact precautions to prevent spread of infection. 49. The nurse observes an 18-month-old toddler keeping a bottle of milk in the mouth throughout the history-taking and assessment process during a well-child visit. The mother confirms that the child has a bottle available most of the day and remarks that it makes a great pacifier. Which response should the nurse provide? a. The bottle will assist in preventing thumb sucking. b. Using milk rather than juice helps to avoid tooth decay. c. Prolonged bottle use can increase risk for cavities. d. A bottle is generally much better than using a pacifier. 50. A school age child is brought to the Emergency Center with fever and joint pain and is diagnosed with rheumatic fever. Which explanation should the nurse provide the parents regarding the cause of this condition? a. An infection in the mitral valve results in a systemic infection that affects all heart valves. b. Scar tissues causes the leaflets in the heart valves to become rigid and closed. c. A previous bacterial infection causes a chronic condition that effects the heart valves. d. The valves in the heart develop lesions that cause inflammation and scarring. 51. When caring for a child with sickle cell disease, the nurse knows that the child will most likely exhibit which sign when experiencing a sickle cell crisis? a. Decreased hemoglobin b. Pain c. Dehydration d. Infection 52. A 10-year-old boy is admitted to the emergency department. He is unresponsive and his laboratory values include a blood sugar of 800 mg/gL (44.4 mmol/L), potassium of 5 mEq/L (5 mmol/L), and arterial blood gas levels of pH 7.30, HCO3 15 mEq/L (15 mmol/L), PaCo2 37 mmHg. Which intervention has the highest priority? a. Maintain strict intake and output record. b. Frequently assess the child’s respiratory effort. c. Give subcutaneous regular insulin by protocol. d. Administer IV of normal saline and insulin. 53. A 3-year-old boy is receiving a weekly chemotherapy treatment. Which toy is best for the nurse to provide for this child? a. Remote-controlled car. b. Coloring book with crayons. c. Bouncy ball. d. Duck that squeaks. 54. How should the nurse instruct the parents of a 4-month-old with seborrheic dermatitis (cradle cap) to shampoo the child’s hair? a. Avoid scrubbing the scalp until the scales disappear. b. Avoid washing the child’s hair more than once a week. c. Use soap and water and avoid shampoos. d. Use a soft brush and gently scrub the area. 55. A 3-year old girl has been blind since birth is hospitalized because of a compound fracture of the femur and is not in traction. Which intervention is best for the nurse to implement to address this child’s blindness? a. Request parents bring familiar objects such as a stuffed animal from home. b. Use a touch tour to allow the child to familiarize herself with the room layout. c. Play a game where the child must identify unfamiliar sounds in the environment. d. Perform the child’s self-care activities until the child is no longer in traction. 10.A toddler is hospitalized with Kawasaki’s disease. Pharmacological management includes aspiration therapy. Which is the primary benefit of the aspirin? a. Reduce joint swelling b. Manage irritability c. Control high fever d. Minimize vascular inflammation 11.A mother brings her 10-year-old boy who is holding his abdomen to the clinic because of fever, vomiting and abdominal pain for the past 12 hours. Which assessment data is most important for the nurse to obtain? a. Activity history 24 hours prior to the onset of pain b. His description of the quantity and nature of the pain c. A complete blood count, including differential count d. His typical pattern and type of bowel movements 12.The nurse is discharging a school-aged child who is newly diagnosed with congenital adrenal hyperplasia. Which information should the nurse instruct the parents to report to the HCP immediately? a. Persistent vomiting b. Weakness when walking c. Fatigue during the day d. Constipation 13.A 3-year-old male child is seen in the outpatient clinic with reddish vesicles on his legs. The medical diagnosis is impetigo contagiosa. The child’s mother is concerned about the long-term effects of the condition. The nurse should inform the mother of which probable outcome? a. Deep pitted scarring b. Pigmented scarring c. Slightly reddened scarring d. No scarring 14.The nurse is assessing an adolescent who arrived at the clinic for a physical examination before high school starts. The adolescent reports trouble hearing and a constant ringing in the ears. Which action should the nurse implement first? a. View the oropharynx and obtain an oral temperature b. Perform an otoscopic ear examination c. Ask about frequent use of earbuds to listen to music d. Evaluate lying and standing blood pressures 15.A 2-year-old girl is brought to the clinic by her 17-year-old mother. When the nurse observes that the child is drinking sweetened soda from her bottle, what information should the nurse discuss with his mother? (Select all that apply) a. Drinking soda is related to childhood obesity b. Toddlers should be drinking from a cup by age 2 c. Dental caries are associated with drinking soda d. Toddlers should be sleeping 10 hours a right e. A 2-year-old should be speaking in 2 word phrases 16.The nurse is examining an infant for possible cryptorchidism. Which exam technique should be used? a. Place the infant in a warm room and use a calm approach b. Cleanse the penis with an antiseptic-soaked pad c. Hold the penis and retract the foreskin gently d. Placed the infant in side-lying position to facilitate the exam 17.A 6-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child? a. List of achievement timeline for developmental milestones b. Mother’s use of alcohol, drugs, or cigarettes during pregnancy c. A history or rubella, rubeola, or chicken pox d. Reactions to any previous hospitalizations 18.Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. Which instructions should the nurse give the parents if their child becomes pale, cool and lethargic? a. Provide a quiet time by holding or rocking the toddler b. Encourage oral electrolyte solution intake c. Contact their healthcare provider immediately d. Assist the child to a recumbent position 19.Which nutritional information should the nurse plan to provide the mother of a 6- month-old regarding introduction of solid foods? a. Foods are best introduced by mixing them with formula and feeding them to the infant with a feeder bottle b. Introduce fruits and vegetables simultaneously into the diet c. Foods should be introduced into a child’s diet one at a time, at 4 to 7 day intervals d. Begin introducing solid foods into the child’s diet after the child reaches one year of age 20.The nurse is teaching the parents of a child with cystic fibrosis about homecare. Which intervention should the nurse ensure the parents understand about managing the child’s respiratory secretions? a. Percussion and postural drainage b. Vitamin supplementation c. Inhaled hypotonic saline d. Prophylactic antibiotics 21.A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticaria, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take? a. Change the latex-free gloves when handling infant b. Apply zinc oxide to perineum with each diaper change c. Draw blood to analyze for streptococcal infection d. Auscultate the lungs for respiratory pneumonia 22.The heart rate for a 3 year old child with a congenital heart defect has steadily decreased over the last few hours, and is now at 76 beats/minute. The previous reading 4 hours ago was 110 beats/minute. Which additional clinical finding should be reported immediately to the healthcare provider? a. Oxygen saturation of 94% b. Respiratory rate of 25 breaths/minute c. Urine output of 20 ml/hour d. Blood pressure of 70/40 mmHg 23.A mother brings her 3 year old son to the emergency room and tells the nurse that he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102 F (38.9 C). He is drooling and becoming increasingly more restless. What action should the nurse take first? A. Listen to lung sounds and place him in a mist tent B. Assist the child to lie down and examine his throat C. Put a cold cloth on his head and administer acetaminophen D. Notify the healthcare provider and obtain a tracheostomy tray that the child is in acute respiratory distress? a. Bilateral bronchial breath sounds b. Flaring of the nares c. A resting respiratory rate of 35 breaths/min d. Diaphragmatic respirations 36.The nurse is caring for a 6 year old child with leukemia who had a recent bone marrow aspiration to evaluate response to chemotherapy. Laboratory results reveal a platelet count of 24,500 cells/ mm 3 (24.5 x 10 9/L). Which intervention should the nurse implement? a. Initiate bleeding precautions due to myelosuppression b. Wear a mask to ensure droplet transmission c. Start contact precautions for blood borne infections d. Place the child on neutropenic precautions 37.A 12 year old is admitted to the hospital with possible encephalitis, and a lumbar puncture is scheduled. Which information should the nurse provide this child concerning the procedure? a. Reassure the child that there will be no restrictions on activity after the procedure is completed. b. Describe the side lying, knees to the chest position that must be assumed during the procedure c. Tell the child to expect loud clicking noises during the procedure that may be slightly annoying d. Explain that fluids cannot be taken for 8 hours before the procedure for 4 hours after the procedure 38.When obtaining an adolescent’s health history, which intervention is most important of the nurse to implement? a. Ask the parents to leave the room. b. Obtain a smoking history c. Assess for the use of illicit drugs d. Evaluate vital signs and lab findings 39.A 9 year old boy is diagnosed with diabetes mellitus type 1. Which stage of Erikson’s theory of psychosocial development is the nurse addressing when teaching this client about insulin injections? a. Identity b. Autonomy c. Industry d. Initiative 40. A child receives a prescription for clarithromycin 215 mg by mouth four times a day with food. The drug is available as an oral suspension labeled “125mg/5 mL”. How many mL per dose should the nurse administer? 8.6 mL 41.Albumin 25 % IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect? a. Reduction of edema b. Reduction of fever c. Weight gain d. Improved caloric intake 42.A child with possible duchenne muscular dystrophy (MD) undergoes an electromyogram (EMG). following the procedure, the child’s parents tell the nurse that the child is complaining of sore muscles. How should the nurse respond? a. Encourage the parents to monitor b. Advise the parents that children with chronic disease may seek attention by reporting pain or other unpleasant symptoms c. Explain that muscle aches and pain are commonly experienced by children with this form of muscular dystrophy d. Offer reassurance that muscle soreness following this procedure is temporary and does not indicate a problem 43.The parents of a 14-year-old child who is hospitalized due to febrile seizures tell the nurse that they fear their child will have lifelong seizures. Which information should the nurse convey to their parents? a. Ibuprofen should be used prophylactically to prevent febrile seizures. b. Avoid excessive visual stimuli because it can precipitate seizure activity. c. Provide the child with a sponge bath for temperature over 100.6˚F (38.1˚C). d. Reassure the parents that febrile seizures decrease as the child grows older. 44.The nurse is teaching the parents about important dietary changes for their child who is newly diagnosed with celiac disease. Which foods should the nurse include in the list of allowed foods for the child? a. Oats. b. Barley. c. Rye. d. Rice. 45.The mother of an infant born with hypospadias is concerned because she has been told that her child cannot be circumcised according to her Jewish faith tradition. Which response is best for the nurse to provide? a. “Circumcising the penis can contribute to frequent urinary infections b. “During the surgery part of the foreskin is used to repair the meatus.” c. “Your faith is important, but correcting this problem is priority for your son.” d. “I understand your concern. Would you like to talk to the pediatrician?” 46.When inspecting the spine of a 10-year-old, the nurse notes a concave curvature at the back of the neck. How should this finding be classified? Chapter 01: Perspectives of Pediatric Nursing MULTIPLE CHOICE 1. The clinic nurse is reviewing statistics on infant mortality for the United States versus other countries. Compared with other countries that have a population of at least 25 million, the nurse makes which determination? a. The United States is ranked last among 27 countries. b. The United States is ranked similar to 20 other developed countries. c. The United States is ranked in the middle of 20 other developed countries. d. The United States is ranked highest among 27 other industrialized countries. ANS: A Although the death rate has decreased, the United States still ranks last in infant mortality among nations with a population of at least 25 million. The United States has the highest infant death rate of developed nations. DIF: Cognitive Level: Remembering REF: p. 6 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 2. Which is the leading cause of death in infants younger than 1 year in the United States? a. Congenital anomalies b. Sudden infant death syndrome c. Disorders related to short gestation and low birth weight d. Maternal complications specific to the perinatal period ANS: A Congenital anomalies account for 20.1% of deaths in infants younger than 1 year compared with sudden infant death syndrome, which accounts for 8.2%; disorders related to short gestation and unspecified low birth weight, which account for 16.5%; and maternal complications such as infections specific to the perinatal period, which account for 6.1% of deaths in infants younger than 1 year of age. DIF: Cognitive Level: Remembering REF: p. 7 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 3. What is the major cause of death for children older than 1 year in the United States? a. Heart disease b. Childhood cancer c. Unintentional injuries d. Congenital anomalies ANS: C Unintentional injuries (accidents) are the leading cause of death after age 1 year through adolescence. The leading cause of death for those younger than 1 year is congenital anomalies, and childhood cancers and heart disease cause a significantly lower percentage of deaths in children older than 1 year of age. DIF: Cognitive Level: Understanding REF: p. 7 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 4. In addition to injuries, what are the leading causes of death in adolescents ages 15 to 19 years? a. Suicide and cancer b. Suicide and homicide c. Drowning and cancer d. Homicide and heart disease ANS: B Suicide and homicide account for 16.7% of deaths in this age group. Suicide and cancer account for 10.9% of deaths, heart disease and cancer account for approximately 5.5%, and homicide and heart disease account for 10.9% of the deaths in this age group. DIF: Cognitive Level: Remembering REF: p. 7 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 5. The nurse is planning a teaching session to adolescents about deaths by unintentional injuries. Which should the nurse include in the session with regard to deaths caused by injuries? a. More deaths occur in males. b. More deaths occur in females. c. The pattern of deaths does not vary according to age and sex. d. The pattern of deaths does not vary widely among different ethnic groups. ANS: A The majority of deaths from unintentional injuries occur in males. The pattern of death does vary greatly among different ethnic groups, and the causes of unintentional deaths vary with age and gender. DIF: Cognitive Level: Applying REF: pp. 7-8 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 6. What do mortality statistics describe? a. Disease occurring regularly within a geographic location b. The number of individuals who have died over a specific period c. The prevalence of specific illness in the population at a particular time d. Disease occurring in more than the number of expected cases in a community ANS: B Mortality statistics refer to the number of individuals who have died over a specific period. Morbidity statistics show the prevalence of specific illness in the population at a particular time. Data regarding disease within a geographic region, or in greater than expected numbers in a community, may be extrapolated from analyzing the morbidity statistics. DIF: Cognitive Level: Remembering REF: p. 3 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 7. The nurse should assess which age group for suicide ideation since suicide in which age group is the third leading cause of death? a. Preschoolers b. Young school age c. Middle school age d. Late school age and adolescents ANS: D Suicide is the third leading cause of death in children ages 10 to 19 years; therefore, the age group should be late school age and adolescents. Suicide is not one of the leading causes of death for preschool and young or middle school-aged children. DIF: Cognitive Level: Understanding REF: p. 6 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 8. Parents of a hospitalized toddler ask the nurse, “What is meant by family-centered care?” The nurse should respond with which statement? a. Family-centered care reduces the effect of cultural diversity on the family. b. Family-centered care encourages family dependence on the health care system. c. Family-centered care recognizes that the family is the constant in a child’s life. d. Family-centered care avoids expecting families to be part of the decision-making process. ANS: C The three key components of family-centered care are respect, collaboration, and support. Family-centered care recognizes the family as the constant in the child’s life. The family should be enabled and empowered to work with the health care system and is expected to be part of the decision-making process. The nurse should also support the family’s cultural diversity, not reduce its effect. DIF: Cognitive Level: Applying REF: p. 8 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 9. The nurse is describing clinical reasoning to a group of nursing students. Which is most descriptive of clinical reasoning? a. Purposeful and goal directed b. A simple developmental process c. Based on deliberate and irrational thought d. Assists individuals in guessing what is most appropriate ANS: A Clinical reasoning is a complex developmental process based on rational and deliberate thought. When thinking is clear, precise, accurate, relevant, consistent, and fair, a logical connection develops between the elements of thought and the problem at hand. DIF: Cognitive Level: Applying REF: p. 12 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 10. Evidence-based practice (EBP), a decision-making model, is best described as which? MSC: Client Needs: Psychosocial Integrity 15. The nurse is aware that which age group is at risk for childhood injury because of the cognitive characteristic of magical and egocentric thinking? a. Preschool b. Young school age c. Middle school age d. Adolescent ANS: A Preschool children have the cognitive characteristic of magical and egocentric thinking, meaning they are unable to comprehend danger to self or others. Young and middle school-aged children have transitional cognitive processes, and they may attempt dangerous acts without detailed planning but recognize danger to themselves or others. Adolescents have formal operational cognitive processes and are preoccupied with abstract thinking. DIF: Cognitive Level: Understanding REF: p. 4 TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 16. The school nurse is assessing children for risk factors related to childhood injuries. Which child has the most risk factors related to childhood injury? a. Female, multiple siblings, stable home life b. Male, high activity level, stressful home life c. Male, even tempered, history of previous injuries d. Female, reacts negatively to new situations, no serious previous injuries ANS: B Boys have a preponderance for injuries over girls because of a difference in behavioral characteristics, a high activity temperament is associated with risk-taking behaviors, and stress predisposes children to increased risk taking and self-destructive behaviors. Therefore, a male child with a high activity level and living in a stressful environment has the highest number of risk factors. A girl with several siblings and a stable home life is low risk. A boy with previous injuries has two risk factors, but an even temper is not a risk factor for injuries. A girl who reacts negatively to new situations but has no previous serious illnesses has only one risk factor. DIF: Cognitive Level: Analyzing REF: p. 4 TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 17. The school nurse is evaluating the number of school-age children classified as obese. The nurse recognizes that the percentile of body mass index that classifies a child as obese is greater than which? a. 50th percentile b. 75th percentile c. 80th percentile d. 95th percentile ANS: D Obesity in children and adolescents is defined as a body mass index at or greater than the 95th percentile for youth of the same age and gender. DIF: Cognitive Level: Remembering REF: p. 3 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 18. The nurse is teaching parents about the types of behaviors children exhibit when living with chronic violence. Which statement made by the parents indicates further teaching is needed? a. “We should watch for aggressive play.” b. “Our child may show lasting symptoms of stress.” c. “We know that our child will show caring behaviors.” d. “Our child may have difficulty concentrating in school.” ANS: C The statement that the child will show caring behaviors needs further teaching. Children living with chronic violence may exhibit behaviors such as difficulty concentrating in school, memory impairment, aggressive play, uncaring behaviors, and lasting symptoms of stress. DIF: Cognitive Level: Applying REF: p. 6 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 19. The nurse is evaluating research studies according to the GRADE criteria and has determined the quality of evidence on the subject is moderate. Which type of evidence does this determination indicate? a. Strong evidence from unbiased observational studies b. Evidence from randomized clinical trials showed inconsistent results c. Consistent evidence from well-performed randomized clinical trials d. Evidence for at least one critical outcome from randomized clinical trials had serious flaws ANS: B Evidence from randomized clinical trials with important limitations indicates that the evidence is of moderate quality. Strong evidence from unbiased observational studies and consistent evidence from well-performed randomized clinical trials indicates high quality. Evidence for at least one critical outcome from randomized clinical trials that has serious flaws indicates low quality. DIF: Cognitive Level: Remembering REF: p. 12 TOP: Nursing Process: Evaluation MSC: Client Needs: Safe and Effective Care Environment 20. An adolescent patient wants to make decisions about treatment options, along with his parents. Which moral value is the nurse displaying when supporting the adolescent to make decisions? a. Justice b. Autonomy c. Beneficence d. Nonmaleficence ANS: B Autonomy is the patient’s right to be self-governing. The adolescent is trying to be autonomous, so the nurse is supporting this value. Justice is the concept of fairness. Beneficence is the obligation to promote the patient’s well-being. Nonmaleficence is the obligation to minimize or prevent harm. DIF: Cognitive Level: Analyzing REF: p. 11 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 21. The nurse manager is compiling a report for a hospital committee on the quality of nursing-sensitive indicators for a nursing unit. Which does the nurse manager include in the report? a. The average age of the nurses on the unit b. The salary ranges for the nurses on the unit c. The education and certification of the nurses on the unit d. The number of nurses who have applied but were not hired for the unit ANS: C Nursing-sensitive indicators reflect the structure, process, and outcomes of nursing care. For example, the number of nursing staff, the skill level of the nursing staff, and the education and certification of nursing staff indicate the structure of nursing care. The average age of the nurses, salary range, and number of nurses who have applied but were not hired for the unit are not nursing-sensitive indicators. DIF: Cognitive Level: Applying REF: p. 15 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Safe and Effective Care Environment MULTIPLE RESPONSE 1. Which responsibilities are included in the pediatric nurse’s promotion of the health and well-being of children? (Select all that apply.) a. Promoting disease prevention b. Providing financial assistance c. Providing support and counseling d. Establishing lifelong friendships e. Establishing a therapeutic relationship f. Participating in ethical decision making ANS: A, C, E, F The pediatric nurse’s role includes promoting disease prevention, providing support and counseling, establishing a therapeutic relationship, and participating in ethical decision making; a pediatric nurse does not need to establish lifelong friendships or provide financial assistance to children and their families. Boundaries should be set and clear. DIF: Cognitive Level: Applying REF: pp. 9-11 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance Overweight youth have increased risk for a cluster of cardiovascular factors that include hypertension, altered glucose metabolism, and dyslipidemia. Irritable bowel disease and asthma are not linked to obesity. DIF: Cognitive Level: Applying REF: p. 3 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 8. The nurse is reviewing the Healthy People 2020 leading health indicators for a child health promotion program. Which are included in the leading health indicators? (Select all that apply.) a. Decrease tobacco use. b. Improve immunization rates. c. Reduce incidences of cancer. d. Increase access to health care. e. Decrease the number of eating disorders. ANS: A, B, D The Healthy People 2020 leading health indicators provide a framework for identifying essential components for child health promotion programs designed to prevent future health problems in our nation’s children. Some of the leading health indicators include decreasing tobacco use, improving immunization rates, and increasing access to health care. Reducing the incidence of cancer and decreasing the number of eating disorders are not on the list as leading health indicators. DIF: Cognitive Level: Analyzing REF: p. 2 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 9. Which actions by the nurse demonstrate clinical reasoning? (Select all that apply.) a. Basing decisions on intuition b. Considering alternative action c. Using formal and informal thinking to gather data d. Giving deliberate thought to a patient’s problem e. Developing an outcome focused on optimum patient care ANS: B, C, D, E Clinical reasoning is a cognitive process that uses formal and informal thinking to gather and analyze patient data, evaluate the significance of the information, and consider alternative actions. Clinical reasoning is a complex developmental process based on rational and deliberate thought and developing an outcome focused on optimum patient care. Clinical reasoning is based on the scientific method of inquiry; it is not based solely on intuition. DIF: Cognitive Level: Applying REF: p. 12 TOP: Nursing Process: Evaluation MSC: Client Needs: Safe and Effective Care Environment COMPLETION 1. The nurse is determining if a newborn is classified in the low birth weight (LBW) category of less than 2500 g. The newborn’s weight is 5 lb, 4 oz. What is the newborn’s weight in grams? Record your answer in a whole number. ANS: 2386 Convert the 4 oz to a decimal by dividing 4 by 16 = 0.25. Use 5.25 lb and divide by 2.2 to get 2.386 kg. Multiply by 1000 to convert to grams = 2386. DIF: Cognitive Level: Applying REF: p. 3 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance MATCHING The nursing process is a method of problem identification and problem solving that describes what the nurse actually does. Match each step of the nursing process with its definition. a. Assessment b. Diagnosis c. Outcomes identification d. Planning e. Implementation f. Evaluation 1. Problem identification 2. Expected patient goals 3. Purposeful collection of data 4. Development of a care plan 5. Determines if the outcome was met 6. Interventions are put into action 1. ANS: B DIF: Cognitive Level: Understanding REF: p. 13 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 2. ANS: C DIF: Cognitive Level: Understanding REF: p. 13 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 3. ANS: A DIF: Cognitive Level: Understanding REF: p. 13 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 4. ANS: D DIF: Cognitive Level: Understanding REF: p. 13 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 5. ANS: F DIF: Cognitive Level: Understanding REF: p. 14 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 6. ANS: E DIF: Cognitive Level: Understanding REF: p. 14 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance Ethical dilemmas arise when competing moral considerations underlie various alternatives. Match each competing moral value with its definition. a. Autonomy b. Nonmaleficence c. Beneficence d. Justice 7. The obligation to promote the patient’s well-being 8. The obligation to minimize or prevent harm 9. The patient’s right to be self-governing 10. The concept of fairness 7. ANS: C DIF: Cognitive Level: Understanding REF: p. 11 TOP: Integrated Process: Caring MSC: Client Needs: Health Promotion and Maintenance 8. ANS: B DIF: Cognitive Level: Understanding REF: p. 11 TOP: Integrated Process: Caring MSC: Client Needs: Health Promotion and Maintenance 9. ANS: A DIF: Cognitive Level: Understanding REF: p. 11 TOP: Integrated Process: Caring MSC: Client Needs: Health Promotion and Maintenance 10. ANS: D DIF: Cognitive Level: Understanding REF: p. 11 TOP: Integrated Process: Caring MSC: Client Needs: Health Promotion and Maintenance Whenever possible, nurses should facilitate the integration of ethnic practices into health care provision. The ethnic background is part of the individual; it should be difficult to eliminate the influence of ethnic background. The ethnic practices need to be evaluated within the context of the health care setting to determine whether they are conflicting. DIF: Cognitive Level: Applying REF: p. 34 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Integrity 6. The nurse discovers welts on the back of a Vietnamese child during a home health visit. The child’s mother says she has rubbed the edge of a coin on her child’s oiled skin. The nurse should recognize this as what? a. Child abuse b. Cultural practice to rid the body of disease c. Cultural practice to treat enuresis or temper tantrums d. Child discipline measure common in the Vietnamese culture ANS: B This is descriptive of coining. The welts are created by repeatedly rubbing a coin on the child’s oiled skin. The mother is attempting to rid the child’s body of disease. Coining is a cultural healing practice. Coining is not specific for enuresis or temper tantrums. This is not child abuse or discipline. DIF: Cognitive Level: Understanding REF: p. 41 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 7. A Hispanic toddler has pneumonia. The nurse notices that the parent consistently feeds the child only the broth that comes on the clear liquid tray. Food items, such as Jell-O, Popsicles, and juices, are left. Which statement best explains this? a. The parent is trying to feed the child only what the child likes most. b. Hispanics believe the “evil eye” enters when a person gets cold. c. The parent is trying to restore normal balance through appropriate “hot” remedies. d. Hispanics believe an innate energy called chi is strengthened by eating soup. ANS: C In several cultures, including Filipino, Chinese, Arabic, and Hispanic, hot and cold describe certain properties completely unrelated to temperature. Respiratory conditions such as pneumonia are “cold” conditions and are treated with “hot” foods. The child may like broth but is unlikely to always prefer it to Jell-O, Popsicles, and juice. The evil eye applies to a state of imbalance of health, not curative actions. Chinese individuals, not Hispanic individuals, believe in chi as an innate energy. DIF: Cognitive Level: Applying REF: p. 40 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 8. How is family systems theory best described? a. The family is viewed as the sum of individual members. b. A change in one family member cannot create a change in other members. c. Individual family members are readily identified as the source of a problem. d. When the family system is disrupted, change can occur at any point in the system. ANS: D Family systems theory describes an interactional model. Any change in one member will create change in others. Although the family is the sum of the individual members, family systems theory focuses on the number of dyad interactions that can occur. The interactions, not the individual members, are considered to be the problem. DIF: Cognitive Level: Analyzing REF: p. 18 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 9. Which family theory is described as a series of tasks for the family throughout its life span? a. Exchange theory b. Developmental theory c. Structural-functional theory d. Symbolic interactional theory ANS: B In developmental systems theory, the family is described as a small group, a semiclosed system of personalities that interact with the larger cultural system. Changes do not occur in one part of the family without changes in others. Exchange theory assumes that humans, families, and groups seek rewarding statuses so that rewards are maximized while costs are minimized. Structural-functional theory states that the family performs at least one societal function while also meeting family needs. Symbolic interactional theory describes the family as a unit of interacting persons with each occupying a position within the family. DIF: Cognitive Level: Remembering REF: p. 19 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 10. Which family theory explains how families react to stressful events and suggests factors that promote adaptation to these events? a. Interactional theory b. Family stress theory c. Erikson’s psychosocial theory d. Developmental systems theory ANS: B Family stress theory explains the reaction of families to stressful events. In addition, the theory helps suggest factors that promote adaptation to the stress. Stressors, both positive and negative, are cumulative and affect the family. Adaptation requires a change in family structure or interaction. Interactional theory is not a family theory. Interactions are the basis of general systems theory. Erikson’s theory applies to individual growth and development, not families. Developmental systems theory is an outgrowth of Duvall’s theory. The family is described as a small group, a semiclosed system of personalities that interact with the larger cultural system. Changes do not occur in one part of the family without changes in others. DIF: Cognitive Level: Remembering REF: p. 19 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 11. Which type of family should the nurse recognize when the paternal grandmother, the parents, and two minor children live together? a. Blended b. Nuclear c. Extended d. Binuclear ANS: C An extended family contains at least one parent, one or more children, and one or more members (related or unrelated) other than a parent or sibling. A blended family contains at least one stepparent, stepsibling, or half-sibling. A nuclear family consists of two parents and their children. No other relatives or nonrelatives are present in the household. In binuclear families, parents continue the parenting role while terminating the spousal unit. For example, when joint custody is assigned by the court, each parent has equal rights and responsibilities for the minor child or children. DIF: Cognitive Level: Remembering REF: pp. 20-21 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 12. Which type of family should the nurse recognize when a mother, her children, and a stepfather live together? a. Traditional nuclear b. Blended c. Extended d. Binuclear ANS: B A blended family contains at least one stepparent, stepsibling, or half-sibling. A traditional nuclear family consists of a married couple and their biologic children. No other relatives or nonrelatives are present in the household. An extended family contains at least one parent, one or more children, and one or more members (related or unrelated) other than a parent or sibling. In binuclear families, parents continue the parenting role while terminating the spousal unit. For example, when joint custody is assigned by the court, each parent has equal rights and responsibilities for the minor child or children. DIF: Cognitive Level: Remembering REF: p. 20 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 13. Which is an accurate description of homosexual (or gay-lesbian) families? a. A nurturing environment is lacking. b. The children become homosexual like their parents. c. The stability needed to raise healthy children is lacking. d. The quality of parenting is equivalent to that of nongay parents. ANS: D Although gay or lesbian families may be different from heterosexual families, the environment can be as healthy as any other. Lacking a nurturing environment and stability is reflective on the parents and family, not the type of family. There is little evidence to support that children become homosexual like their parents. DIF: Cognitive Level: Understanding REF: pp. 21-22 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 19. A 3-year-old child was adopted immediately after birth. The parents have just asked the nurse how they should tell the child that she is adopted. Which guideline concerning adoption should the nurse use in planning a response? a. It is best to wait until the child asks about it. b. The best time to tell the child is between the ages of 7 and 10 years. c. It is not necessary to tell a child who was adopted so young. d. Telling the child is an important aspect of their parental responsibilities. ANS: D It is important for the parents not to withhold information about the adoption from the child. It is an essential component of the child’s identity. There is no recommended best time to tell children. It is believed that children should be told young enough so they do not remember a time when they did not know. It should be done before the children enter school to prevent third parties from telling the children before the parents have had the opportunity. DIF: Cognitive Level: Analyzing REF: p. 27 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 20. Children may believe that they are responsible for their parents’ divorce and interpret the separation as punishment. At which age is this most likely to occur? a. 1 year b. 4 years c. 8 years d. 13 years ANS: B Preschool-age children are most likely to blame themselves for the divorce. A 4-year-old child will fear abandonment and express bewilderment regarding all human relationships. A 4-year-old child has magical thinking and believes his or her actions cause consequences, such as divorce. For infants, divorce may increase their irritability and interfere with the attachment process, but they are too young to feel responsibility. School-age children will have feelings of deprivation, including the loss of a parent, attention, money, and a secure future. Adolescents are able to disengage themselves from the parental conflict. DIF: Cognitive Level: Analyzing REF: p. 29 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity 21. A parent of a school-age child tells the school nurse that the parents are going through a divorce. The child has not been doing well in school and sometimes has trouble sleeping. The nurse should recognize this as what? a. Indicative of maladjustment b. A common reaction to divorce c. Suggestive of a lack of adequate parenting d. An unusual response that indicates a need for referral ANS: B Parental divorce affects school-age children in many ways. In addition to difficulties in school, they often have profound sadness, depression, fear, insecurity, frequent crying, loss of appetite, and sleep disorders. The child’s responses are common reactions of school-age children to parental divorce. DIF: Cognitive Level: Applying REF: p. 29 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 22. A mother brings 6-month-old Eric to the clinic for a well-baby checkup. She comments, “I want to go back to work, but I don’t want Eric to suffer because I’ll have less time with him.” Which is the nurse’s most appropriate answer? a. “I’m sure he’ll be fine if you get a good babysitter.” b. “You will need to stay home until Eric starts school.” c. “Let’s talk about the child care options that will be best for Eric.” d. “You should go back to work so Eric will get used to being with others.” ANS: C Asking the mother about child care options is an open-ended statement that will assist the mother in exploring her concerns about what is best for both her and Eric. The other three answers are directive; they do not address the effect that her working will have on Eric. DIF: Cognitive Level: Applying REF: p. 32 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 23. A foster parent is talking to the nurse about the health care needs for the child who has been placed in the parent’s care. Which statement best describes the health care needs of foster children? a. Foster children always come from abusive households and are emotionally fragile. b. Foster children tend to have a higher than normal incidence of acute and chronic health problems. c. Foster children are usually born prematurely and require technologically advanced health care. d. Foster children will not stay in the home for an extended period, so health care needs are not as important as emotional fulfillment. ANS: B Children who are placed in foster care have a higher incidence of acute and chronic health problems and may experience feelings of isolation and confusion; therefore, they should be monitored closely. Foster children do not always come from abusive households and may or may not be emotionally fragile; not all foster children are born prematurely or require technically advanced health care; and foster children may stay in the home for extended periods, so their health care needs require attention. DIF: Cognitive Level: Applying REF: p. 32 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 24. The nurse is planning to counsel family members as a group to assess the family’s group dynamics. Which theoretic family model is the nurse using as a framework? a. Feminist theory b. Family stress theory c. Family systems theory d. Developmental theory ANS: C In family systems theory, the family is viewed as a system that continually interacts with its members and the environment. The emphasis is on the interaction between the members; a change in one family member creates a change in other members, which in turn results in a new change in the original member. Assessing the family’s group dynamics is an example of using this theory as a framework. Family stress theory explains how families react to stressful events and suggests factors that promote adaptation to stress. Developmental theory addresses family change over time using Duvall’s family life cycle stages based on the predictable changes in the family’s structure, function, and roles, with the age of the oldest child as the marker for stage transition. Feminist theories assume that privilege and power are inequitably distributed based upon gender, race, and class. DIF: Cognitive Level: Applying REF: p. 18 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity 25. The nurse is reviewing the importance of role learning for children. The nurse understands that children’s roles are primarily shaped by which members? a. Peers b. Parents c. Siblings d. Grandparents ANS: B Children’s roles are shaped primarily by the parents, who apply direct or indirect pressures to induce or force children into the desired patterns of behavior or direct their efforts toward modification of the role responses of the child on a mutually acceptable basis. DIF: Cognitive Level: Analyzing REF: pp. 22-23 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 26. The nurse is caring for an adolescent hospitalized for asthma. The adolescent belongs to a large family. The nurse recognizes that the adolescent is likely to relate to which group? a. Peers b. Parents c. Siblings d. Teachers ANS: A Adolescents from a large family are more peer oriented than family oriented. Adolescents in small families identify more strongly with their parents and rely more on them for advice. DIF: Cognitive Level: Understanding REF: p. 23 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Integrity MULTIPLE RESPONSE 1. The nurse is presenting a staff development program about understanding culture in the health care encounter. Which components should the nurse include in the program? (Select all that apply.) a. Cultural humility b. Cultural research c. Cultural sensitivity d. Cultural competency ANS: A, C, D There are several different ways health care providers can best attend to all the different facets that make up an individual’s culture. Cultural competence tends to promote building information about a specific culture. Cultural sensitivity, a second way of understanding culture in the context of the clinical encounter, may be understood as a way of using one’s knowledge, consideration, understanding, respect, and tailoring after realizing awareness of self and others and encountering a diverse group or individual. Cultural humility, the third component, is a commitment and active engagement in a lifelong process that individuals enter into for an ongoing basis with patients, communities, colleagues, and themselves. Cultural research is not a component of understanding culture in the health care encounter. DIF: Cognitive Level: Analyzing REF: p. 38 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 2. The parents of a 5-year-old child ask the nurse how they can minimize misbehavior. Which responses should the nurse give? (Select all that apply.) a. Set clear and reasonable goals. b. Praise your child for desirable behavior. c. Don’t call attention to unacceptable behavior. d. Teach desirable behavior through your own example. e. Don’t provide an opportunity for your child to have any control. ANS: A, B, D To minimize misbehavior, parents should (1) set clear and reasonable rules and expect the same behavior regardless of the circumstances, (2) praise children for desirable behavior with attention and verbal approval, and (3) teach desirable behavior through their own example. Parents should call attention to unacceptable behavior as soon as it begins and provide children with opportunities for power and control. DIF: Cognitive Level: Applying REF: p. 25 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 3. Which describe the feelings and behaviors of early preschool children related to divorce? (Select all that apply.) a. Regressive behavior b. Fear of abandonment c. Fear regarding the future d. Blame themselves for the divorce e. Intense desire for reconciliation of parents ANS: A, B, D Feelings and behaviors of early preschool children related to divorce include regressive behavior, fear of abandonment, and blaming themselves for the divorce. Fear regarding the future and intense desire for reconciliation of parents is a reaction later school-age children have to divorce. DIF: Cognitive Level: Understanding REF: p. 29 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Integrity 4. Which describe the feelings and behaviors of adolescents related to divorce? (Select all that apply.) a. Disturbed concept of sexuality b. May withdraw from family and friends c. Worry about themselves, parents, or siblings d. Expression of anger, sadness, shame, or embarrassment e. Engage in fantasy to seek understanding of the divorce ANS: A, B, C, D Feelings and behaviors of adolescents related to divorce include a disturbed concept of sexuality; withdrawing from family and friends; worrying about themselves, parents, and siblings; and expressions of anger, sadness, shame, and embarrassment. Engaging in fantasy to seek understanding of the divorce is a reaction by a child who has preconceptual cognitive processes, not the formal thinking processes adolescents have. DIF: Cognitive Level: Understanding REF: p. 29 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Integrity 5. The nurse is teaching parents about the effects of media on childhood obesity. The nurse realizes the parents understand the teaching if they make which statements? (Select all that apply.) a. “Advertising of unhealthy food can increase snacking.” b. “Increased screen time may be related to unhealthy sleep.” c. “There is a link between the amount of screen time and obesity.” d. “Increased screen time can lead to better knowledge of nutrition.” e. “Physical activity increases when children increase the amount of screen time.” ANS: A, B, C A number of studies have demonstrated a link between the amount of screen time and obesity. Advertising of unhealthy food to children is a long-standing marketing practice, which may increase snacking in the face of decreased activity. In addition, both increased screen time and unhealthy eating may also be related to unhealthy sleep. Increased screen time does not lead to a better knowledge of nutrition or increased physical activity. DIF: Cognitive Level: Applying REF: p. 38 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity MATCHING Culture characterizes a particular group with its values, beliefs, norms, patterns, and practices that are learned, shared, and transmitted from one generation to another. Match the terms used to describe groups with shared values, beliefs, norms, patterns, and practices. a. Race b. Gender c. Ethnicity d. Social class e. Socialization 1. Incorporates levels of education, occupation, income, and access to resources 2. Distinguishes humans by physical traits 3. Persons who have unique cultural, social, and linguistic heritage 4. Process by which society communicates its competencies, values, and expectations 5. An individual’s self-identification as man or woman 1. ANS: D DIF: Cognitive Level: Understanding REF: p. 39 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Integrity 2. ANS: A DIF: Cognitive Level: Understanding REF: p. 39 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Integrity 3. ANS: C DIF: Cognitive Level: Understanding REF: p. 39 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Integrity 4. ANS: E DIF: Cognitive Level: Understanding REF: p. 39 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Integrity 5. ANS: B DIF: Cognitive Level: Understanding REF: p. 39 TOP: Integrated Process: Caring MSC: Client Needs: Psychosocial Integrity Turner syndrome is caused by an absence of one of the X chromosomes. Most girls who have this disorder have one X chromosome missing from all cells. No Y chromosome is present in individuals with Turner syndrome. These young women have 45 rather than 46 chromosomes. DIF: Cognitive Level: Understanding REF: p. 53 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 7. Which is a sex chromosome abnormality that is caused by the presence of one or more additional X chromosomes in a male? a. Turner b. Triple X c. Klinefelter d. Trisomy 13 ANS: C Klinefelter syndrome is characterized by one or more additional X chromosomes. These individuals are tall with male secondary sexual characteristics that may be deficient, and they may be learning disabled. An absence of an X chromosome results in Turner syndrome. Triple X and trisomy 13 are not abnormalities that involve one or more additional X chromosomes in a male (Klinefelter syndrome). DIF: Cognitive Level: Understanding REF: p. 53 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 8. Parents ask the nurse about the characteristics of autosomal dominant inheritance. Which statement is characteristic of autosomal dominant inheritance? a. Females are affected with greater frequency than males. b. Unaffected children of affected individuals will have affected children. c. Each child of a heterozygous affected parent has a 50% chance of being affected. d. Any child of two unaffected heterozygous parents has a 25% chance of being affected. ANS: C In autosomal dominant inheritance, only one copy of the mutant gene is necessary to cause the disorder. When a parent is affected, there is a 50% chance that the chromosome with the gene for the disorder will be contributed to each pregnancy. Males and females are equally affected. The disorder does not “skip” a generation. If the child is not affected, then most likely he or she is not a carrier of the gene for the disorder. In autosomal recessive inheritance, any child of two unaffected heterozygous parents has a 25% chance of being affected. DIF: Cognitive Level: Applying REF: p. 57 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 9. Parents ask the nurse about the characteristics of autosomal recessive inheritance. Which is characteristic of autosomal recessive inheritance? a. Affected individuals have unaffected parents. b. Affected individuals have one affected parent. c. Affected parents have a 50% chance of having an affected child. d. Affected parents will have unaffected children. ANS: A Parents who are carriers of a recessive gene are asymptomatic. For a child to be affected, both parents must have a copy of the gene, which is passed to the child. Both parents are asymptomatic but can have affected children. In autosomal recessive inheritance, there is a 25% chance that each pregnancy will result in an affected child. In autosomal dominant inheritance, affected parents can have unaffected children. DIF: Cognitive Level: Applying REF: p. 62 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 10. Which is characteristic of X-linked recessive inheritance? a. There are no carriers. b. Affected individuals are principally males. c. Affected individuals are principally females. d. Affected individuals will always have affected parents. ANS: B In X-linked recessive disorders, the affected individuals are usually male. With recessive traits, usually two copies of the gene are needed to produce the effect. Because the male only has one X chromosome, the effect is visible with only one copy of the gene. Females are usually only carriers of X-linked recessive disorders. The X chromosome that does not have the recessive gene will produce the “normal” protein, so the woman will not show evidence of the disorder. The transmission is from mother to son. Usually the mother and father are unaffected. DIF: Cognitive Level: Understanding REF: p. 64 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 11. A father with an X-linked recessive disorder asks the nurse what the probability is that his sons will have the disorder. Which response should the nurse make? a. “Male children will be carriers.” b. “All male children will be affected.” c. “None of the sons will have the disorder.” d. “It cannot be determined without more data.” ANS: C When a male has an X-linked recessive disorder, he has one copy of the allele on his X chromosome. The father passes only his Y chromosome (not the X chromosome) to his sons. Therefore, none of his sons will have the X-linked recessive gene. They will not be carriers or be affected by the disorder. No additional data are needed to answer this question. DIF: Cognitive Level: Applying REF: p. 64 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 12. The inheritance of which is X-linked recessive? a. Hemophilia A b. Marfan syndrome c. Neurofibromatosis d. Fragile X syndrome ANS: A Hemophilia A is inherited as an X-linked recessive trait. Marfan syndrome and neurofibromatosis are inherited as autosomal dominant disorders. Fragile X is inherited as an X-linked trait. DIF: Cognitive Level: Understanding REF: p. 64 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 13. Chromosome analysis of the fetus is usually accomplished through the testing of which? a. Fetal serum b. Maternal urine c. Amniotic fluid d. Maternal serum ANS: C Amniocentesis is the most common method to retrieve fetal cells for chromosome analysis. Viable fetal cells are sloughed off into the amniotic fluid, and when a sample is taken, they can be cultured and analyzed. It is difficult to obtain a sample of the fetal blood. It is a high-risk situation for the fetus. Fetal cells are not present in the maternal urine or blood. DIF: Cognitive Level: Analyzing REF: p. 46 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 14. A couple asks the nurse about the optimal time for genetic counseling. They do not plan to have children for several years. When should the nurse recommend they begin genetic counseling? a. As soon as the woman suspects that she may be pregnant b. Whenever they are ready to start their family c. Now, if one of them has a family history of congenital heart disease d. Now, if they are members of a population at risk for certain diseases ANS: D Persons who seek genetic evaluation and counseling must first be aware if there is a genetic or potential problem in their families. Genetic testing should be done now if the couple is part of a population at risk. It is not feasible at this time to test for all genetic diseases. The optimal time for genetic counseling is before pregnancy occurs. During the pregnancy, genetic counseling may be indicated if a genetic disorder is suspected. Congenital heart disease is not a single-gene disorder. DIF: Cognitive Level: Applying REF: p. 62 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance DIF: Cognitive Level: Applying REF: pp. 54-55 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 20. The nurse is reviewing a client’s prenatal history. Which prescribed medication does the nurse understand is not considered a teratogen and prescribed during pregnancy? a. Phenytoin (Dilantin) b. Warfarin (Coumadin) c. Isotretinoin (Accutane) d. Heparin sodium (Heparin) ANS: D Teratogens, agents that cause birth defects when present in the prenatal environment, account for the majority of adverse intrauterine effects not attributable to genetic factors. Types of teratogens include drugs (phenytoin [Dilantin], warfarin [Coumadin], isotretinoin [Accutane]). Heparin is the anticoagulant used during pregnancy and is not a teratogen. It does not cross the placenta. DIF: Cognitive Level: Analyzing REF: p. 68 TOP: Nursing Process: Evaluation MSC: Integrated Process: Physiological Integrity 21. The nurse is teaching student nurses about newborn screening. Which statement made by the student indicates understanding of the teaching? a. “The newborn screening is not mandatory but voluntary.” b. “It is acceptable to ‘layer’ the blood on the Guthrie paper.” c. “The initial specimen should be collected as close to discharge as possible.” d. “It is best to collect the specimen before the newborn takes the first feeding.” ANS: C Because of early discharge of newborns, recommendations for screening include collecting the initial specimen as close as possible to discharge. Newborn screening tests are mandatory in all 50 U.S. states. When collecting the specimen, avoid “layering” the blood specimen on the special Guthrie paper. Layering is placing one drop of blood on top of the other or overlapping the specimen. Best results are obtained by collecting the specimen with a pipette from the heel stick and spreading the blood uniformly over the blot paper. The screening test is most reliable if the blood sample is taken after the infant has ingested a source of protein. DIF: Cognitive Level: Applying REF: p. 71 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 22. A hospitalized school-age child with phenylketonuria (PKU) is choosing foods from the hospital’s menu. Which food choice should the nurse discourage the child from choosing? a. Banana b. Milkshake c. Fruit juice d. Corn on the cob ANS: B Foods with low phenylalanine levels (e.g., some vegetables [except legumes]; fruits; juices; and some cereals, breads, and starches) must be measured to provide the prescribed amount of phenylalanine. Most high-protein foods, such as meat and dairy products, are either eliminated or restricted to small amounts. DIF: Cognitive Level: Applying REF: pp. 71-72 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 23. The nurse understands that which occurring soon after birth can indicate cystic fibrosis? a. Murmur b. Hypoglycemia c. Meconium ileus d. Muscle weakness ANS: C A symptom of cystic fibrosis is a meconium ileus soon after birth. A murmur can be a sign of a congenital heart disease. Hypoglycemia can be a sign of Beckwith-Wiedemann syndrome. Muscle weakness can be a sign of myotonic dystrophy. DIF: Cognitive Level: Understanding REF: p. 59 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 24. A newborn has been diagnosed with congenital adrenal hyperplasia. Which assessment finding should the nurse expect? a. Ambiguous genitalia b. Prenatal growth retardation c. An abnormally large tongue d. Legs and arms significantly shorter than torso ANS: A A newborn diagnosed with congenital adrenal hyperplasia can have ambiguous genitalia or virilization of female external genitalia caused by elevated androgen levels. Prenatal growth retardation is present with Bloom syndrome. An abnormally large tongue is seen with Beckwith-Wiedemann syndrome. Legs and arms significantly shorter than torso are seen with achondroplasia. DIF: Cognitive Level: Analyzing REF: p. 59 TOP: Nursing Process: Assessment MSC: Integrated Process: Physiological Integrity 25. Parents of a child with hemophilia A ask the nurse, “What is the deficiency with this disorder?” Which correct response should the nurse make? a. “Hemophilia A has a deficiency in red blood cells.” b. “Hemophilia A has a deficiency in platelets.” c. “Hemophilia A has a deficiency in factor IX.” d. “Hemophilia A has a deficiency in factor VIII.” ANS: D Hemophilia A is deficient in factor VIII. Glucose-6-phosphate dehydrogenase (G6PD) deficiency shows low red blood cells (hemolytic anemia). Immunosuppression may be the cause of a deficient number of platelets. Hemophilia B is deficient in factor IX. DIF: Cognitive Level: Applying REF: p. 60 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 26. A child with Prader-Willi syndrome has been hospitalized. Which assessment findings does the nurse expect with this syndrome? a. Nonverbal b. Insatiable hunger c. Abnormal, puppetlike gait d. Paroxysms of inappropriate laughter ANS: B Prader-Willi syndrome is characterized by insatiable hunger that can lead to morbid obesity in childhood. Abnormal, puppetlike gait, paroxysms of inappropriate laughter, and nonverbal are characteristics seen in Angelman syndrome. DIF: Cognitive Level: Analyzing REF: p. 66 TOP: Nursing Process: Assessment MSC: Integrated Process: Physiological Integrity 27. Which ethnic group is at risk for Tay-Sachs disease? a. Black African b. Mediterranean c. Ashkenazi Jewish d. Southern and Southeast Asian ANS: C The Ashkenazi Jewish ethnic group is at higher risk for Tay-Sachs disease. The black African, Mediterranean, and Southern and Southeast Asian ethnicities are at higher risk for sickle cell anemia disease. DIF: Cognitive Level: Understanding REF: p. 78 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 28. A child has been found to have a deficiency in 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase. Which condition is this child at risk for? a. Increased uric acid b. Hypercholesterolemia c. Increased phenylketones d. Altered oxygen transport ANS: B HMG-CoA leads to a disruption of metabolic feedback mechanism and accumulation of end product (cholesterol) with the resulting condition of hypercholesterolemia. DIF: Cognitive Level: Analyzing REF: p. 48 TOP: Nursing Process: Assessment MSC: Integrated Process: Physiological Integrity 29. Phenylketonuria is a genetic disease that results in the body’s inability to correctly metabolize which? a. Glucose 4. Which are signs and symptoms the nurse should assess in the newborn that can indicate an inborn error of metabolism? (Select all that apply.) a. Jaundice b. Strabismus c. Poor feeding d. Acrocyanosis e. Metabolic acidosis ANS: A, C, E Signs of inborn errors of metabolism include jaundice, poor feeding, and metabolic acidosis. Strabismus and acrocyanosis are normal findings in the newborn. DIF: Cognitive Level: Applying REF: p. 68 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 5. The nurse is interviewing a prenatal client about specific risk factors that are indications for prenatal testing. Which specific risk factors should the nurse note? (Select all that apply.) a. Previous twins b. Inherited disorder c. Previous preterm birth d. Cytomegalovirus infection e. Previous stillbirth or neonatal death ANS: B, D, E Specific risk factors that are indications for prenatal testing include inherited disorder, cytomegalovirus infection (teratogenic infection), and previous stillbirth or neonatal death. Previous twins or previous preterm birth are not specific risk factors that are indications for prenatal testing. DIF: Cognitive Level: Analyzing REF: p. 82 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 6. The nurse is teaching nursing students about assessment clues to genetic disorders in the newborn. Which should the nurse include in the teaching session? (Select all that apply.) a. Low-set ears b. Mongolian spots c. Epicanthal folds d. Cephalohematoma e. Forehead prominence ANS: A, C, E Assessment clues to genetic disorders in the newborn include low-set ears, epicanthal folds, and forehead prominence. Mongolian spots and cephalohematoma are findings in a newborn that are not indicative of a genetic disorder. DIF: Cognitive Level: Applying REF: p. 45 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance MATCHING Match the key genetic terms to their definitions. a. Concordant b. Congenital c. Cytogenetics d. Genome e. Teratogen 1. Study of chromosomes, with special focus on chromosome abnormalities 2. Complete genetic information of an organism 3. A condition in which two individuals have the same genetic trait 4. Present at birth 5. An environmental agent capable of producing a birth defect 1. ANS: C DIF: Cognitive Level: Understanding REF: p. 47 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 2. ANS: D DIF: Cognitive Level: Understanding REF: p. 46 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 3. ANS: A DIF: Cognitive Level: Understanding REF: p. 46 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 4. ANS: B DIF: Cognitive Level: Understanding REF: p. 46 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 5. ANS: E DIF: Cognitive Level: Understanding REF: p. 48 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance Chapter 04: Communication, Physical, and Developmental Assessment MULTIPLE CHOICE 1. The nurse is seeing an adolescent and the parents in the clinic for the first time. Which should the nurse do first? a. Introduce him- or herself. b. Make the family comfortable. c. Give assurance of privacy. d. Explain the purpose of the interview. ANS: A The first thing that nurses must do is to introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they specify a preferred name. Clarification of the purpose of the interview and the nurse’s role is the second thing that should be done. During the initial part of the interview, the nurse should include general conversation to help make the family feel at ease. The interview also should take place in an environment as free of distraction as possible. In addition, the nurse should clarify which information will be shared with other members of the health care team and any limits to the confidentiality. DIF: Cognitive Level: Applying REF: p. 91 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 2. Which is considered a block to effective communication? a. Using silence b. Using clichés c. Directing the focus d. Defining the problem ANS: B Using stereotyped comments or clichés can block effective communication. After the nurse uses such trite phrases, parents often do not respond. Silence can be an effective interviewing tool. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions. To be effective, the nurse must be able to direct the focus of the interview while allowing maximum freedom of expression. By using open-ended questions and guiding questions, the nurse can obtain the necessary information and maintain a relationship with the family. The nurse and parent must collaborate and define the problem that will be the focus of the nursing intervention. DIF: Cognitive Level: Applying REF: p. 94 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 3. Which is the single most important factor to consider when communicating with children? a. Presence of the child’s parent b. Child’s physical condition c. Child’s developmental level d. Child’s nonverbal behaviors School-age children require explanations and reasons for everything. They are interested in the functional aspect of all procedures, objects, and activities. It is appropriate for the nurse to explain how equipment works and what will happen to the child so that the child can then observe during the procedure. The nurse should respond positively for requests for information about procedures and health information. By not responding, the nurse may be limiting communication with the child. The child is not exhibiting anxiety in asking how the blood pressure apparatus works, just requesting clarification of what will occur. DIF: Cognitive Level: Applying REF: p. 96 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance 9. The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which technique should be most helpful? a. Recommend that the child keep a diary. b. Provide supplies for the child to draw a picture. c. Suggest that the parent read fairy tales to the child. d. Ask the parent if the child is always uncommunicative. ANS: B Drawing is one of the most valuable forms of communication. Children’s drawings tell a great deal about them because they are projections of the children’s inner self. A diary should be difficult for a 6-year-old child, who is most likely learning to read. The parent reading fairy tales to the child is a passive activity involving the parent and child; it should not facilitate communication with the nurse. The child is in a stressful situation and is probably uncomfortable with strangers, not always uncommunicative. DIF: Cognitive Level: Applying REF: p. 99 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 10. Which data should be included in a health history? a. Review of systems b. Physical assessment c. Growth measurements d. Record of vital signs ANS: A A review of systems is done to elicit information concerning any potential health problems. This further guides the interview process. Physical assessment, growth measurements, and a record of vital signs are components of the physical examination. DIF: Cognitive Level: Remembering REF: p. 100 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 11. The nurse is taking a health history of an adolescent. Which best describes how the chief complaint should be determined? a. Request a detailed listing of symptoms. b. Ask the adolescent, “Why did you come here today?” c. Interview the parent away from the adolescent to determine the chief complaint. d. Use what the adolescent says to determine, in correct medical terminology, what the problem is. ANS: B The chief complaint is the specific reason for the child’s visit to the clinic, office, or hospital. Because the adolescent is the focus of the history, this is an appropriate way to determine the chief complaint. Requesting a detailed list of symptoms makes it difficult to determine the chief complaint. The parent and adolescent may be interviewed separately, but the nurse should determine the reason the adolescent is seeking attention at this time. The chief complaint is usually written in the words that the parent or adolescent uses to describe the reason for seeking help. DIF: Cognitive Level: Applying REF: p. 99 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 12. The nurse is interviewing the mother of an infant. The mother reports, “I had a difficult delivery, and my baby was born prematurely.” This information should be recorded under which heading? a. History b. Present illness c. Chief complaint d. Review of systems ANS: A The history refers to information that relates to previous aspects of the child’s health, not to the current problem. The difficult delivery and prematurity are important parts of the infant’s history. The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Unless the chief complaint is directly related to the prematurity, this information is not included in the history of the present illness. The chief complaint is the specific reason for the child’s visit to the clinic, office, or hospital. It should not include the birth information. The review of systems is a specific review of each body system. It does not include the premature birth but might include sequelae such as pulmonary dysfunction. DIF: Cognitive Level: Understanding REF: p. 100 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 13. Where in the health history does a record of immunizations belong? a. History b. Present illness c. Review of systems d. Physical assessment ANS: A The history contains information relating to all previous aspects of the child’s health status. The immunizations are appropriately included in the history. The present illness, review of systems, and physical assessment are not appropriate places to record the immunization status. DIF: Cognitive Level: Understanding REF: p. 100 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 14. The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active? a. Ask her, “Are you sexually active?” b. Ask her, “Are you having sex with anyone?” c. Ask her, “Are you having sex with a boyfriend?” d. Ask both the girl and her parent if she is sexually active. ANS: B Asking the adolescent girl if she is having sex with anyone is a direct question that is well understood. The phrase sexually active is broadly defined and may not provide specific information for the nurse to provide necessary care. The word “anyone” is preferred to using gender-specific terms such as “boyfriend” or “girlfriend.” Using gender-neutral terms is inclusive and conveys acceptance to the adolescent. Questioning about sexual activity should occur when the adolescent is alone. DIF: Cognitive Level: Applying REF: p. 102 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 15. When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet is which? a. Lacking in protein b. Indicating they live in poverty c. Providing sufficient amino acids d. Needing enrichment with meat and milk ANS: C A diet that contains vegetables, legumes, and starches may provide sufficient essential amino acids even though the actual amount of meat or dairy protein is low. Combinations of foods contain the essential amino acids necessary for growth. Many cultures use diets that contain this combination of foods. It is not indicative of poverty. A dietary assessment should be done, but many vegetarian diets are sufficient for growth. DIF: Cognitive Level: Applying REF: p. 106 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 16. Which parameter correlates best with measurements of total muscle mass? a. Height b. Weight c. Skinfold thickness d. Upper arm circumference ANS: D TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 23. During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action? a. Recheck head control at next visit. b. Teach the parents appropriate exercises. c. Schedule the child for further evaluation. d. Refer the child for further evaluation if the anterior fontanel is still open. ANS: C Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation. Head control is part of normal development. Exercises will not be effective. The lack of achievement of this developmental milestone must be evaluated. DIF: Cognitive Level: Applying REF: pp. 125-126 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 24. The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the child’s head (opisthotonos) with pain on flexion. Which is the most appropriate action? a. Ask the parent when the neck was injured. b. Refer for immediate medical evaluation. c. Continue assessment to determine the cause of the neck pain. d. Record “head lag” on the assessment record and continue the assessment of the child. ANS: B Hyperextension of the child’s head with pain on flexion is indicative of meningeal irritation and needs immediate evaluation. No indication of injury is present. This situation is not descriptive of head lag. DIF: Cognitive Level: Analyzing REF: p. 125 TOP: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 25. During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is which? a. A normal finding b. A sign of a possible visual defect and a need for vision screening c. An abnormal finding requiring referral to an ophthalmologist d. A sign of small hemorrhages, which usually resolve spontaneously ANS: A A brilliant, uniform red reflex is an important normal finding. It rules out many serious defects of the cornea, aqueous chamber, lens, and vitreous chamber. DIF: Cognitive Level: Analyzing REF: p. 127 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 26. Which explains the importance of detecting strabismus in young children? a. Color vision deficit may result. b. Amblyopia, a type of blindness, may result. c. Epicanthal folds may develop in the affected eye. d. Corneal light reflexes may fall symmetrically within each pupil. ANS: B By the age of 3 to 4 months, infants are able to fixate on one visual field with both eyes simultaneously. In strabismus, or cross-eye, one eye deviates from the point of fixation. If misalignment is constant, the weak eye becomes “lazy,” and the brain eventually suppresses the image produced from that eye. If strabismus is not detected and corrected by age 4 to 6 years, blindness from disuse, known as amblyopia, may occur. Color vision is not the only concern. Epicanthal folds are not related to amblyopia. In children with strabismus, the corneal light reflex will not be symmetric for each eye. DIF: Cognitive Level: Understanding REF: p. 127 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 27. Which is the most frequently used test for measuring visual acuity? a. Snellen letter chart b. Ishihara vision test c. Allen picture card test d. Denver eye screening test ANS: A The Snellen letter chart, which consists of lines of letters of decreasing size, is the most frequently used test for visual acuity. The Ishihara Vision Test is used for color vision. The Allen picture card test and Denver eye screening test involve single cards for children ages 2 years and older who are unable to use the Snellen letter chart. DIF: Cognitive Level: Understanding REF: p. 129 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 28. The nurse is testing an infant’s visual acuity. By which age should the infant be able to fix on and follow a target? a. 1 month b. 1 to 2 months c. 3 to 4 months d. 6 months ANS: C Visual fixation and ability to follow a target should be present by ages 3 to 4 months. One to 2 months is too young for this developmental milestone. If an infant is not able to fix and follow by 6 months, further ophthalmologic evaluation is needed. DIF: Cognitive Level: Applying REF: p. 129 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 29. During an otoscopic examination on an infant, in which direction is the pinna pulled? a. Up and back b. Up and forward c. Down and back d. Down and forward ANS: C In infants and toddlers, the ear canal is curved upward. To visualize the ear canal, it is necessary to pull the pinna down and back to the 6 to 9 o’clock range to straighten the canal. In children older than age 3 years and adults, the canal curves downward and forward. The pinna is pulled up and back to the 10 o’clock position. Up and forward and down and forward are positions that do not facilitate visualization of the ear canal. DIF: Cognitive Level: Understanding REF: p. 131 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 30. What is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child? a. Rinne test b. Weber test c. Pure tone audiometry d. Eliciting the startle reflex ANS: C Pure tone audiometry uses an audiometer that produces sounds at different volumes and pitches in the child’s ears. The child is asked to respond in some way when the tone is heard in the earphone. The Rinne and Weber tests measure bone conduction of sound. Eliciting the startle reflex may be useful in infants. DIF: Cognitive Level: Understanding REF: p. 132 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 31. What is the appropriate placement of a tongue blade for assessment of the mouth and throat? a. On the lower jaw b. Side of the tongue c. Against the soft palate d. Center back area of the tongue ANS: B The side of the tongue is the correct position. It avoids the gag reflex yet allows visualization. On the lower jaw and against the soft palate are not appropriate places for the tongue blade. Placement in the center back area of the tongue elicits the gag reflex. DIF: Cognitive Level: Applying REF: p. 134 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 32. When assessing a preschooler’s chest, what should the nurse expect? a. Respiratory movements to be chiefly thoracic b. Anteroposterior diameter to be equal to the transverse diameter TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 38. Superficial palpation of the abdomen is often perceived by the child as tickling. Which measure by the nurse is most likely to minimize this sensation and promote relaxation? a. Palpate another area simultaneously. b. Ask the child not to laugh or move if it tickles. c. Begin with deeper palpation and gradually progress to superficial palpation. d. Have the child “help” with palpation by placing his or her hand over the palpating hand. ANS: D Having the child “help” with palpation by placing his or her hand over the palpating hand will help minimize the feeling of tickling and enlist the child’s cooperation. Palpating another area simultaneously will create the sensation of tickling in the other area also. Asking the child not to laugh or move will bring attention to the tickling and make it more difficult for the child. Superficial palpation is done before deep palpation. DIF: Cognitive Level: Applying REF: p. 142 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 39. During examination of a toddler’s extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is which? a. Abnormal and requires further investigation b. Abnormal unless it occurs in conjunction with knock-knee c. Normal if the condition is unilateral or asymmetric d. Normal because the lower back and leg muscles are not yet well developed ANS: D Lateral bowing of the tibia (bowlegged) is an expected finding in toddlers when they begin to walk. It usually persists until all of their lower back and leg muscles are well developed. Further evaluation is needed if it persists beyond ages 2 to 3 years, especially in African American children. DIF: Cognitive Level: Understanding REF: p. 145 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 40. The nurse is caring for a non–English-speaking child and family. Which should the nurse consider when using an interpreter? a. Pose several questions at a time. b. Use medical jargon when possible. c. Communicate directly with family members when asking questions. d. Carry on some communication in English with the interpreter about the family’s needs. ANS: C When using an interpreter, the nurse should communicate directly with family members when asking questions to reinforce interest in them and to observe nonverbal expressions. Questions should be posed one at a time to elicit only one answer at a time. Medical jargon should be avoided whenever possible. The nurse should avoid discussing the family’s needs with the interpreter in English because some family members may understand some English. DIF: Cognitive Level: Applying REF: p. 94 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance 41. Which action should the nurse implement when taking an axillary temperature? a. Take the temperature through one layer of clothing. b. Add a degree to the result when recording the temperature. c. Place the tip of the thermometer under the arm in the center of the axilla. d. Hold the child’s arm away from the body while taking the temperature. ANS: C The thermometer tip should be placed under the arm in the center of the axilla and kept close to the skin, not clothing. The temperature should not be taken through any clothing. The child’s arm should be pressed firmly against the side, not held away from the body. The temperature should be recorded without a degree added and designated as being taken by the axillary method. DIF: Cognitive Level: Applying REF: p. 119 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 42. The nurse is aware that skin turgor best estimates what? a. Perfusion b. Adequate hydration c. Amount of body fat d. Amount of anemia ANS: B Skin turgor is one of the best estimates of adequate hydration and nutrition. It does not indicate amount of body fat and is not a test for anemia. DIF: Cognitive Level: Understanding REF: p. 125 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 43. The Asian parent of a child being seen in the clinic avoids eye contact with the nurse. What is the best explanation for this considering cultural differences? a. The parent feels inferior to the nurse. b. The parent is showing respect for the nurse. c. The parent is embarrassed to seek health care. d. The parent feels responsible for her child’s illness. ANS: B In some ethnic groups, eye contact is avoided. In the Vietnamese culture, an individual may not look directly into the nurse’s eyes as a sign of respect. The nurse providing culturally competent care would recognize that the other answers listed are not why the parent avoids eye contact with the nurse. DIF: Cognitive Level: Analyzing REF: p. 93 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity MULTIPLE RESPONSE 1. The nurse is performing an otoscopic examination on a child. Which are normal findings the nurse should expect? (Select all that apply.) a. Ashen gray areas b. A well-defined light reflex c. A small, round, concave spot near the center of the drum d. The tympanic membrane is a nontransparent grayish color e. A whitish line extending from the umbo upward to the margin of the membrane ANS: B, C, E Normal findings include the light reflex and bony landmarks. The light reflex is a fairly well-defined, cone-shaped reflection that normally points away from the face. The bony landmarks of the eardrum are formed by the umbo, or tip of the malleus. It appears as a small, round, opaque, concave spot near the center of the eardrum. The manubrium (long process or handle) of the malleus appears to be a whitish line extending from the umbo upward to the margin of the membrane. The tympanic membrane should be light pearly pink or gray and translucent, not nontransparent. Ashen gray areas indicate signs of scarring from a previous perforation. DIF: Cognitive Level: Understanding REF: p. 132 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 2. The nurse is assessing breath sounds on a child. Which are expected auscultated breath sounds? (Select all that apply.) a. Wheezes b. Crackles c. Vesicular d. Bronchial e. Bronchovesicular ANS: C, D, E Normal breath sounds are classified as vesicular, bronchovesicular, or bronchial. Wheezes or crackles are abnormal or adventitious sounds. DIF: Cognitive Level: Applying REF: p. 137 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 3. The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.) a. Lightly brush the palate with a cotton swab. b. Perform the examination in front of a mirror. c. Let the child examine someone else’s mouth first. d. Have the child breathe deeply and hold his or her breath. e. Use a tongue blade to help the child open his or her mouth.