Peds Exam 1

Peds Exam 1 Which nursing role is not directly involved when providing family-centered approach to the pediatric population? 1. Advocacy 2. Case management 3. Patient education 4. Researcher - ANS 4. Researcher A nurse is working with pediatric clients in a research facility. The nurse recognizes that federal guidelines are in place that delineate which pediatrics clients must give assent for participation in research trials. Based upon the clients age, the nurse would seek assent from which children? Select all that apply. 1. The precocious 4-year-old starting as a cystic fibrosis research-study participant. 2. The 7-year-old leukemia client electing to receive a newly developed medication, now being researched. 3. The 10-year-old starting in an investigative study for clients with precocious puberty. 4. The 13-year-old client beginning participation in a research program for ADHD treatments. - ANS 2. The 7-year-old leukemia client electing to receive a newly developed medication, now being researched. 3. The 10-year-old starting in an investigative study for clients with precocious puberty. 4. The 13-year-old client beginning participation in a research program for ADHD treatments. The nurse in a pediatric acute-care unit is assigned the following tasks. Which task is not appropriate for the registered to nurse complete? 1. Diagnose an 8-year-old with acute otitis media and prescribe an antibiotic. 2. Listen to the concerns of an adolescent about being out of school for a lengthy surgical recovery. 3. Provide information to a mother of a newly diagnosed 4-year-old diabetic about local support-group options. 4. Diagnose a 6-year-old with Diversional Activity Deficit related to placement in isolation. - ANS 1. Diagnose an 8-year-old with acute otitis media and prescribe an antibiotic. A 7-year-old child is admitted for acute appendicitis. The parents are questioning the nurse about expectations during the childs recovery. Which information tool would be most useful in answering a parents questions about the timing of key events? 1. Healthy People 2020 2. Clinical pathways 3. Child mortality statistics 4. National clinical practice guidelines - ANS 2. Clinical pathways The nurse recognizes that the pediatric client is from a cultural background different from that of the hospital staff. Which goal is most appropriate for this client when planning nursing care? 1. Overlook or minimize the differences that exist. 2. Facilitate the family's ability to comply with the care needed. 3. Avoid inadvertently offending the family by imposing the nurses perspective. 4. Encourage complementary beneficial cultural practices as primary therapies. - ANS 2. Facilitate the family's ability to comply with the care needed. The telephone triage nurse at a pediatric clinic knows each call is important. Which call would require extra attentiveness from the registered nurse because of an increased risk of mortality? 1. A 3-week-old infant born at 35 weeks gestation with gastroenteritis 2. A term 2-week-old infant of American Indian descent with an upper respiratory infection 3. A post term 4-week-old infant non-Hispanic black descent with moderate emesis after feeding 4. A 1-week-old infant born at 40 weeks gestation with symptoms of colic - ANS 1. A 3-week-old infant born at 35 weeks gestation with gastroenteritis Despite the availability of Childrens Health Insurance Programs (CHIP), many eligible children are not enrolled. Which nursing intervention would be the most appropriate to help children become enrolled in CHIP? 1. Assessment of the details of the familys income and expenditures 2. Case management to limit costly, unnecessary duplication of services 3. To advocate for the child by encouraging the family to investigate its CHIP eligibility 4. To educate the family about the need for keeping regular well-childvisit appointments - ANS 3. To advocate for the child by encouraging the family to investigate its CHIP eligibility A supervisor is reviewing the documentation of the nurses in the unit. Which client documentation is the most accurate and contains all the required part for a narrative entry? 1. 2/2/05 1630 Catheterized using an 8 French catheter, 45 mL clear yellow urine obtained, specimen sent to lab, squirmed and cried softly during insertion of catheter. Quiet in mothers arms following catheter removal. M. May RN 2. 1/9/05 2 pm NG tube placement confirmed and irrigated with 30 ml sterile water. Suction set at low, intermittent. Oxygen via nasal canal at 2 L/min. Nares patent, pink, and nonirritated. K. Earnst RN 3. 4:00 Trach dressing removed with dime-size stain of dry serous exudate. Site cleansed with normal saline. Dried with sterile gauze. New sterile trach sponge and trach ties applied. Respirations regular and even throughout the procedure. F. Luck RN 4. Feb. 05 Port-A-Cath assessed with Huber needle. Blood return presen - ANS 1. 2/2/05 1630 Catheterized using an 8 French catheter, 45 mL clear yellow urine obtained, specimen sent to lab, squirmed and cried softly during insertion of catheter. Quiet in mothers arms following catheter removal. M. May RN A 12-year-old pediatric client is in need of surgery. Which member of the health care team is legally responsible for obtaining informed consent for an invasive procedure? 1. Nurse 2. Physician 3. Unit secretary 4. Social worker - ANS 2. Physician A child is being prepared for an invasive procedure. The mother of the child has legal custody but is not present. After details of the procedure are explained, who can provide legal consent on behalf of a minor child for treatment? 1. The divorced parent without custody 2. A cohabitating unmarried boyfriend of the childs mother 3. A grandparent who lives in the home with the child 4. A babysitter with written proxy consent - ANS 4. A babysitter with written proxy consent A 12-year-old child is admitted to the unit for a surgical procedure. The child is accompanied by two parents and a younger sibling. What is the level of involvement in treatment decision making for this child? 1. That of an emancipated minor. 2. That of a mature minor. 3. That of assent. 4. None. - ANS 3. That of assent. Which nursing intervention is most appropriate when providing education to the pediatric client and family? 1. Giving primary care for high-risk children who are in hospital settings 2. Giving primary care for healthy children 3. Working toward the goal of informed choices with the family 4. Obtaining a physician consultation for any technical procedures at delivery - ANS 3. Working toward the goal of informed choices with the family What is the pediatric nurses best defense against an accusation of malpractice or negligence? 1. Following the physicians written orders 2. Meeting the scope and standards of practice for pediatric nursing 3. Being a nurse practitioner or clinical nurse specialist 4. Acting on the advice of the nurse manager - ANS 2. Meeting the scope and standards of practice for pediatric nursing Which legal or ethical offense would be committed if a nurse tells family members the condition of a newborn baby without first consulting the parents? 1. A breach of privacy 2. Negligence 3. Malpractice 4. A breach of ethics - ANS 1. A breach of privacy Pediatric nurses have foundational knowledge obtained in nursing school and add specific competencies related to the pediatric client. Which would be considered an additional specific expected competency of the pediatric nurse? 1. Physical assessment 2. Anatomical and developmental differences 3. Nursing process 4. Management of healthcare conditions - ANS 2. Anatomical and developmental differences The nurse is planning care for an adolescent client who will be hospitalized for several weeks following a traumatic brain injury. Which interventions will enhance family-centered care for this client and family? Select all that apply. 1. Making all ADL decisions for the adolescent and family 2. Asking the adolescent what foods to include during meal time 3. Allowing the family time to pray each day with the adolescent 4. Encouraging the adolescents friends to visit during visiting hours 5. Leaving all questions for the healthcare provider - ANS 2. Asking the adolescent what foods to include during meal time 3. Allowing the family time to pray each day with the adolescent 4. Encouraging the adolescents friends to visit during visiting hours A new pediatric hospital will open soon. While planning nursing care, the hospital administration is considering two models of providing health care: family-focused care and family-centered care. Which action best implements family-centered care? 1. Telling the family what must be done for the familys health 2. Assuming the role of an expert professional to direct the health care 3. Intervening for the child and family as a unit 4. Conferring with the family in deciding which healthcare option will be chosen - ANS 4. Conferring with the family in deciding which healthcare option will be chosen A school-age client tells you that Grandpa, Mommy, Daddy, and my brother live at my house. Which type of family will the nurse identify in the medical record based on this description? 1. Binuclear family 2. Extended family 3. Gay or lesbian family 4. Traditional nuclear family - ANS 2. Extended family The nurse is performing an assessment of a childs biologic family history. Which situation would necessitate the nurses asking the mother for information should use the term childs father instead of your husband? 1. Traditional nuclear family 2. Traditional extended family 3. Two-income nuclear family 4. Cohabitating informal stepfamily - ANS 4. Cohabitating informal stepfamily Several children arrived at the emergency department accompanied only by their fathers. Which father may legally sign emergency medical consent for treatment? 1. The divorced one from the binuclear family 2. The stepfather from the blended or reconstituted family 3. The divorced one when the single-parent mother has custody 4. The nonbiologic one from the heterosexual cohabitating family - ANS 1. The divorced one from the binuclear family The community-health nurse is assessing several families for various strengths and needs in regard to after-school and backup child-care arrangements. Which family type will benefit the most from this assessment and subsequent interventions? 1. The binuclear family 2. The extended family 3. The single-parent family 4. The traditional nuclear family - ANS 3. The single-parent family The nurse is working on parenting skills with a group of mothers. Which mother would need the fewest discipline-related suggestions? 1. Authoritarian one 2. Authoritative one 3. Indifferent one 4. Permissive one - ANS 2. Authoritative one The nurse in the pediatric clinic observes a parental lack of warmth and interest toward the child. Which family style will the nurse most likely document in this situation? 1. Authoritarian 2. Authoritative 3. Indifferent 4. Permissive - ANS 3. Indifferent The nurse is working on parenting skills with a mother of three children. The nurse demonstrates a strategy that uses reward to increase positive behavior. Which strategy will the nurse document in the medical record based on this description? 1. Time out 2. Reasoning 3. Behavior modification 4. Experiencing consequences of misbehavior - ANS 3. Behavior modification The nurse is assessing a family's effective coping strategies and ineffective defensive strategies. Which family-social-system theory is the nurse using in this assessment of the family? 1. Family-stress theory 2. Family-development theory 3. Family-systems theory 4. Family life-cycle theory - ANS 1. Family-stress theory The nurse is assigned to a child in a spica cast for a fractured femur suffered in an automobile accident. The childs teenage brother was driving the car, which was totaled. The nurse learns that the father lost his job three weeks ago and the mother has just accepted a temporary waitress job. Which nursing diagnosis will the nurse use when planning care for this child and family? 1. Compromised Family Coping Related to the Effects of Multiple Simultaneous Stressors 2. Impaired Social Interaction (Parent and Child) Related to the Lack of Family or Respite Support 3. Interrupted Family Processes Related to Child with Significant Disability Requiring Alteration in Family Functioning 4. Risk for Caregiver Role Strain Related to Child with a Newly Acquired Disability and the Associated Financial Burden - ANS 1. Compromised Family Coping Related to the Effects of Multiple Simultaneous Stressors A nurse is working with the family of a pediatric client. When planning to obtain an accurate family assessment, which initial step is the most appropriate? 1. Establish a trusting relationship with the family. 2. Select the most relevant family-assessment tool. 3. Focus primarily upon the mother, while learning her greatest concern. 4. Observe the family in the home setting, since this step always proves indispensable. - ANS 1. Establish a trusting relationship with the family. The camp nurse is assessing a group of children attending summer camp. The nurse will expect which children to most likely have problems perceiving a sense of belonging? 1. Children whose parents divorced recently 2. Children who gained a stepparent recently 3. Children recently placed into foster care 4. Children adopted as infants - ANS 3. Children recently placed into foster care There are several tools that help with obtaining a cultural assessment of a client and his family. Which tool would be appropriate to gather 12 major concepts of cultural assessment? 1. Sunrise enabler 2. Model for cultural competence 3. Transcultural assessment model 4. Health traditions model - ANS 2. Model for cultural competence Cultures have many different childrearing practices. Which culture is known to value the male child more than the female child, and often teaches children to avoid displaying emotion? 1. Mexican 2. Amish 3. Chinese 4. Navajo - ANS 3. Chinese The nurse is planning care for a school-age client and family who have expressed wanting to use complementary and alternative modalities (CAM) in the treatment plan. Which interventions can the nurse safely implement into the plan of care? Select all that apply. 1. Substituting an herbal remedy for a prescribed medication 2. Encouraging the parents to share which modalities they would like to implement 3. Educating on the benefits and risks for each modality 4. Using essential oils to decrease nausea 5. Discouraging the use of faith-based therapies - ANS 2. Encouraging the parents to share which modalities they would like to implement 3. Educating on the benefits and risks for each modality 4. Using essential oils to decrease nausea While in the pediatricians office for their childs 12-month well-child exam, the parents ask the nurse for advice on age-appropriate toys for their child. Based on the child's developmental level, which types of toys would the nurse suggest? Select all that apply. 1. Soft toys that can be manipulated 2. Small toys that can pop apart and go back together 3. Jack-in-the-box toys 4. Toys with black and white patterns 5. Push-and-pull toys - ANS 1. Soft toys that can be manipulated 3. Jack-in-the-box toys 5. Push-and-pull toys A mother of a school-age client who recently had surgery for the removal of tonsils and adenoids complains that the child has begun sucking his thumb again. Which coping mechanisms is the child using to cope with the surgery and hospitalization? 1. Repression 2. Rationalization 3. Regression 4. Fantasy - ANS 3. Regression While being comforted in the emergency department, a young school-age sibling of a pediatric trauma victim blurts out to the nurse, Its all my fault! When we were fighting yesterday, I told him I wished he was dead! Which response is most appropriate by the nurse? 1. Asking the child if she would like to sit down and drink some water 2. Sitting the child down in an empty room with markers and paper so that she can draw a picture 3. Calmly discussing the catheters, tubes, and equipment that the patient requires and explaining to the sibling why the patient needs them 4. Reassuring the child that it is normal to get angry and say things that we do not mean but that we have no control over whether or not an accident happens - ANS 4. Reassuring the child that it is normal to get angry and say things that we do not mean but that we have no control over whether or not an accident happens While assessing the development of a 9-month-old infant, the nurse asks the mother if the child actively looks for toys when they are placed out of sight. Which developmental task is the nurse assessing this infant for? 1. Object permanence 2. Centration 3. Transductive reasoning 4. Conservation - ANS 1. Object permanence The nurse is counseling the parents of a 6-1/2-month-old infant. Which age-appropriate toy is most appropriate for the nurse to suggest to these parents? 1. Soft, fluid-filled ring that can be chilled in the refrigerator 2. Colorful rattle 3. Jack-in-the-box toy 4. Push-and-pull toy - ANS 1. Soft, fluid-filled ring that can be chilled in the refrigerator A nurse is assessing language development in all the infants presenting at the doctors office for well-child visits. At which age range would the nurse expect a child to verbalize the words dada and mama? 1. 3 and 5 months 2. 6 and 8 months 3. 9 and 12 months 4. 13 and 18 months - ANS 3. 9 and 12 months The parents of an 8-year-old state that their son seems very interested in trying new activities. When the parents ask for suggested activities for this age child, the nurse recommends scouts as an activity that will foster growth and development. In which stage of Eriksons psychosocial stages of development is this child? 1. Trust versus mistrust 2. Initiative versus guilt 3. Industry versus inferiority 4. Identity versus role confusion - ANS 3. Industry versus inferiority Two 3-year-olds are playing in a hospital playroom together. One is working on a puzzle while the other is stacking blocks. Which type of play are these children exhibiting? 1. Cooperative play 2. Associative play 3. Parallel play 4. Solitary play - ANS 3. Parallel play The nurse, talking with the parents of a toddler who is struggling with toilet training, reassures them that their child is demonstrating a typical developmental stage. According to Erikson, which developmental stage will the nurse document in the medical record for this toddler? 1. Trust versus mistrust 2. Autonomy versus shame and doubt 3. Initiative versus guilt 4. Industry versus inferiority - ANS 2. Autonomy versus shame and doubt A new parent group inquires about the stages through which their children will progress as they grow older. The nurse is discussing Piagets developmental stages. In what order would the nurse expect the child to progress through Piagets stages of development? List them in order. Choice 1. Sensorimotor Choice 2. Formal operational Choice 3. Preoperational Choice 4. Concrete operational - ANS Choice 1. Sensorimotor Choice 3. Preoperational Choice 4. Concrete operational Choice 2. Formal operational While trying to inform a young school-age client about what will occur during an upcoming CT scan, the nurse notices that the child is engaged in a collective monologue, talking about a new puppy. Which response by the nurse is the most appropriate in this situation? 1. Please stop talking about your puppy. I need to tell you about your CT scan. 2. Ignore the child's responses and continue discussing the procedure. 3. I'll come back when you are ready to talk with me more about your CT scan. 4. You must be so excited to have a new puppy! They are so much fun. Now, let me tell you again about going downstairs in a wheelchair to a special room. - ANS 4. You must be so excited to have a new puppy! They are so much fun. Now, let me tell you again about going downstairs in a wheelchair to a special room. An adolescent client with cystic fibrosis suddenly becomes non-compliant with the medication regime. Which intervention by the nurse will most likely improve compliance for this client? 1. Give the child a computer-animated game that presents information on the management of cystic fibrosis. 2. Arrange for the physician to sit down and talk to the child about the risks related to non-compliance with medications. 3. Set up a meeting with some older teens with cystic fibrosis who have been managing their disease effectively. 4. Discuss with the child's parents the privileges that can be taken away, such as cell phone, if compliance fails to improve. - ANS 3. Set up a meeting with some older teens with cystic fibrosis who have been managing their disease effectively. A neonatal nurse who encourages parents to hold their baby and provides opportunities for Kangaroo Care most likely is demonstrating concern for which aspect of the infants psychosocial development? 1. Attachment 2. Assimilation 3. Centration 4. Resilience - ANS 1. Attachment Which statement by the nurse is most appropriate prior to giving an intramuscular injection to a 2-1/2-year-old child? 1. We will give you your shot when your mommy comes back. 2. This is medicine that will make you better. First we will hold your leg, then I will wipe it off with this magic cloth that kills the germs on your leg right here, then I will hold the needle like this and say one, two, three . . . go and give you your shot. Are you ready? 3. It is all right to cry, I know that this hurts. After we are done you can go to the box and pick out your favorite sticker. 4. This is a magic sword that will give you your medicine and make you all better. - ANS 3. It is all right to cry, I know that this hurts. After we are done you can go to the box and pick out your favorite sticker. The parents of a 1-year-old infant are concerned that this baby seems more shy and scared of new situations than their other child and ask the nurse if this is normal. The nurse knows that the infant is exhibiting a characteristic of the slow-to-warm-up. Which statement to the parents is most appropriate by the nurse? 1. Your infant is showing a regularity in patterns of eating. 2. Your infant displays a predominantly negative mood. 3. Your infant initially reacts to new situations by withdrawing. 4. Your infant has intense reactions to the environment. - ANS 2. Your infant displays a predominantly negative mood. The nurse educator is presenting a lecture about risks to developmental progression. Which items will the educator include in the lecture? Select all that apply. 1. Family support 2. Access to the Internet 3. Recent loss of employment 4. Terminal illness of a family member 5. Hazards within the home environment - ANS 3. Recent loss of employment 4. Terminal illness of a family member 5. Hazards within the home environment The nurse is performing an assessment of the ecological systems of childhood. What will the nurse include when assessing mesosystems? Select all that apply. 1. Parental involvement in school 2. Local political influences 3. Libraries in the community 4. Influences of the religious community 5. Age of each family member - ANS 1. Parental involvement in school 4. Influences of the religious community The nurse is taking a health history from a family of a 3-year-old child. Which statement by the nurse would most likely establish rapport and elicit an accurate response from the family? 1. Does any member of your family have a history of asthma, heart disease, or diabetes? 2. Hello, I would like to talk with you and get some information on you and your child. 3. Tell me about the concerns that brought you to the clinic today. 4. You will need to fill out these forms; make sure that the information is as complete as possible. - ANS 3. Tell me about the concerns that brought you to the clinic today. When assessing the cognitive development, which technique would be appropriate to test the remote memory of a 5-year-old? 1. Say the name of an object and after 5 minutes ask the child to tell you what you said the object was. 2. Ask the child to repeat his address. 3. Ask the child to say a poem and listen to the child's speech articulation. 4. Have the child point to various parts of the body as you name them. - ANS 2. Ask the child to repeat his address. Place the nursing assessments of a toddler in the best order. Choice 1. Examination of eyes, ears, and throat Choice 2. Auscultation of chest Choice 3. Palpation of abdomen Choice 4. Developmental assessment - ANS Choice 4. Developmental assessment Choice 2. Auscultation of chest Choice 3. Palpation of abdomen Choice 1. Examination of eyes, ears, and throat While assessing a 10-month-old African American infant, the nurse notices that the sclerae have a yellowish tint. Which organ system should the nurse further evaluate to determine an ongoing disease process? 1. Cardiac 2. Respiratory 3. Gastrointestinal 4. Genitourinary - ANS 3. Gastrointestinal A nurse caring for a school-age client notices some swelling in the childs ankles. The nurse presses against the ankle bone for five seconds, then releases the pressure and notices a markedly slow disappearance of the indentation. Which priority nursing assessment is appropriate? 1. Skin integrity, especially in the lower extremities 2. Urine output 3. Level of consciousness 4. Range of motion and ankle mobility - ANS 2. Urine output A new mother is worried about a soft spot on the top of her newborn infants head. The nurse informs her that this is a normal physical finding called the anterior fontanel. At what age will the nurse educate the mother that the soft spot will close? 1. 2 to 3 months of age 2. 6 to 9 months of age 3. 12 to 18 months of age 4. Approximately 2 years of age - ANS 3. 12 to 18 months of age While inspecting a 5-year-old childs ears, the nurse notes that the right pinna protrudes outward and that there is a mass behind the right ear. In light of these findings, which vital-sign parameter would the nurse assess on priority? 1. Temperature 2. Heart rate 3. Respirations 4. Blood pressure - ANS 1. Temperature A 7-year-old child presents to the clinic with an exacerbation of asthma symptoms. On physical examination, the nurse would expect which assessment findings? Select all that apply. 1. Wheezing 2. Increased tactile fremitus 3. Decreased vocal resonance 4. Decreased tactile fremitus 5. Bronchophony - ANS 1. Wheezing 3. Decreased vocal resonance 4. Decreased tactile fremitus The nurse is caring for a newly-admitted infant diagnosed with failure to thrive. The nurse begins to implement the healthcare provider prescribed orders by taking blood pressures in all four extremities. Which congenital cardiac defect does the nurse anticipate based on the prescribed order? 1. Tetralogy of Fallot 2. Pulmonary atresia 3. Coarctation of the aorta 4. Ventricular septal defect - ANS 3. Coarctation of the aorta During an examination, a nurse asks a 5-year-old child to repeat his address. What is the nurse evaluating with this action? 1. Recent memory 2. Language development 3. Remote memory 4. Social-skill development - ANS 3. Remote memory During the newborn examination, the nurse assesses the infant for signs of developmental dysplasia of the hip. A finding that would strongly indicate this disorder would be: 1. soles are flat with prominent fat pads. 2. positive Babinski reflex. 3. metatarsus varus. 4. asymmetric thigh and gluteal folds. - ANS 4. asymmetric thigh and gluteal folds. The nurse must assess each of the 2-year-olds listed below. Which one should be evaluated first? 1. A child with a temperature of 101 degrees F 2. A child who has stridor 3. A child who has absent Babinski sign 4. A child who has a pot belly appearance - ANS 2. A child who has stridor The nurse notes a history of a grade III heart murmur in a small infant. When assessing the heart, the nurse would expect to: 1. hear a quiet but easily heard murmur. 2. hear a moderately loud murmur without a palpable thrill. 3. hear a very loud murmur with easily palpable thrill. 4. listen without a stethoscope and hear a murmur at chest wall. - ANS 2. hear a moderately loud murmur without a palpable thrill. The nurse is measuring an abdominal girth on a child with abdominal distension. Identify the area on the child's abdomen where the tape measure should be placed for an accurate abdominal girth. 1. Just above the umbilicus, around the largest circumference of the abdomen 2. Below the umbilicus 3. Just below the sternum 4. Just above the pubic bone - ANS 1. Just above the umbilicus, around the largest circumference of the abdomen The nurse is preparing to assessment a toddler client. Which activities would gain cooperation from the toddler? Select all that apply. 1. Asking the parents to wait outside 2. Allowing the client to sit in the parents lap 3. Administering vaccinations prior to the assessment 4. Handing the client a stethoscope while taking the health history 5. Making a game out of the assessment process - ANS 2. Allowing the client to sit in the parents lap 4. Handing the client a stethoscope while taking the health history The nurse is assessing an infant client during a health supervision visit. Which assessment findings are considered normal variations for this client? Select all that apply. 1. Sucking pads in the mouth 2. A rounded chest 3. Hearing breath sounds over the entire chest 4. Pubertal development 5. Knock-knees - ANS 1. Sucking pads in the mouth 2. A rounded chest 3. Hearing breath sounds over the entire chest The nurse is conducting a health surveillance visit with a 6-month-old infant. Which methods are appropriate to monitor the infants growth pattern since birth? Select all that apply. 1. Weigh the infant twice and average together 2. Measure the infants height 3. Measure the infant's head circumference 4. Determine the infant's body mass index 5. Plot the infants growth on appropriate chart - ANS 1. Weigh the infant twice and average together 3. Measure the infant's head circumference 5. Plot the infants growth on appropriate chart A nursery nurse is planning care for the newborns currently in the newborn nursery. Which activities does the nurse plan for the first 48 hours of life? Select all that apply. 1. Monitor feeding behaviors. 2. Perform a hearing screening. 3. Perform a heel stick to obtain blood for the newborn screen. 4. Monitor the mother as she performs the first newborn bath to remove blood and amniotic fluids. 5. Administer folic-acid injection to the infant to prevent bleeding. - ANS 1. Monitor feeding behaviors. 2. Perform a hearing screening. 3. Perform a heel stick to obtain blood for the newborn screen. The nurse is planning care for clients seen in a newborn clinic. Which is the priority for a newborn client during the first clinic visit? 1. Providing pamphlets to reinforce information provided at the visit 2. Assessing the newborn-and-family interactions 3. Modeling infant-nurturing behaviors 4. Informing the parents of the infants gains in height and weight - ANS 2. Assessing the newborn-and-family interactions The nurse in the newborn nursery is admitting a neonate. To determine the health and development of the newborn, what will the nurse include in the assessment? Select all that apply. 1. Head circumference 2. Body length 3. Weight 4. Length of pregnancy 5. Hearing screens - ANS 1. Head circumference 2. Body length 3. Weight 4. Length of pregnancy An infant weighs 9 pounds, 3 ounces at birth. The nurse plans to make a home visit to the mother and infant when the infant is 7 days old. What is the lowest acceptable weight the infant should be at this age? 1. 7 pounds, 12 ounces 2. 8 pounds, 2 ounces 3. 8 pounds, 12 ounces 4. 9 pounds - ANS 2. 8 pounds, 2 ounces The nurse is teaching a new mother developmental expectations. Which activity should the nurse expect a newborn to do within the first month of life? 1. Bring hands to eyes and mouth. 2. Push up with hands, moving chest up. 3. Keep hands in a relaxed position. 4. Roll over from back to abdomen. - ANS 1. Bring hands to eyes and mouth. The nurse is providing anticipatory guidance instructions to the parents of a newborn. Which instruction should the nurse give as a strategy for illness/disease prevention? 1. Don't allow visitors for the first month. 2. Smoke outside only. 3. Take the newborn to weekly child-stimulation classes. 4. SIDS risk-reduction measures - ANS 4. SIDS risk-reduction measures A nurse assesses the height and weight measurements on an infant and documents these measurements at the 75th percentile. The nurse notes that the previous measurements two months ago were at the 25th percentile. Which interpretation by the nurse is the most accurate? 1. The infant is not gaining enough weight. 2. The infant has gained a significant amount of weight. 3. The previous measurements were most likely inaccurate. 4. These measurements are most likely inaccurate. - ANS 2. The infant has gained a significant amount of weight. A nurse asks the mother of a 4-month-old infant to undress the infant. The nurse observes the mother taking off several layers of clothing and knows that the outdoor temperature is 70 degrees Fahrenheit. Which statement by the nurse is most appropriate in this situation? 1. My, you are dressing your infant warmly today. 2. Did you think it was cold when you left your home this morning? 3. I see that you have many layers of clothing on your baby. This may cause your baby's temperature to rise. 4. When you leave the office, only put one layer of clothing on your baby. - ANS 3. I see that you have many layers of clothing on your baby. This may cause your baby's temperature to rise. The nurse working with a family has observed that the older children have a large number of dental caries and plans to provide the mother with information to prevent the development of dental caries in her new infant. Which interventions will prevent the development of dental caries in the infant? Select all that apply. 1. Avoiding nursing or giving the infant a bottle at bedtime 2. Giving foods high in sugar only at breakfast time 3. Using a soft moist gauze for cleaning 4. Using a topical anesthetic daily beginning as soon as the first tooth begins to erupt - ANS 1. Avoiding nursing or giving the infant a bottle at bedtime 3. Using a soft moist gauze for cleaning A nurse is assessing an 11-month-old infant and notes that the infants height and weight are at the 5th percentile on the growth chart. Family history reveals that the infants two siblings are at the 50th percentile for height and at the 75th percentile for weight. Psychosocial history reveals that the parents are separated and are planning to divorce. Which of these nursing diagnoses takes priority? 1. Alteration in Growth Pattern Related to Parental Anxiety 2. Alteration in Growth Pattern Secondary to Familial Short Stature 3. Nutritional Intake: Excessive Secondary to Maternal Feeding Patterns 4. At Risk for Constitutional Growth Delay Related to Decreased Appetite - ANS 1. Alteration in Growth Pattern Related to Parental Anxiety While teaching parents of a newborn about normal growth and development, which statement is most appropriate for the nurse to include in the session? 1. Weight should triple by 6 months of age. 2. Weight should double by 1 year of age. 3. Weight should double by 4 months of age. 4. Weight should triple by 1 year of age. - ANS 4. Weight should triple by 1 year of age. A mother who is bottle feeding her newborn asks to be discharged 24 hours post delivery, because she also has twin 2-year-old children at home. When should the nurse schedule the first office visit for this newborn? 1. Within 48 hours of discharge 2. Within one week of discharge 3. Within two weeks of discharge 4. When the infant is 1 month old - ANS 1. Within 48 hours of discharge A follow-up visit for a newborn client is scheduled with the pediatric nurse practitioner 3 days after discharge. What will the nurse include in the assessment during the scheduled visit for this newborn? Select all that apply. 1. Feeding pattern 2. Jaundice 3. Length 4. Vision screen 5. Sleep pattern - ANS 1. Feeding pattern 2. Jaundice 5. Sleep pattern A mother asks which developmental milestones she can expect when her baby is 6 months old. Which response by the nurse is the most appropriate? 1. Lifts head momentarily when prone 2. Has well-developed pincer grasp 3. Transfers objects from one hand to the other 4. Rolls from front to back - ANS 3. Transfers objects from one hand to the other Injury prevention is an important aspect of parent teaching. Which injury prevention strategy would reduce the risk of suffocation? 1. Measure crib slat spacing at 2-3/8 inches or less. 2. Never leave an infant alone in a bath. 3. Position the infant on her back to sleep. 4. Use only approved restraint systems. - ANS 3. Position the infant on her back to sleep. The nurse is assessing an infant client and parents during a routine health supervision visit at 2 months of age. Which items will the nurse assess to determine if the infants mental health needs are being addressed? Standard Text: Select all that apply. 1. Immunization record 2. Newborn screen results 3. Temperament during the visit 4. Feeding schedule 5. Sleep-wake patterns - ANS 3. Temperament during the visit 4. Feeding schedule 5. Sleep-wake patterns Which of these aspects of developmental health supervision should be included in each healthcare visit of young children? Select all that apply. 1. Assessment 2. Discipline 3. Education 4. Intervention 5. Toilet training - ANS 1. Assessment 3. Education 4. Intervention A 27-month-old toddler who is in the pediatric office for a well-child visit begins to cry the moment he is placed on the examination table. The parent attempts to comfort the toddler; however, nothing is effective. Which of these actions by the nurse takes priority? 1. Instruct the father to hold the toddler down tightly to complete the examination. 2. Allow the toddler to sit on the parents lap and begin the assessment. 3. Allow the toddler to stand on the floor until he stops crying. 4. Ask another nurse in the office to hold the toddler, since the parent is not able to control the toddlers behavior. - ANS 2. Allow the toddler to sit on the parents lap and begin the assessment. At a routine healthcare visit, a nurse measures a toddler and plots the height and weight on the growth charts. The nurse documents that the toddler is above the 95th percentile for weight and is at the 5th percentile for height. How should the nurse interpret these data? 1. The toddler is proportionate for the age. 2. The toddler needs to eat more at each feeding. 3. The height and weight are disproportionate, and the toddler needs further evaluation. 4. The family is most likely short. - ANS 3. The height and weight are disproportionate, and the toddler needs further evaluation. A nurse is preparing to perform a physical assessment on a toddler. Which action is most appropriate for the nurse to take? 1. Perform the assessment from head to toe. 2. Leave intrusive procedures such as ear and eye examinations until the end. 3. Explain each part of the examination to the child before performing it. 4. Ask the mother to tell the child not to be afraid. - ANS 2. Leave intrusive procedures such as ear and eye examinations until the end. Which of these developmental milestones should the nurse expect to find in children who are between 2 and 3 years old? Select all that apply. 1. Always feeds self 2. Scribbles and draws on paper 3. Kicks a ball 4. Throws ball overhand 5. Goes up and down stairs - ANS 2. Scribbles and draws on paper 3. Kicks a ball 5. Goes up and down stairs A nurse observes the parent/child interaction during the 4-year-old well-child checkup and notes that the parent speaks harshly to the child and uses negative remarks when speaking with the nurse. Which statement by the nurse would be most beneficial? 1. Perhaps you should leave the room so that I can speak with your child privately. 2. I am going to refer you for counseling since your interactions with your child seem so negative. 3. Let's talk privately. Let's discuss the way you speak with your child and possible ways to be more positive. 4. Addressing the child, the nurse says, Are you unhappy when Mommy talks to you like this? - ANS 3. Let's talk privately. Let's discuss the way you speak with your child and possible ways to be more positive. A nurse who is the manager of an ambulatory pediatric healthcare center is planning protocols for the routine healthcare visits of the children. Children at this care center have a high incidence of obesity. At which age should the nurses at this clinic calculate the body mass index (BMI) for all pediatric clients? 1. 12 months 2. 24 months 3. 36 months 4. 4 years - ANS 2. 24 months Which of these measures used by a nurse will help relieve parental anxiety related to the changing appetite in the toddler who is gaining weight along the 50th percentile? 1. Discussing the growth of the toddler as compared to the growth chart 2. Suggesting ways to have the toddler eat higher calorie foods 3. Instructing the mother to feed the toddler alone without any distractions such as TV or music 4. Teaching the mother to avoid disciplining the toddler within one-half hour of eating - ANS 1. Discussing the growth of the toddler as compared to the growth chart Parents of a preschool child report that they find it necessary to spank the child at least once a day. Which response should the nurse make to the parents? 1. Spanking is one form of discipline; however, you want to be certain that you do not leave any marks on the child. 2. Lets talk about other forms of discipline that have a more positive effect on the child. 3. Can you try only spanking the child every other day for one week and see how that affects the child's behavior? 4. I think you are not parenting your child properly, so let's talk about ways to improve your parenting skills. - ANS 2. Lets talk about other forms of discipline that have a more positive effect on the child. A parent questions how her toddler plays with other toddlers. Which response by the nurse displays the best description of the differences in play between the toddler and the preschooler? 1. Toddlers play side by side, while preschoolers play cooperatively. 2. Toddlers play house and imitate adult roles, while preschoolers become the Mom or Dad while playing house. 3. Toddlers play cooperatively, while preschoolers play interactive games. 4. There are no differences between toddlers and preschoolers since both groups play cooperatively. - ANS 1. Toddlers play side by side, while preschoolers play cooperatively. A mother of an 18-month old asks the nurse whether she can begin to introduce low-fat milk like the rest of the family drinks. The nurse answers the mother based on the knowledge that low-fat milk can safely be introduced at what age? 1. 18 months 2. 24 months 3. 3 years 4. 4 years - ANS 2. 24 months The nurse is evaluating the car seat of a 3-year-old who weighs 42 pounds. Which recommendation should the nurse make about the car seat to the parents? 1. Convertible, rear-facing seat 2. Belt-positioning booster seat 3. A car seat with a harness approved for higher weights and heights 4. A regular seat with lap and shoulder strap - ANS 3. A car seat with a harness approved for higher weights and heights During a clinic visit, the parents of a 15-month-old ask what disease and injury prevention topics would be appropriate to discuss at this age. Which response by the nurse is the most appropriate? 1. It's never too early to teach a child to wear a helmet when riding a bicycle. 2. Teaching simple handwashing is a good topic at this age. 3. Tell the child over and over to stay away from water unless you are with him. 4. Tell him firmly no when he tries to cross the street. - ANS 2. Teaching simple handwashing is a good topic at this age. Which assessment question would get the most accurate response when a nurse is assessing learning/reading skills in the early childhood years? 1. What rewards do you use when your child does something good? 2. What is your childs language like now? 3. Does your child get along well with others? 4. Do you keep books for your child readily available? - ANS 4. Do you keep books for your child readily available? The nurse is asked to teach injury prevention measures to a classroom of 4-year-old preschoolers. Which teaching points are most appropriate at this age? Select all that apply. 1. Stop, drop and roll if clothes catch fire 2. Never go into the road alone. 3. Acceptable places for climbing 4. Safe meeting place outside the house in case of fire 5. Car seat safety - ANS 1. Stop, drop and roll if clothes catch fire 2. Never go into the road alone. 4. Safe meeting place outside the house in case of fire 5. Car seat safety The nurse is performing a well-child exam on a child who turned 4 years old 3 months ago. What can the nurse ask the child to do to assess appropriate milestones for this age? 1. Jump up and down 2. Throw a ball 3. Stack three or more blocks 4. Draw lines on paper - ANS 2. Throw a ball Which health promotion activities can the nurse recommend to the parents of a preschool-age child in order to enhance the childs self-concept? Select all that apply. 1. Encourage a play date with a school-age child. 2. Praise the child for staying dry at night. 3. Tell the child there will be a punishment for bathroom accidents. 4. Set aside time for the child each day. 5. Discuss appropriate activities to engage in with the daycare provider. - ANS 1. Encourage a play date with a school-age child. 2. Praise the child for staying dry at night. 4. Set aside time for the child each day. The nurse is planning care for a preschool-age child and family. In order to assess the family, what should the nurse plan to do during each health supervision visit? Select all that apply. 1. Discuss of the child's developmental status 2. Observe interactions among the family members 3. Discuss concerns with the parents 4. Administer age appropriate vaccinations 5. Record height and weight - ANS 1. Discuss of the child's developmental status 2. Observe interactions among the family members 3. Discuss concerns with the parents An adolescent female presents at a nurse practitioners office and requests a signature for working papers. The nurse reviews her chart and notes that the last physical examination was two years ago. In addition to providing the signature for the working papers, what else should the nurse use this visit? 1. An opportunity to discuss birth-control measures 2. A time to discuss exercise and sports participation 3. A health-supervision opportunity 4. A chance to discuss the importance of pursuing post secondary education - ANS 3. A health-supervision opportunity An adolescent is accompanied by the mother for an annual physical examination. The nurse is aware of privacy issues related to the adolescent. While the mother is in the room, the nurse should avoid which questions? Select all that apply. 1. Sexual activity 2. Cigarette smoking 3. School performance 4. Use of alcohol 5. Car seatbelt use - ANS 1. Sexual activity 2. Cigarette smoking 4. Use of alcohol The school nurse performs screenings on all students in the middle school. In addition, the nurse will perform selected screenings on individual school-age children. When planning the screenings for the year, which screenings will the nurse include for all school-age children? Select all that apply. 1. Hearing 2. Height and weight 3. Blood-pressure measurement 4. Hepatitis B profile serology 5. Chest x-ray - ANS 1. Hearing 2. Height and weight 3. Blood-pressure measurement A school nurse is performing annual height and weight screening. The nurse notes that three females who are close friends each lost 15 pounds over the past year. What is the priority nursing action in this situation? 1. Call the respective parents to discuss the eating patterns of each adolescent. 2. Speak with the girls in a group to discuss the problems associated with anorexia nervosa. 3. Refer these adolescents to the school psychologist. 4. Obtain a nutritional history for each of these adolescents. - ANS 4. Obtain a nutritional history for each of these adolescents. An school-age client who recently moved to a new school in a different town presents to an ambulatory care center and describes the following: I have no friends in my new school, and I no longer want to go to play soccer. I know I will be lonely there, too. Which of these takes priority when speaking with the school-age client? 1. Helping the school-age client realize the value of soccer 2. Promoting healthy mental-health outcomes 3. Acknowledging the fact that it takes several months to make new friends at a new school 4. Stressing the importance of remaining in a close parent-child relationship during these stressful times - ANS 2. Promoting healthy mental-health outcomes An adolescent reports participating in an exercise program at school each Wednesday throughout the school year. Further history reveals that the adolescent does not participate in any other physical activities. Which outcome is most appropriate for this adolescent? 1. The adolescent is reporting information consistent with what 60 percent of adolescents report as participation in physical activities. 2. The adolescent is not meeting the recommendations of the Healthy People 2020 initiative. 3. The adolescent should be encouraged to continue this program of exercise, since something is better than nothing. 4. The adolescent should be encouraged to vigorously exercise for at least five minutes each day. - ANS 2. The adolescent is not meeting the recommendations of the Healthy People 2020 initiative. An adolescent reports the following: I get up at 6 am, I attend early-morning band classes three times each week, I play sports for two hours each day after school, and homework takes me three hours each night. I always feel tired. Which question by the nurse is most appropriate based on this information? 1. How many hours of sleep do you get each night? 2. Do you consume foods high in iron? 3. Do you think you are doing too much? 4. Have you considered talking with your teachers about decreasing your homework, since you have so many extracurricular activities? - ANS 1. How many hours of sleep do you get each night? The nurse working in the clinic includes an adolescent history in every client intake interview. Which issue should the nurse address when the parents are not present? 1. Possible domestic violence 2. Teen job responsibilities 3. Activities that are done as a family 4. The adolescents role in the family - ANS 1. Possible domestic violence The nurse is reviewing the immunization record of an adolescent who will be seen later in the day. Which item in the client's history makes hepatitis B status a priority? 1. Chronic acne 2. Overuse injuries from playing varsity sports 3. Chronic asthma 4. Plans to get a tattoo - ANS 4. Plans to get a tattoo An obese adolescent who adamantly denies sexual activity has a positive pregnancy test, which was performed in the adolescent clinic. Which statement by the nurse is the most appropriate in this situation? 1. Tell me how you feel about your body image. 2. When was your last menstrual period (LMP)? 3. Let's discuss some activities that you have done within the past few months that could possibly lead to pregnancy. - ANS 3. Let's discuss some activities that you have done within the past few months that could possibly lead to pregnancy. A mother reports that her adolescent is always late. The mother states, She was born late and has been late every day of her life. Which response should the nurse make to this mother? 1. You need to establish specific time frames for your adolescent and be certain she adheres to them. 2. You should not expect your adolescent to be an on-time individual unless you set specific alarms and then reinforce the value of being on-time. 3. You should not expect your adolescent to be on time. Teenagers are always late. 4. You have a major problem. There must be a lot of screaming in your home. - ANS 2. You should not expect your adolescent to be an on-time individual unless you set specific alarms and then reinforce the value of being on-time. When examining a 7-year-old, which action by the nurse would be most appropriate? 1. Allow the child to participate in the exam. 2. Ask the parent what kind of food the child likes to eat. 3. Ask the child whether he plays outside for at least 30 minutes a day. 4. Allow the child to decide whether he is ready for his next immunization. - ANS 1. Allow the child to participate in the exam. The school health nurse recognizes that children who display certain characteristics are at risk for poor school performance. The nurse will, therefore, observe each school-age child for which characteristics? Select all that apply. 1. Decreased ability to perform visual tracking. 2. Decreased auditory stimulation. 3. Decreased muscle tone. 4. Multiple dental caries. 5. Chronic tonsillitis. - ANS 1. Decreased ability to perform visual tracking. 2. Decreased auditory stimulation. 3. Decreased muscle tone. A nurse obtains a nutritional health history from a 10-year-old child. Which of these food selections, if consumed on a regular basis, should lead the nurse to become concerned about the need for improving oral hygiene? 1. Peanuts and crackers 2. Sorbet and yogurt 3. Gummy bears and licorice 4. Fluoridated water - ANS 3. Gummy bears and licorice The school health nurse is evaluating the home environment of several children as it relates to child safety. The nurse visits the home of each child and gathers the following data. Which activity places a child at greatest risk for bodily harm? 1. The parents are in a methadone program. 2. The parents consume alcohol on a daily basis. 3. The child is permitted to target practice with a revolver, unsupervised. 4. The child is a latchkey child. - ANS 3. The child is permitted to target practice with a revolver, unsupervised. The school nurse is teaching a class about safety. The nurse will teach the children that they should wear protective athletic gear when participating in selected activities. Which of these activities require protective athletic gear? Select all that apply. 1. Skateboarding 2. Playing football 3. Swimming 4. Playing lacrosse 5. Performing acrobatic tricks - ANS 1. Skateboarding 2. Playing football 4. Playing lacrosse A 9-year-old child who has been followed in the same pediatric home since birth is at the healthcare center for a well-child visit. A nurse who measures the height and weight of the child documents 35th percentile for height and 90th percentile for weight. How should the nurse interpret these data? 1. The child is beginning a growth spurt. 2. The child is obese and needs dietary counseling. 3. The parents are most likely below the 50th percentile for height and weight. 4. As soon as the child begins the adolescent growth spurt, the height and weight measurements will normalize. - ANS 2. The child is obese and needs dietary counseling. The nurse is preparing to complete a health surveillance appointment with a school-age client and parents. Which observations would necessitate the need for further assessment by the nurse? Select all that apply. 1. Client who does not make eye contact 2. Client with visible bruises in various stages of healing 3. Client holding a video game talking with parent 4. Client playing a card game with sibling 5. Client who appears red in the face while walking to exam room - ANS 1. Client who does not make eye contact 2. Client with visible bruises in various stages of healing 5. Client who appears red in the face while walking to exam room The parents of a critically injured child wish to stay in the room while the child is receiving emergency care. Which action by the nurse is the most appropriate? 1. Escort the parents to the waiting room and assure them that they can see their child soon. 2. Allow the parents to stay with the child. 3. Ask the physician if the parents can stay with the child. 4. Tell the parents that they do not need to stay with the child. - ANS 2. Allow the parents to stay with the child. The charge nurse on a hospital unit is developing plans of care related to separation anxiety. The charge nurse recognizes that which hospitalized child at highest risk to experience separation anxiety when parents cannot stay? 1. 6-month-old 2. 18-month-old 3. 3-year-old 4. 4-year-old - ANS 2. 18-month-old A group of children on one hospital unit are all suffering separation anxiety. Which child is experiencing the despair stage of separation anxiety? 1. Does not cry if parents return and leave again 2. Screams and cries when parents leave 3. Appears to be happy and content with staff 4. Lies quietly in bed - ANS 4. Lies quietly in bed A preschool-age client is seen in the clinic for a sore throat. In this child's mind, what is the most likely causative agent for the sore throat? 1. Was exposed to someone else with a sore throat. 2. Did not eat the right foods. 3. Yelled at his brother. 4. Did not take his vitamins. - ANS 3. Yelled at his brother. The charge nurse is concerned with reducing the stressors of hospitalization. Which nursing intervention is most helpful in decreasing the stressors for the toddler-age client? 1. Assign the same nurse to the toddler as much as possible. 2. Let the child listen to an audiotape of the mother's voice. 3. Place a picture of the family at the bedside. 4. Encourage a parent to stay with the child. - ANS 4. Encourage a parent to stay with the child. The nurse is caring for a client in the pediatric intensive-care unit (PICU). The parents have expressed anger over the nursing care their child is receiving. Which nursing intervention is most appropriate based on the situation? 1. Ask the physician to talk with the family. 2. Explain to the parents that their anger is affecting their child so they will not be allowed to visit the child until they calm down. 3. Acknowledge the parents concerns and collaborate with them regarding the care of their child. 4. Call the chaplain to sit with the family. - ANS 3. Acknowledge the parents concerns and collaborate with them regarding the care of their child. A toddler recently diagnosed with a seizure disorder will be discharged home on an anticonvulsant. Which action by the mother best demonstrates understanding of how to give the medication? 1. Verbalizing how to give the medication 2. Acknowledging understanding of written instructions 3. Drawing up the medication correctly in an oral syringe and administering it to the child 4. Observing the nurse draw up the medication and administering it to the child. - ANS 3. Drawing up the medication correctly in an oral syringe and administering it to the child The nurse must perform a procedure on a toddler. Which technique is the most appropriate when performing the procedure? 1. Ask the mother to restrain the child during the procedure. 2. Ask the child if it is okay to start the procedure. 3. Perform the procedure in the child's hospital bed. 4. Allow the child to cry or scream. - ANS 4. Allow the child to cry or scream. A young school-age client is in the playroom when the respiratory therapist arrives on the pediatric unit to give the child a scheduled breathing treatment. Which action by the nurse is the most appropriate? 1. Reschedule the treatment for a later time. 2. Show the respiratory therapist to the playroom so the treatment may be performed. 3. Escort the child to his room and ask the child-life specialist to bring toys to the bedside. 4. Assist the child back to his room for the treatment but reassure the child that he may return when the procedure is completed. - ANS 4. Assist the child back to his room for the treatment but reassure the child that he may return when the procedure is completed. The nurse is working with a hospitalized preschool-age child. The nurse is planning activities to reduce anxiety in this child. Which action by the nurse is the most appropriate? 1. Provide the child with a doll and safe medical equipment. 2. Read a story to the child. 3. Use an anatomically correct doll to teach the child about the illness. 4. Talk to the child about the hospitalization. - ANS 1. Provide the child with a doll and safe medical equipment. The nurse needs to administer a medication to a preschool-age child. The medication is only available in tablet form. Which action by the nurse is the most appropriate? 1. Place the tablet on the child's tongue and give the child a drink of water. 2. Break the tablet in small pieces and ask the child to swallow the pieces one by one. 3. Crush the tablet and mix it in a teaspoon of applesauce. 4. Crush the table and mix it in a cup of juice. - ANS 3. Crush the tablet and mix it in a teaspoon of applesauce. A child is being discharged from the hospital after a 3-week stay following a motor vehicle accident. The mother expresses concern about caring for the child's wounds at home. She has demonstrated appropriate technique with medication administration and wound care. Which nursing diagnosis is the priority in this situation? 1. Knowledge Deficit of Home Care 2. Altered Family Processes Related to Hospitalization 3. Parental Anxiety Related to Care of the Child at Home 4. Risk for Infection Related to Presence of Healing Wounds - ANS 3. Parental Anxiety Related to Care of the Child at Home An infant has been NPO for surgery for 4 hours and does not have an intravenous line. The nurse receives a call from the operating room with the information that the surgery has been postponed due to an emergency. Which action by the nurse is the most appropriate? 1. Feed the infant 4 ounces of formula. 2. Reassure the parents that it will not be much longer before surgery. 3. Allow the parents to feed the infant an ounce of oral rehydration solution. 4. Call the physician to see if the infant needs to have an intravenous line started. - ANS 4. Call the physician to see if the infant needs to have an intravenous line started. The nurse is working with an adolescent client who will be admitted to the hospital in two days. Which nursing approach is most appropriate to prepare this client for hospitalization? 1. Have teens who have had similar experiences talk to the adolescent about hospitalization. 2. Provide an opportunity for the child to talk with an adult who has had a similar experience. 3. Teach parents what to expect so the information can be shared with the adolescent. 4. Provide an opportunity for the teen to try on surgical attire. - ANS 1. Have teens who have had similar experiences talk to the adolescent about hospitalization. The nurse is providing care to a school-age client who is admitted to the hospital after a motor vehicle accident. Which interventions are appropriate to prepare this client and family for their hospital stay? Select all that apply. 1. A hospital tour 2. A health fair brochure 3. An orientation to the unit 4. An age-appropriate explanation of procedures 5. A child life program consultation - ANS 3. An orientation to the unit 4. An age-appropriate explanation of procedures 5. A child life program consultation The nurse is providing care to a preschool-age client who was admitted to the medicalsurgical unit after an acute asthma attack. Which interventions foster a family-centered focus to client care? Select all that apply. 1. Discussing rooming in with the parents of the client 2. Allowing the client to cry it out after the parents leave for the evening 3. Providing comfort items from home, such as a blanket 4. Maintaining strict visitation for the family 5. Discussing what to expect during the hospital stay - ANS 1. Discussing rooming in with the parents of the client 3. Providing comfort items from home, such as a blanket 5. Discussing what to expect during the hospital stay The nurse is ad