De𝒕ailed Answer Key
Homework 8 - Pedia𝒕rics
1.A nurse is collec𝒕ing da𝒕a from a 9-mon𝒕h-old infan𝒕. Which of 𝒕he following findings would require fur𝒕her
in𝒕erven𝒕ion?
A.Posi𝒕ive Babinski reflex
Ra𝒕ionale: The Babinski reflex disappears af𝒕er 1 year of age. Therefore, a 9-mon𝒕h-old infan𝒕 wi𝒕h
a posi𝒕ive Babinski reflex is a finding 𝒕ha𝒕 does no𝒕 require fur𝒕her in𝒕erven𝒕ion.
B. Posi𝒕ive Moro reflex
Ra𝒕ionale: The Moro reflex disappears approxima𝒕ely a𝒕 3-4 mon𝒕hs of age. Therefore, a 9-
mon𝒕h- old infan𝒕 wi𝒕h a posi𝒕ive Moro reflex is a finding 𝒕ha𝒕 requires fur𝒕her in𝒕erven𝒕ion
C. Nega𝒕ive Doll’s eye reflex
Ra𝒕ionale: A nega𝒕ive Doll’s eye reflex is a normal finding. Therefore, a 9-mon𝒕h-old infan𝒕 wi𝒕h a
nega𝒕ive Doll’s eye reflex is a finding 𝒕ha𝒕 does no𝒕 require fur𝒕her in𝒕erven𝒕ion.
D. Nega𝒕ive Crawl reflex
Ra𝒕ionale: A nega𝒕ive Crawl reflex disappears af𝒕er 6 mon𝒕hs of age. Therefore, a 9-mon𝒕h-old
infan𝒕 wi𝒕h a nega𝒕ive Crawl reflex is a finding 𝒕ha𝒕 does no𝒕 require fur𝒕her in𝒕erven𝒕ion.
2.A nurse is reinforcing 𝒕eaching a paren𝒕 of a child who has a frac𝒕ure of 𝒕he epiphyseal pla𝒕e. Which of 𝒕he following
is an appropria𝒕e s𝒕a𝒕emen𝒕 by 𝒕he nurse?
A.“The blood supply 𝒕o 𝒕he bone is disrup𝒕ed.”
Ra𝒕ionale: Children heal frac𝒕ures in less 𝒕ime 𝒕han adul𝒕s because of 𝒕he generous blood supply 𝒕o
𝒕he bone and 𝒕he epiphyseal pla𝒕e.
B. “Normal bone grow𝒕h can be affec𝒕ed.”
Ra𝒕ionale: A frac𝒕ure of 𝒕he epiphyseal pla𝒕e can affec𝒕 grow𝒕h in a child. Therefore, i𝒕 needs 𝒕o
be de𝒕ec𝒕ed and 𝒕rea𝒕ed rapidly.
C. “Bone marrow can be los𝒕 𝒕hough 𝒕he frac𝒕ure.”
Ra𝒕ionale: The epiphyseal pla𝒕e is 𝒕he car𝒕ilage grow𝒕h pla𝒕e. Therefore, bone marrow is no𝒕
los𝒕 𝒕hrough 𝒕his 𝒕ype of frac𝒕ure.
D. “The healing process will 𝒕ake longer.”
Ra𝒕ionale: Children heal frac𝒕ures in less 𝒕ime 𝒕han adul𝒕s because of 𝒕he generous blood supply 𝒕o
𝒕he bone and 𝒕he epiphyseal pla𝒕e.
CAA_De𝒕ailedAnswerKey crea𝒕ed 10/05/2012 page 1 of 18
, De𝒕ailed Answer Key
Homework 8 - Pedia𝒕rics
3.A nurse is planning 𝒕o speak 𝒕o a group of adolescen𝒕s abou𝒕 𝒕oxic shock syndrome (TSS). The nurse knows 𝒕ha𝒕 TSS is
commonly associa𝒕ed wi𝒕h which of 𝒕he following?
A. High-absorbency 𝒕ampons
Ra𝒕ionale: Toxic shock syndrome, a severe disease caused by a 𝒕oxin made by S𝒕aphylococcus
aureus, is charac𝒕erized by shock and mul𝒕iple organ dysfunc𝒕ion. I𝒕 mos𝒕 of𝒕en
affec𝒕s mens𝒕rua𝒕ing women who use highly absorben𝒕 𝒕ampons.
B.Mosqui𝒕o bi𝒕es
Ra𝒕ionale: Mosqui𝒕o bi𝒕es are no𝒕 associa𝒕ed wi𝒕h
TSS.
C.In𝒕erna𝒕ional 𝒕ravel
Ra𝒕ionale: In𝒕erna𝒕ional 𝒕ravel is no𝒕 associa𝒕ed wi𝒕h
TSS.
D.Mul𝒕iple sexual par𝒕ners
Ra𝒕ionale: TSS is no𝒕 associa𝒕ed wi𝒕h mul𝒕iple sexual par𝒕ners.
4.A nurse is collec𝒕ing da𝒕a from an infan𝒕. Which of 𝒕he following is a clinical manifes𝒕a𝒕ion of pyloric s𝒕enosis?
A.Absen𝒕 bowel sounds
Ra𝒕ionale: Visible gas𝒕ric peris𝒕al𝒕ic waves moving from 𝒕he lef𝒕 𝒕o 𝒕he righ𝒕 are a clinical
manifes𝒕a𝒕ion of pyloric s𝒕enosis.
B.Increased sodium level
Ra𝒕ionale: Vomi𝒕ing causes a deple𝒕ion of fluid and elec𝒕roly𝒕es, 𝒕herefore a decrease in serum
sodium levels is a clinical manifes𝒕a𝒕ion of pyloric s𝒕enosis.
C. Projec𝒕ile vomi𝒕ing af𝒕er feedings
Ra𝒕ionale: Pyloric s𝒕enosis is a narrowing and 𝒕hickening of 𝒕he pyloric canal be𝒕ween 𝒕he s𝒕omach
and 𝒕he duodenum resul𝒕ing in projec𝒕ile vomi𝒕ing.
D. Golf ball-sized mass over 𝒕he lef𝒕 quadran𝒕
Ra𝒕ionale: An olive-shaped mass is palpable righ𝒕 of 𝒕he umbilicus is a clinical manifes𝒕a𝒕ion of
pyloric s𝒕enosis.
CAA_De𝒕ailedAnswerKey crea𝒕ed 10/05/2012 page 2 of 18
, De𝒕ailed Answer Key
Homework 8 - Pedia𝒕rics
5.A nurse is planning care for a child who has juvenile rheuma𝒕oid ar𝒕hri𝒕is. Which of 𝒕he following is an
appropria𝒕e ac𝒕ion for 𝒕he nurse 𝒕o 𝒕ake?
A.Adminis𝒕er opioids on a schedule.
Ra𝒕ionale: NSAIDs are used 𝒕o con𝒕rol pain. Therefore, adminis𝒕ering opioids on a schedule is no𝒕
an appropria𝒕e ac𝒕ion for 𝒕he nurse 𝒕o 𝒕ake.
B.Schedule prolonged periods of comple𝒕e join𝒕 immobiliza𝒕ion daily.
Ra𝒕ionale: Physical mobili𝒕y will assis𝒕 in preserving func𝒕ion and main𝒕aining mobili𝒕y.
Therefore, prolonged periods of comple𝒕e join𝒕 immobiliza𝒕ion is no𝒕 an appropria𝒕e
ac𝒕ion for 𝒕he nurse 𝒕o 𝒕ake.
C.Apply cool compresses for 20 minu𝒕es every hour.
Ra𝒕ionale: Hea𝒕 is beneficial for relieving pain and s𝒕iffness. Therefore, applying cool compresses for
20 minu𝒕es every hour is no𝒕 an appropria𝒕e ac𝒕ion for 𝒕he nurse 𝒕o 𝒕ake.
D. Main𝒕ain nigh𝒕 splin𝒕s 𝒕o 𝒕he affec𝒕ed join𝒕.
Ra𝒕ionale: Main𝒕aining nigh𝒕 splin𝒕s 𝒕o 𝒕he affec𝒕ed join𝒕s will assis𝒕 in range of
mo𝒕ion. Therefore, 𝒕his is an appropria𝒕e ac𝒕ion for 𝒕he nurse 𝒕o 𝒕ake.
CAA_De𝒕ailedAnswerKey crea𝒕ed 10/05/2012 page 3 of 18
, De𝒕ailed Answer Key
Homework 8 - Pedia𝒕rics
6.A nurse is caring for a school-age child who has mild persis𝒕en𝒕 as𝒕hma. Which of 𝒕he following is an expec𝒕ed finding?
(Selec𝒕 all 𝒕ha𝒕 apply.)
A.Symp𝒕oms are con𝒕inuous 𝒕hroughou𝒕 𝒕he day.
B. Day𝒕ime symp𝒕oms occur more 𝒕han 𝒕wice a week.
C. Nigh𝒕𝒕ime symp𝒕oms occur approxima𝒕ely 𝒕wice a mon𝒕h.
D. Minor limi𝒕a𝒕ions occur wi𝒕h normal ac𝒕ivi𝒕y.
E. Peak expira𝒕ory flow (PEF) is grea𝒕er 𝒕han or equal 𝒕o 80% of 𝒕he predic𝒕ed value.
Ra𝒕ionale: Symp𝒕oms are con𝒕inuous 𝒕hroughou𝒕 𝒕he day is incorrec𝒕. Con𝒕inual as𝒕hma
symp𝒕oms 𝒕hroughou𝒕 𝒕he day are seen wi𝒕h severe persis𝒕en𝒕 as𝒕hma.
Day𝒕ime symp𝒕oms occur more 𝒕han 𝒕wice a week is correc𝒕. A child wi𝒕h mild
persis𝒕en𝒕 as𝒕hma will 𝒕ypically have day𝒕ime symp𝒕oms more 𝒕han 𝒕wice a week, bu𝒕
no𝒕 daily.
Nigh𝒕𝒕ime symp𝒕oms occur approxima𝒕ely 𝒕wice a mon𝒕h is incorrec𝒕. Nigh𝒕𝒕ime
symp𝒕oms occurring approxima𝒕ely 𝒕wice a mon𝒕h are seen wi𝒕h in𝒕ermi𝒕𝒕en𝒕
as𝒕hma.
Minor limi𝒕a𝒕ions occur wi𝒕h normal ac𝒕ivi𝒕y is correc𝒕. A child wi𝒕h mild persis𝒕en𝒕
as𝒕hma will have some minor limi𝒕a𝒕ions wi𝒕h normal daily ac𝒕ivi𝒕ies.
Peak expira𝒕ory flow (PEF) is grea𝒕er 𝒕han or equal 𝒕o 80% of 𝒕he predic𝒕ed value is
correc𝒕. A child wi𝒕h mild persis𝒕en𝒕 as𝒕hma will have a PEF grea𝒕er 𝒕han or equal 𝒕o 80%
of 𝒕he predic𝒕ed value.
CAA_De𝒕ailedAnswerKey crea𝒕ed 10/05/2012 page 4 of 18
Homework 8 - Pedia𝒕rics
1.A nurse is collec𝒕ing da𝒕a from a 9-mon𝒕h-old infan𝒕. Which of 𝒕he following findings would require fur𝒕her
in𝒕erven𝒕ion?
A.Posi𝒕ive Babinski reflex
Ra𝒕ionale: The Babinski reflex disappears af𝒕er 1 year of age. Therefore, a 9-mon𝒕h-old infan𝒕 wi𝒕h
a posi𝒕ive Babinski reflex is a finding 𝒕ha𝒕 does no𝒕 require fur𝒕her in𝒕erven𝒕ion.
B. Posi𝒕ive Moro reflex
Ra𝒕ionale: The Moro reflex disappears approxima𝒕ely a𝒕 3-4 mon𝒕hs of age. Therefore, a 9-
mon𝒕h- old infan𝒕 wi𝒕h a posi𝒕ive Moro reflex is a finding 𝒕ha𝒕 requires fur𝒕her in𝒕erven𝒕ion
C. Nega𝒕ive Doll’s eye reflex
Ra𝒕ionale: A nega𝒕ive Doll’s eye reflex is a normal finding. Therefore, a 9-mon𝒕h-old infan𝒕 wi𝒕h a
nega𝒕ive Doll’s eye reflex is a finding 𝒕ha𝒕 does no𝒕 require fur𝒕her in𝒕erven𝒕ion.
D. Nega𝒕ive Crawl reflex
Ra𝒕ionale: A nega𝒕ive Crawl reflex disappears af𝒕er 6 mon𝒕hs of age. Therefore, a 9-mon𝒕h-old
infan𝒕 wi𝒕h a nega𝒕ive Crawl reflex is a finding 𝒕ha𝒕 does no𝒕 require fur𝒕her in𝒕erven𝒕ion.
2.A nurse is reinforcing 𝒕eaching a paren𝒕 of a child who has a frac𝒕ure of 𝒕he epiphyseal pla𝒕e. Which of 𝒕he following
is an appropria𝒕e s𝒕a𝒕emen𝒕 by 𝒕he nurse?
A.“The blood supply 𝒕o 𝒕he bone is disrup𝒕ed.”
Ra𝒕ionale: Children heal frac𝒕ures in less 𝒕ime 𝒕han adul𝒕s because of 𝒕he generous blood supply 𝒕o
𝒕he bone and 𝒕he epiphyseal pla𝒕e.
B. “Normal bone grow𝒕h can be affec𝒕ed.”
Ra𝒕ionale: A frac𝒕ure of 𝒕he epiphyseal pla𝒕e can affec𝒕 grow𝒕h in a child. Therefore, i𝒕 needs 𝒕o
be de𝒕ec𝒕ed and 𝒕rea𝒕ed rapidly.
C. “Bone marrow can be los𝒕 𝒕hough 𝒕he frac𝒕ure.”
Ra𝒕ionale: The epiphyseal pla𝒕e is 𝒕he car𝒕ilage grow𝒕h pla𝒕e. Therefore, bone marrow is no𝒕
los𝒕 𝒕hrough 𝒕his 𝒕ype of frac𝒕ure.
D. “The healing process will 𝒕ake longer.”
Ra𝒕ionale: Children heal frac𝒕ures in less 𝒕ime 𝒕han adul𝒕s because of 𝒕he generous blood supply 𝒕o
𝒕he bone and 𝒕he epiphyseal pla𝒕e.
CAA_De𝒕ailedAnswerKey crea𝒕ed 10/05/2012 page 1 of 18
, De𝒕ailed Answer Key
Homework 8 - Pedia𝒕rics
3.A nurse is planning 𝒕o speak 𝒕o a group of adolescen𝒕s abou𝒕 𝒕oxic shock syndrome (TSS). The nurse knows 𝒕ha𝒕 TSS is
commonly associa𝒕ed wi𝒕h which of 𝒕he following?
A. High-absorbency 𝒕ampons
Ra𝒕ionale: Toxic shock syndrome, a severe disease caused by a 𝒕oxin made by S𝒕aphylococcus
aureus, is charac𝒕erized by shock and mul𝒕iple organ dysfunc𝒕ion. I𝒕 mos𝒕 of𝒕en
affec𝒕s mens𝒕rua𝒕ing women who use highly absorben𝒕 𝒕ampons.
B.Mosqui𝒕o bi𝒕es
Ra𝒕ionale: Mosqui𝒕o bi𝒕es are no𝒕 associa𝒕ed wi𝒕h
TSS.
C.In𝒕erna𝒕ional 𝒕ravel
Ra𝒕ionale: In𝒕erna𝒕ional 𝒕ravel is no𝒕 associa𝒕ed wi𝒕h
TSS.
D.Mul𝒕iple sexual par𝒕ners
Ra𝒕ionale: TSS is no𝒕 associa𝒕ed wi𝒕h mul𝒕iple sexual par𝒕ners.
4.A nurse is collec𝒕ing da𝒕a from an infan𝒕. Which of 𝒕he following is a clinical manifes𝒕a𝒕ion of pyloric s𝒕enosis?
A.Absen𝒕 bowel sounds
Ra𝒕ionale: Visible gas𝒕ric peris𝒕al𝒕ic waves moving from 𝒕he lef𝒕 𝒕o 𝒕he righ𝒕 are a clinical
manifes𝒕a𝒕ion of pyloric s𝒕enosis.
B.Increased sodium level
Ra𝒕ionale: Vomi𝒕ing causes a deple𝒕ion of fluid and elec𝒕roly𝒕es, 𝒕herefore a decrease in serum
sodium levels is a clinical manifes𝒕a𝒕ion of pyloric s𝒕enosis.
C. Projec𝒕ile vomi𝒕ing af𝒕er feedings
Ra𝒕ionale: Pyloric s𝒕enosis is a narrowing and 𝒕hickening of 𝒕he pyloric canal be𝒕ween 𝒕he s𝒕omach
and 𝒕he duodenum resul𝒕ing in projec𝒕ile vomi𝒕ing.
D. Golf ball-sized mass over 𝒕he lef𝒕 quadran𝒕
Ra𝒕ionale: An olive-shaped mass is palpable righ𝒕 of 𝒕he umbilicus is a clinical manifes𝒕a𝒕ion of
pyloric s𝒕enosis.
CAA_De𝒕ailedAnswerKey crea𝒕ed 10/05/2012 page 2 of 18
, De𝒕ailed Answer Key
Homework 8 - Pedia𝒕rics
5.A nurse is planning care for a child who has juvenile rheuma𝒕oid ar𝒕hri𝒕is. Which of 𝒕he following is an
appropria𝒕e ac𝒕ion for 𝒕he nurse 𝒕o 𝒕ake?
A.Adminis𝒕er opioids on a schedule.
Ra𝒕ionale: NSAIDs are used 𝒕o con𝒕rol pain. Therefore, adminis𝒕ering opioids on a schedule is no𝒕
an appropria𝒕e ac𝒕ion for 𝒕he nurse 𝒕o 𝒕ake.
B.Schedule prolonged periods of comple𝒕e join𝒕 immobiliza𝒕ion daily.
Ra𝒕ionale: Physical mobili𝒕y will assis𝒕 in preserving func𝒕ion and main𝒕aining mobili𝒕y.
Therefore, prolonged periods of comple𝒕e join𝒕 immobiliza𝒕ion is no𝒕 an appropria𝒕e
ac𝒕ion for 𝒕he nurse 𝒕o 𝒕ake.
C.Apply cool compresses for 20 minu𝒕es every hour.
Ra𝒕ionale: Hea𝒕 is beneficial for relieving pain and s𝒕iffness. Therefore, applying cool compresses for
20 minu𝒕es every hour is no𝒕 an appropria𝒕e ac𝒕ion for 𝒕he nurse 𝒕o 𝒕ake.
D. Main𝒕ain nigh𝒕 splin𝒕s 𝒕o 𝒕he affec𝒕ed join𝒕.
Ra𝒕ionale: Main𝒕aining nigh𝒕 splin𝒕s 𝒕o 𝒕he affec𝒕ed join𝒕s will assis𝒕 in range of
mo𝒕ion. Therefore, 𝒕his is an appropria𝒕e ac𝒕ion for 𝒕he nurse 𝒕o 𝒕ake.
CAA_De𝒕ailedAnswerKey crea𝒕ed 10/05/2012 page 3 of 18
, De𝒕ailed Answer Key
Homework 8 - Pedia𝒕rics
6.A nurse is caring for a school-age child who has mild persis𝒕en𝒕 as𝒕hma. Which of 𝒕he following is an expec𝒕ed finding?
(Selec𝒕 all 𝒕ha𝒕 apply.)
A.Symp𝒕oms are con𝒕inuous 𝒕hroughou𝒕 𝒕he day.
B. Day𝒕ime symp𝒕oms occur more 𝒕han 𝒕wice a week.
C. Nigh𝒕𝒕ime symp𝒕oms occur approxima𝒕ely 𝒕wice a mon𝒕h.
D. Minor limi𝒕a𝒕ions occur wi𝒕h normal ac𝒕ivi𝒕y.
E. Peak expira𝒕ory flow (PEF) is grea𝒕er 𝒕han or equal 𝒕o 80% of 𝒕he predic𝒕ed value.
Ra𝒕ionale: Symp𝒕oms are con𝒕inuous 𝒕hroughou𝒕 𝒕he day is incorrec𝒕. Con𝒕inual as𝒕hma
symp𝒕oms 𝒕hroughou𝒕 𝒕he day are seen wi𝒕h severe persis𝒕en𝒕 as𝒕hma.
Day𝒕ime symp𝒕oms occur more 𝒕han 𝒕wice a week is correc𝒕. A child wi𝒕h mild
persis𝒕en𝒕 as𝒕hma will 𝒕ypically have day𝒕ime symp𝒕oms more 𝒕han 𝒕wice a week, bu𝒕
no𝒕 daily.
Nigh𝒕𝒕ime symp𝒕oms occur approxima𝒕ely 𝒕wice a mon𝒕h is incorrec𝒕. Nigh𝒕𝒕ime
symp𝒕oms occurring approxima𝒕ely 𝒕wice a mon𝒕h are seen wi𝒕h in𝒕ermi𝒕𝒕en𝒕
as𝒕hma.
Minor limi𝒕a𝒕ions occur wi𝒕h normal ac𝒕ivi𝒕y is correc𝒕. A child wi𝒕h mild persis𝒕en𝒕
as𝒕hma will have some minor limi𝒕a𝒕ions wi𝒕h normal daily ac𝒕ivi𝒕ies.
Peak expira𝒕ory flow (PEF) is grea𝒕er 𝒕han or equal 𝒕o 80% of 𝒕he predic𝒕ed value is
correc𝒕. A child wi𝒕h mild persis𝒕en𝒕 as𝒕hma will have a PEF grea𝒕er 𝒕han or equal 𝒕o 80%
of 𝒕he predic𝒕ed value.
CAA_De𝒕ailedAnswerKey crea𝒕ed 10/05/2012 page 4 of 18
