1200 Hesi Questions Pediatrics Exam Version B

1200 HESI QUESTIONS PEDIATRICS EXAM VERSION B1.The nurse is preparing to catheterize an 8-year-old child. Before starting the procedure, which action should the nurse take first? A. Obtain the parent's cooperation before initiating the procedure. B. Explain to the child and the parents that the procedure needs to be done. C. After talking with the parents about the procedure, ask them to leave the room. D. Provide the child with privacy by conducting the procedure in the treatment room. An 8-year-old uses concrete operational thought (Piaget), can cooperate, and should be included in the plan of care (B). (A) is indicated for a pre-school aged child, and does not acknowledge the school-aged child's cognitive ability. (C and D) may be needed, but should occur after (B). Points Earned: 0/1 Correct Answer: B You r Response: D 2. Which neurological test should the nurse implement to assess cerebellar function in a 5-year-old with symptoms of hyperactivity? A. Finger-to-nose. B. Quadriceps reflex. C. Two-point discrimination. D. Ability to follow directions. The cerebellum controls balance and coordination and is significant in children with symptoms of hyperactivity or learning difficulty, so difficulty in performing a finger-tonose test (A) indicates poor sense of position (especially with the eyes closed) and incoordination (especially with the eyes opened). Superficial reflexes (B), sensory discrimination (C), and ability to follow directions (D) are aspects of a neurologic examination but do not test cerebellar function. Points Earned: 0/1 Correct Answer: A 2 | P a g eYour Response: C 3. An infant with developmental dysplasia of the hip is placed in a Pavlik harness. What instructions should the nurse include in a teaching plan for the parents? A. Apply lotion or powder to minimize skin irritation. B. Put clothing over harness for maximum effectiveness. Check for red areas under the straps three times a day. . D.Use a thin absorbent disposable diaper over the harness. The Pavlik harness, which maintains the hips in abduction, is the most widely used device for developmental dysplasia of the hip. An infant who continuously wears a Pavlik harness is at risk for skin breakdown, so parents should be instructed to check two to three times a day for red areas under clothing and harness straps (C). Lotions and powders (A) can cake or irritate the skin and should be avoided. To avoid direct contact with the skin, clothing and diapers should be placed under the straps (B and D). Points Earned: 1/1 Correct Answer: C Your Response: C 4.Which research finding provides evidence-based practice for an infant's risk for sudden infant death syndrome (SIDS)? A. Breastfeeding reduces the risk for and the incidence of SIDS. B. Infants should be positioned supine or supported laterally to sleep. C. The prone position should be used when an infant sleeps after feeding. D. The peak incidence occurs between the ages of 1 and 2 months. Research has shown that placing babies on their backs for sleep reduces the risk of SIDS (B). Although breastfeeding is recommended to boost neonatal immunity, (A) is unrelated to SIDS. A population-based study found the prone sleep position (C) was associated with twice (2.4% odds ratio) the rate of SIDS compared with infants placed nonprone to sleep. SIDS remains the third leading cause of death in children between the ages of 1 month and 1 year, not (D). Points Earned: 0/1 Correct Answer: B Your Response: D 5. During the well-child assessment of an 18-month-old male toddler, the nurse determines the child does not walk while holding on to furniture but prefers to crawl, rarely speaks, has a flat affect, and is small for his age. Which nursing diagnosis should the nurse formulate? A. Alteration in nutrition. B. Alteration in parenting. C. Delayed growth and development. D. Alteration in health maintenance. 3 | P a g eThis child does not demonstrate gross motor or psychosocial skills typical of an 18- month-old toddler, which best supports delayed growth and development (C). Additional information about the child's growth parameters is needed to support (A, B, or D). Points Earned: 0/1 Correct Answer: C Your Response: A 6. A 4-year-old boy is brought to the emergency department by his parent, who reports that the child has been pointing at his stomach and saying, "It hurts so bad." Which pain-assessment tool should the nurse use? A. Descriptor Scale. B. Brief Pain Inventory. C. A numeric rating scale. D. Wong-Baker FACES Scale. A pain rating scale using pictures, such as the Wong-Baker FACES Scale (D), allows the child to choose a facial expression that shows how much hurt you have now and should be used for a preschool-aged child. (A, B, and C) are used for older children who are able to conceptualize pain using a number or descriptive narratives. Points Earned: 0/1 Corre ct Answ er: D Your Resp onse: 7. The parents of a child with Asperger's disorder asks the nurse to explain the differences between Asperger's and autism. Which information should the nurse share with the parents about Asperger's disorder that is not characteristic in autism? A. Obsession with moving objects. B. Repetitive patterns of behavior. C Age-appropriate language development. . D.Stereotypic movements and speech patterns. Communication is not delayed in Asperger's disorder (C), but impaired communication with delays of spoken language is characteristic of autism. Asperger's disorder has many characteristics also found in autistic disorder, such as self-injurious behavior, behaviors 4 | P a g ethat lead to social impairment (A), and restrictive, repetitive forms of behaviors (B and D). Points Earned: 0/1 Correct Answer: C Your Response: C 8. The nurse notices that the hem of a skirt on a pre-adolescent girl is uneven when she comes to the clinic. What procedure should the nurse follow to examine the girl for scoliosis? (Arrange the examination process from first on top to last on the bottom.) A. Ask the girl to remove her shirt but leave on her bra or swimsuit top. B. Examine for scapular prominence. C. Look for asymmetry in the hip area. D. Instruct the girl to bend at the waist so back is parallel to the floor. To screen for scoliosis, the girl should first be asked to remove her shirt, wear her bra, or wear a swimsuit top. Then, as she stands erect, observe for asymmetry of the shoulders, back and hips while standing behind the girl. Next, ask her to bend forward so that the back is parallel to the floor, and finally observe from the side and the back, noting asymmetry or prominence of the rib cage and scapulae. Points Earned: 0/4 Correct Answer: A:1, B:4, C:2, D:3 Your Response: A:-, B:-, C:-, D:- 9. The parents of a 14-year-old girl tell the nurse that their daughter dresses as a tomboy and plays baseball one day and the next day dresses in feminine clothes and becomes a teenage drama queen. What information should the nurse use to respond to the parents? A. Teenagers need a strong role mode to emulate. B. Adolescents try on different roles while seeking their identity. C. Such erratic behavior needs further investigation. D. Fourteen-year-olds often try to please parents with their role choices. As teenagers seek their own identity, they try on different roles to see if they fit (B). Although role models (A) are important, they do not explain the adolescent's exploration for self-identity. Such behaviors seem erratic, but are normal adolescent experiences that needs no further investigation (C). (D) does not provide the best explanation. Points Earned: 0/1 Correct Answer: B Your Response: D 5 | P a g e10. A 2-year-old is receiving care in the emergency department (ED) for a deep laceration on the head. What action should the nurse implement to facilitate the child's cooperation? A. Allow the child to hold a favorite toy or blanket. B. Direct the parents to remain outside the treatment room. C. Keep the child physically restrained during nursing care. D. Let the child decide whether to sit up or lie down for procedures. Allowing a child to hold a favorite toy or blanket (A) provides familiarity and comfort which should facilitate the child's cooperation during treatment. Parents should remain with the child, not (B), to calm and reassure a child who may perceive the ED environment as threatening. A toddler needs autonomy and may not respond well to restriction, such as restraints (C), which should be limited or removed as soon as safety permits. (D) should not be offered to a toddler who is not capable of understanding a position (D) that might be needed during a treatment or procedure. Points Earned: 0/1 Correct Answer: A Your Response: B 11. A 4-year-old is brought to the emergency room for a laceration on the right foot. What action should the nurse implement to help the child in coping with the emergency room experience? A. Avoid the use of bandages to keep wounds open to air. B. Remind the preschooler how big children should act. C. Give the child some time after explaining procedures. D. Avoid using jargon, such as shot, when giving care. Using positive terms and avoiding words that have frightening connotations (D) assist the preschool-age child in coping with an emergency room experience. Bandages (A) are important to preschool-aged children because this age group often believe bandages stop their insides from leaking out. Children need to feel comfortable expressing their fears and feelings and should not be shamed into cooperation by referencing expected big children behaviors (B). Preschool-age children should be told about procedures immediately before they are performed (C), which minimizes the time a child fantasies about the treatment, which causes increased anxiety. Points Earned: 0/1 Correct Answer: D Your Response: B 12. A 6-year-old child is admitted in the emergency department with a systolic blood pressure of 58 mm Hg. What action should the nurse take first? A. Comfort the child. B. Assess responsiveness. C. Alert the healthcare provider. D. Initiate IV fluid replacement. 6 | P a g eThe lower limit for systolic blood pressure for a child older than 1 year of age is 70 mm Hg plus 2 times the child's age in years, so the healthcare provider should be notified (C) of the child's hypotension, and although comforting measures should be provided (A), physiological needs should be met first. Assessing the child's responsiveness is a component of a neurologic assessment, but asystolic blood pressure of 58 mm Hg is a late sign of shock in children and requires immediate intervention (B). The healthcare provider's prescriptions, including IV fluids (D), should be obtained to address shock. Points Earned: 0/1 Correct Answer: C Your Response: D 13. A child is brought to the emergency department with sweating, chills, and snake fang-like puncture marks on the calf. What action should the nurse implement after the type of snake is identified? A. Secure the antivenin. B. Ambulate the child. C. Apply a tourniquet to the leg. D. Reassure the child and parent. Antivenin is essential to the child's survival because the child is showing signs of envenomation (A). When a bite or envenomation is located on an extremity, the extremity should be immobilized, so ambulating the child (B) is contraindicated by the venom circulation increases with the exercise. The use of a tourniquet is not recommended (C). Envenomation is a potentially life-threatening condition, so false reassurance is not helpful (D). Points Earned: 0/1 Correct Answer: A Your Response: C 14. Which finding should the nurse in the emergency department identify as an indicator that a 3-year-old child has been mistreated? A. The toddler does not remember how the injury occurred. B. The parents are extremely calm in the emergency room. C. The injury sustained is highly unusual for 3-year-old children. D. The child was doing something unsafe when the injury occurred. An injury that is highly unusual or inconsistent with the age and condition of the child should raise suspicion of child abuse (C). A 3-year-old child's attention span and interruption of events are consistent with a child's reliability as a historian or not remembering what happened (A) when the injury occurred. Culture, ethnicity, individual experiences and psychological makeup can influence parental reactions to a child who has been injured, so (B) alone is insufficient to deduce child abuse. Additional information should be obtained to determine whether the parents are negligent in the care of the child (D). Points Earned: 0/1 Correct Answer: C 7 | P a g eYour Response: D 15. A crying toddler has a blood pressure measurement of 120/70 mm Hg. What action should the nurse implement? A. Notify the healthcare provider of the measurement. B. Quiet the child and retake the blood pressure. C. Ask the parent if the child has a history of hypertension. D. Document the finding and recheck in 4 hours. When a child is crying, intra-thoracic and abdominal pressures increase and are reflected in an elevation of systemic blood pressure, so the nurse should quiet the child before retaking the blood pressure (B). (A) is not necessary until accurate readings are obtained. (C) is not necessary. An accurate pressure reading should be obtained before implementing (D). Points Earned: 1/1 Correct Answer: B Your Response: B 16. What should the nurse assess last when examining a 5-year-old child? A. Heart. B. Lungs. C. Throat. D. Abdomen. Examination of the mouth, throat, and perineum is considered to be more invasive than other parts of a physical examination, so invasive procedures, such as (C), should be left to the end of the examination for a preschooler. Assessment of (A, B, and D) is not considered as invasive or frightening to the child as (C). Points Earned: 1/1 Correct Answer: C Your Response: C 17. A 15-year-old girl tells the school nurse that she wants to have a baby. How should the nurse respond? A. "Will you be able to support the baby?" B. "Do you have plans to continue school?" C. "Have you talked with your parents about this?" D. "Can you tell me how your life will be if you have an infant?" Developing a dialogue with the teen is important, and by using open-ended questions the nurse will encourage communication and explanation. Asking the teenager to describe how the infant will affect her life (D) directs the teen to consider real life experiences and 8 | P a g eallows the nurse to assess the teen's perception and reality orientation. (A, B, and C) do not facilitate communication and may terminate the communication. Points Earned: 0/1 Correct Answer: D Your Response: C 18. The nurse is caring for a 9-year-old male child who frequently speaks about sex and uses correct sexual vocabulary. What action should the nurse implement with this child? A. Ask the child whether he was sexually abused. B. Ascertain what the child understands about sex. C. Inquire where the child got this important information. D. Involve the child in teaching sex information to peers. School-age children often use correct sexual vocabulary, and yet have no real understanding of what the words mean, so (B) provides clarification of the child's concepts used in conversation. Direct questions about sexual abuse (A) may frighten the child and more information is needed to make the assumption of sexual abuse. Asking the child about his source of information (C) is not as relevant as what the child understands about sex. (D) is not an option. Points Earned: 0/1 Correct Answer: B Your Response: A 19. A mother brings her 6-month-old infant to the clinic for a well-baby routine exam. Which vaccine(s) should the nurse verify the infant has received? (Select all that apply.) A. Meningococcal polysaccharide vaccine (MPSV4). B. Haemophilus influenzae type b conjugate vaccine (Hib). C. Inactivated poliovirus vaccine (IPV). D. Hepatitis B virus vaccine (HepB). E. Diphtheria, tetanus toxoids, and acellular pertussis (DTaP). F. Measles, mumps, and rubella vaccine (MMR). (B, C, D, and E) should be administered prior to 6 months of age. (A) is administered after 24months of age. (F) is administered at 12-months of age. Points Earned: 1/4 Correct Answer: B, C, D, E Your Response: D 20. While assessing the apical pulse of a 13-year-old, the nurse determines that the rate is 88 beats/minute, and the rhythm is irregular. The heart rate is 9 | P a g ephasic with respirations, increasing during inspiration and decreasing with expiration. What action should the nurse take? A. Continue the cardiac examination. B. Inquire about daily caffeine intake. C. Re-assess the apical pulse in 15 minutes. D. Schedule a consultation with a cardiologist. Sinus arrhythmia is characterized by phasic irregularity of the heart rate that occurs with changes in intrathoracic pressure during respiration and is a common phenomenon during childhood and adolescence. No intervention is required, and the nurse should continue with the cardiac exam (A). This finding is not related to caffeine intake (B). (C and D) are not indicated because the heart rate is within the normal range. Points Earned: 0/1 Correct Answer: A Your Response: B 21. The nurse reviews the complete blood count (CBC) findings of an adolescent with acute myelogenous leukemia (AML). The hemoglobin is 13.8 g/dl, hematocrit is 36.7%, white blood cell count is 8,200 mm3, and platelet count is 115,000 mm3. Based on these findings, what is the priority nursing diagnosis for this client's plan of care? A. Impaired gas exchange. B. Risk for infection. C. Risk for injury. D. Risk for activity intolerance. A client with AML is at risk for anemia, neutropenia, and thrombocytopenia. These CBC findings indicate that the platelet count is low (normal 250,000 to 400,000 mm3), which places this client at an increased risk for injury (C), usually manifested as bruising or bleeding. There is no evidence of impaired gas exchange (A) due to respiratory compromise, risk of infection (B) due to neutropenia, or risk for activity intolerance (D) secondary to anemia and fatigue. Points Earned: 1/1 Correct Answer: C Your Response: C 22. The parents of a child with hemophilia A ask the nurse about their probability of having another child with hemophilia A. Which information is the basis for the nurse's response? (Select all that apply.) A. Autosomal dominance occurs with this disorder. B. Sons of female carriers have a 50% chance of inheriting hemophilia. C. Men with hemophilia have sons who also manifest the disease. D. The disease occurs in daughters of men with hemophilia. E. Hemophilia is an X-linked recessive disorder. 10 | P a g eCorrect choices are (B and E). Hemophilia is an inherited disease that manifests in male children whose mother is a carrier. With each pregnancy there is a 50% chance that a male child will inherit the defective gene and manifest hemophilia A (B), which is an X- linked recessive disorder (E). (A) is descriptive of a rare type of hemophilia, known as von Willebrand's disease. Hemophilia is inherited by male offspring of female carriers (C). Daughters (D) do not manifest the disease, but have a 50% chance of being a carrier. Points Earned: 0/2 Correct Answer: B, E Your Response: A, B, C 23.What is a priority nursing diagnosis for a child in the subacute stage of Kawasaki disease? A. Alterations in skin integrity. B. High risk for altered tissue perfusion, cardiopulmonary. C. Risk for imbalanced body temperature, hyperthermia. D. High risk for fluid volume deficit. Kawasaki's disease (KD) is an acute systemic vasculitis that places the child at risk for coronary artery aneurysm, which is most likely to occur during the subacute phase, resulting in reduced cardiac output (B). Kawasaki disease causes rashes and desquamation of the hands and feet (A), but this is not as life-threatening as cardiac involvement. Insensible fluid loss from fever (C) and reduced fluid intake due to oral lesions may alter fluid balance and place the child at risk for fluid volume deficit (D), but these issues are not as critical as possible changes in tissue perfusion. Points Earned: 1/1 Correct Answer: B Your Response: B 25. The nurse is developing the plan of care for a school-aged boy with a chronic disability. The child frequently cries about being different from his siblings and wants others to do things for him that he is capable of doing for himself. To assist the family in coping with this child's chronic illness, which intervention is most important for the nurse to implement? A. Recommend the use of consistent discipline and reward for acceptable behavior. B. Encourage the parents to role model ways to act when one is disappointed. C. Suggest that all the children are included in family decision making. D. Evaluate the proper use of equipment that is provided to improve the child's lifestyle. Focusing on the child, and not the condition, is essential in assisting the child to adapt to a chronic disability or illness. Consistent family rules (A) should be used with a chronically ill child, such as setting boundaries for acceptable behavior, requiring participation in household activities, and fulfilling school responsibilities. (B, C, and D) may be worthwhile interventions, but do not have the priority of providing the child with consistent expectations of acceptable behavior. Points Earned: 0/1 11 | P a g eCorrect Answer: A Your Response: B 26. A man who was recently diagnosed with Huntington's disease asks the nurse if his adolescent son should be tested for the disease. What response is best for the nurse to provide? A. Autosomal dominant disorders, such as Huntington's, cannot be inherited from the parent. B. Testing is needed because there is a 50 percent risk of passing the gene to each offspring. C. Genetic counseling should be provided to ensure an informed decision by the family. D. Positive genetic testing may contribute to insurance discrimination that denies coverage. Huntington's disease, a progressively incapacitating, fatal neuromuscular disease, is an autosomal dominant inherited disease that has a 50% risk of developing in each child of those who have the disorder. The risk of autosomal dominant inheritance should be explained and emphasized (B). (A) is inaccurate. Although the basic tenet of genetic counseling is to provide families with facts to assist them in making informed decisions (C), the basic laws of inheritance should be explained to direct the client to counseling. (D) provides information that does not address the client's question, and might be considered judgmental. Points Earned: 0/1 Correct Answer: B Your Response: A 27. A mother is crying as she holds and rocks her child with tetanus who is having muscular spasms and crying. After administering diazepam (Valium) to the child, what action should the nurse implement? A. Lay the child down and ask the mother to stay near the child in the crib. B. Encourage the mother to take a break and leave the room to stop crying. C. Keep all light sources off and close the window blinds to the room. D. Use calm, reassurance and understanding to comfort the mother. Controlling environmental stimulation such as noise, light, or tactile stimuli helps reduce CNS irritability related to acute tetanus. The mother should be instructed to minimize handling of the child during episodes of muscle spasticity and to stay calmly near the child (A). The mother's presence with the child provides security and support, so (B) is not indicated. Reducing external stimuli (C) may have some effect in reducing the child's distress, but light tends to be less irritating than vibratory or auditory stimuli and is essential for careful observation. Although a calm, reassuring manner and sympathetic understanding (D) can help reduce the mother's anxiety, the most comforting measure for the child is the presence of the mother. Points Earned: 0/1 Correct Answer: A Your Response: C 12 | P a g e27. Which clinical finding should the nurse expect a child with nephrosis to exhibit? A. Elevated blood pressure. B. Blood-tinged urine. C. Elevated temperature. D. Urine protein 3+ to 4+. In nephrosis, renal tubules become permeable to proteins, causing massive proteinuria (D). (A and B) are characteristic of acute glomerulonephritis. Infection, indicated by (C), is not the cause of nephrosis, but may occur secondary to immunosuppressive therapy. Points Earned: 0/1 Correct Answer: D Your Response: B 28. When plotting a 20-week-old infant's weight on a standardized growth chart, the nurse determines that the child's weight is between the 2nd and 3rd percentile. Based on this finding, which action should the nurse take? A. Teach the parents about interventions for failure to thrive syndrome. B. Compare this weight with previous weights recorded in the child's record. C. Evaluate the parent's body build in relation to the infant's weight. D. Obtain a 24-hour nutritional history before making any conclusions. Evaluation of weight using a growth chart requires comparison of consistency of current weight with previous weight measurements (B). The infant is defined as having a failure to thrive (A) if height or weight falls below the 3rd percentile. It is worthwhile to evaluate (C), but first the nurse should review the infant's record to determine the weight history. (D) is important, but does not have the priority of (B). Points Earned: 0/1 Correct Answer: B Your Response: D 29. A 12-year-old male client tells the nurse that he is happy to be taking growth hormones because now he can expect to grow and be just as tall as all of his friends. What response is best for the nurse to provide? A. You must remember that this treatment regimen is not always effective. B. Although being tall is important to you, remember there are far more important characteristics than height. C. You will grow with this medicine, and are likely to be taller than anyone in your family. D. Being taller is important to you and taking your injections will help achieve that goal. It is important to validate his feelings (D) and reinforce the fact that injections are the only way he can get the medication. He will have to take injections three times a week for years. (A) is unnecessarily negative and not indicated at this time. It is important to this 13 | P a g echild how tall he is, and (B) belittles these feelings. While heredity plays an important role in the height this child will achieve, (C) is not true; this child will probably still be shorter than he would have been had he not had this problem. Points Earned: 0/1 Correct Answer: D Your Response: A 30. A 3-year-old boy is brought to the emergency room because of a possible diazepam (Valium) overdose. He is lethargic and confused, and his vital signs are: pulse rate 100 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 70/30. Which nursing intervention has the highest priority? A. Insert an orogastric tube for gastric lavage. B. Prepare a set-up for an endotracheal intubation. C. Draw blood for stat chemistries and blood gases. D. Insert a Foley catheter to monitor renal functioning. Diazepam causes respiratory depression, so preparation for intubation (B) to protect the airway is the priority intervention at this time. (A) may be necessary, but the child is lethargic and confused, with a lowered respiratory rate, so (B) takes priority. (C and D) are interventions that should be implemented, but they are both secondary to ensuring an open airway. Points Earned: 0/1 Correct Answer: B Your Response: C 31. The nurse is developing a plan of care for a newborn with a colostomy due to anal agenesis, and the infant has had three loose stools since surgery yesterday. Which nursing diagnosis has the highest priority? A. Potential for fluid volume deficit. B. Alteration in bowel elimination. C. Pain related to postoperative condition. D. Anxiety of parents related to newborn's condition. All stated nursing diagnoses are appropriate for a postoperative colostomy client. However, fluid balance is the priority concern (A) for any newborn infant. Though three loose stools in 24-hours is not significant, depending on the amount of fluid lost with each stool, potential for fluid volume deficit is always a concern for a postoperative infant. Newborns are extremely vulnerable to fluid imbalances due to immature body systems and a larger percentage of their body weight consisting of fluid. (B, C, and D) do not have the priority of (A). Points Earned: 1/1 Correct Answer: A Your Response: A 14 | P a g e32. The community health nurse teaches the parents of school-aged children about the need for fluoride as part of a dental health program. Which statement by the parents indicates that they understand the teaching? A. Excessive amounts of fluoride will make teeth turn brittle and yellow. B. Having our children brush with fluoride toothpaste is not effective. C. Use of fluoride in water is mostly effective during initial tooth formation. D. Dental caries can be prevented through fluoridation of public water. Dental caries can be prevented through fluoridation of public water (D). Large amounts of fluoride (A) produces yellow and discolored teeth, not brittle teeth. (B) is effective for young teeth. Fluoride is effective throughout the life span, not just during initial tooth formation (C). Points Earned: 0/1 Correct Answer: D Your Response: C 33. A seven-month old infant is admitted with nonorganic failure to thrive (NFTT). To aid the child's growth and development, which intervention is most important for the nurse to implement? A. Encourage the parents to participate in a planned program of play with the infant. B. Refer the parents for psychological counseling to identify parental detachment. C. Demonstrate feeding strategies and infant cues that indicate hunger and satiation. D. Provide instructions about formula preparation and feeding schedules. NFTT most often occurs due to inadequate parent knowledge or a disturbance in maternal-child attachment, but the first goal for infants with NFTT is to provide nutrition to promote catch-up growth. The nurse should demonstrate positive feeding strategies that reduce parent and infant frustration, such as recognizing the infant's cues indicated by vigorous sucking and satiation (C). (A) encourages normal growth and development, but is not likely to teach the parents how to respond to the infant's nutritional needs. Although family dysfunction may contribute to NFTT and (B) may eventually be indicated, additional assessment is needed before such a referral is made. (D) provides a structured schedule, but positive infant feeding strategies should be implemented first. Points Earned: 0/1 Correct Answer: C Your Response: A 34. A 14-year-old returns to the pediatric unit after corrective surgery for scoliosis. In the immediate postoperative period, the nurse should include which action(s) in this client's plan of care? (Select all that apply.) A. Record intake and output every 8 hours. 15 | P a g eB. Elevate the head of the bed 30 degrees. C. Assess bowel sounds every 4 hours. D. Initiate a logrolling schedule every 2 hours. E. Ambulate for 5 minutes 12 hours postoperative. F. Give morphine sulfate 2 mg IV every 4 hours PRN. Correct responses are (A, C, D, and F). Recording intake and output (A) and assessing bowel sounds (C) are critical when determining if the body systems are recovering from the effects of anesthesia. Turning the client using a logrolling technique maintains spinal alignment postoperatively and prevents complications of immobility. Since this is a painful surgery, the nurse should maintain pain control as prescribed (F). Following corrective surgery for scoliosis, a client should be immobilized without spinal flexion for 24 to 48 hours (B), and then ambulated by the physical therapist (E). Points Earned: 2/4 Correct Answer: A, C, D, F Your Response: C, D 35. A Spanish-speaking 5-year-old child starts kindergarten in an English- speaking school. The child cries most of the time, appears helpless and unable to function in the new situation. After assessing the child, how should the school nurse document the situation? A. Experiencing culture shock. B. Lacks the maturity needed in school. C. Refuses to participate in school activities. D. Going through minority group discrimination. An inability to function may apply to persons of all ages undergoing transitions, such as moving to a new country and adjusting to a subculture within a larger culture that is unfamiliar. Culture shock (A) describes feelings of discomfort and disorientation when adapting to new cultural settings. Language barriers inhibit effective communication, so a child who is unable to communicate in the spoken language in the school environment may lack the skills necessary to participate, and is not refusing to participate (C). The child may be adequately mature (B), accepted by peers (D) within the environment, but continues to not join in because of the impact of culture shock. Points Earned: 0/1 Correct Answer: A Your Response: B 36. A mother tells the nurse that her children are asking questions about divorce, but one male child tells her that he is sorry that he caused the divorce of the parents. Which age group is most likely to experience feelings of punishment or responsibility for the divorce of parents? A. 1 year. B. 4 years. C. 8 years. 16 | P a g eD. 13 years. Divorce constitutes a major disruption for children of all ages. Behaviors and feelings differ based on children's developmental stages and cover a wide spectrum, with overlap between stages. A preschool-aged child (B) often feels frightened, confused, and may blame themselves for the divorce, or feel it is their personal punishment. Infants (A) may suffer from interference with attachment and reduced parenting. A school-aged child (C) may react with feelings of panic, sadness, depression, insecurity, and feelings of deprivation. In early adolescence (D), a child may experience a sense of loss of family and childhood, shame and embarrassment, or disturbed sexuality which may manifest in acting-out behaviors. Points Earned: 1/1 Correct Answer: B Your Response: B 37. A mother brings her 6-month-old infant to the clinic for a well-child checkup. She comments, I want to go back to work, but I don't want my baby to suffer because I'll have less time at home. How should the nurse respond to the mother? A. Stay home until the child starts school. B. Find a good baby-sitter close to the house. C. Let's talk about the child care options that are best for the child. D. Go back to work now so the infant will get used to being with others. It is common for mothers to feel torn between their work and child and to have guilt feelings. The nurse should assist the mother to explore her feelings on the subject while focusing on the optimal, appropriate, safe, and available options for her child (C). (A, B, and D) are reflecting the nurse's personal opinions. Points Earned: 1/1 Correct Answer: C Your Response: C 38. How should the nurse measure the length of a 14- month-old child? A. Standing height. B. Prone recumbent position. C. Supine recumbent position. D. Side-lying position. Children younger than 24 to 36 months of age should be measured for length in the supine position (C) from crown to heel, known as recumbent length. Standing height (A) measurements begin after 36 months or older, depending on the ability and cooperation of the child. (B and D) are not conducive to comfort or accurate measurements. 17 | P a g ePoints Earned: 0/1 Correct Answer: C Your Response: B 39. The nurse is assessing a child's skin turgor and grasps the skin on the abdomen between the thumb and index finger, pulls it taut, and quickly releases it. The tissue remains suspended and tented for a few seconds, then slowly falls back on the abdomen. How should the nurse document this finding? A. Adequate hydration. B. Poor skin turgor. C. Normal skin elasticity. D. Assessment inconclusive. Tissue turgor refers to the amount of elasticity in the skin and is one of the best estimates of adequate hydration and nutrition. Elastic tissue immediately resumes its normal position without residual marks or creases. In a child with poor turgor (B), the skin remains tented or suspended for a few seconds before returning to a normal position. (A, C and D) are inaccurate. Points Earned: 0/1 Correct Answer: B Your Response: A 40. The nurse is assessing a child for neurological soft signs. Which finding is most likely demonstrated in the child's behavior? A. Presence of vertigo. B. Loss of visual acuity. C. Poor coordination and sense of position. D. Inability to move tongue in all directions. There is a gray area in neurologic assessment known as soft signs, which are findings that are normal in a young child but disappear in the normal course of maturation. Poor coordination and sense of position (C) are classic signs that are consistent with the failure to perform age-specific tasks and represent the persistence of a more primitive neurological response. (A, B, and D) are symptomatic of other sensory-motor processes. Points Earned: 1/1 Correct Answer: C Your Response: C 41. The nurse is examining a neonate at age 10 minutes. Which site should the nurse expect to see nonpathologic cyanosis? A. Feet and hands. B. Bridge of nose. C. Circumoral area. 18 | P a g eD. Mucous membranes. Acrocyanosis, cyanosis of the hands and feet (A), is a usual finding in the newborn shortly after birth. Cyanosis in other areas (B, C, and D) is not normally present and requires further examination. Points Earned: 0/1 Correct Answer: A Your Response: C 42. A 4-month-old breastfeeding infant is at the 10th percentile for weight and the 75th percentile for height. How should the nurse interpret this finding? A. Milk allergy. B. Failure to thrive. C. Inadequate milk supply in mother. D. Normal growth curve of a breast-fed infant. When plotting weights and heights on a standard growth chart used for both breast-fed and formula-fed infants, the breast-fed infant grows more rapidly during the first 2 months of life, and then growth slows from 3 to 12 months. A breast-fed infant is leaner and has less body fat than a formula-fed infant. Normal patterns of infants who are breast fed (D) differ from those who are formula fed. (A) is an incorrect interpretation of the data. This finding is not consistent with failure to thrive (B) or an inadequate milk supply (C). Points Earned: 0/1 Correct Answer: D Your Response: C 43. The nurse is collecting a blood sample from a newborn for a screening test for phenylketonuria (PKU). When should the nurse obtain the blood sample? A. At birth from cord blood. B. Fourteen days after birth. C. Before oral feedings are initiated. D. After ingestion of a source of protein. Phenylketonuria is a genetic disease caused by the absence of the enzyme needed to metabolize the essential amino acid phenylalanine. The Guthrie blood test is used for early detection to prevent mental retardation and should be collected between 24 hours and 7 days after birth, with fresh heel blood only, and after the infant has ingested a source of protein (D). (A and C) do not ensure the infant has ingested a protein source. (B) delays screening. Points Earned: 0/1 Correct Answer: D Your Response: B 44. A newborn who is breastfeeding is diagnosed with galactosemia. What action should the nurse implement? 19 | P a g eA. Stop the infant breastfeeding. B. Add amino acids to breast milk. C. Give galactokinase with breast milk. D. Substitute a lactose-containing formula. Galactosemia is a rare genetic disorder that involves an inborn error of carbohydrate metabolism in which a hepatic enzyme, galactokinase, involved in the conversion of galactose to glucose is absent. Treatment consists of eliminating all lactose-containing foods, including breast milk, so the infant should stop breastfeeding (A). Soy protein formula is the feeding of choice during infancy. (B, C, and D) contain lactose, which should be eliminated from this child's diet immediately. Points Earned: 0/1 Correct Answer: A Your Response: B 45. The low-birth-weight infant requires a neutral thermal environment. What action should the nurse implement? A. Use wool blankets for covers. B. Avoid using disposable diapers. C. Maintain a high-humidity atmosphere. D. Continue cool oxygenation via a hood. A neutral thermal environment provides adequate warmth so the infant can maintain a normal core temperature with minimum oxygen consumption and calorie expenditure. Low-birth-weight infants are especially vulnerable to temperature instability. A high- humidity atmosphere in an incubator contributes to body temperature maintenance by reducing evaporative heat loss (C). (A, B, and D) do not produce a neutral thermal environment. Points Earned: 0/1 Correct Answer: C Your Response: D 46. The nurse is caring for a premature infant who needs an IV access restarted. What action should the nurse take when using adhesive tape? A. Remove adhesives with water, mineral oil, or petrolatum. B. Avoid using tape and adhesives until skin is more mature. C. Use scissors carefully to remove tape instead of pulling tape off. D. Employ solvents to remove adhesives instead of pulling on skin. The use of adhesives should be minimized as much as possible in the treatment of preterm neonates, so adhesives should be removed after 24 hours using water, mineral oil, or petrolatum (A). (B) is not practical or possible. It is unsafe to use scissors (C) to remove tape because of the risk of injury to delicate skin or damage to tiny digits and extremities. Solvents are avoided (D) because they can burn and dry delicate skin. Points Earned: 0/1 Correct Answer: A 20 | P a g eYour Response: B 47. The nurse is instructing an adolescent with bulimia and a low potassium level about the risk for complications. Which medical problem should be the focus of the nurse's instruction to this client? A. Anemia. B. Cardiac arrhythmias. C. Gastrointestinal reflux. D. Heightened neurologic reflexes. An adolescent with bulimia who purges by frequent self-induced vomiting, diuretic or laxative abuse can experience potassium depletion, which increases the risk for cardiac arrhythmias (B). (A) is more likely related to inadequate iron intake and absorption, not hypokalemia. (C) is related to frequent binging and gastric over-distention. Potassium depletion causes diminished reflexes, not (D). Points Earned: 0/1 Correct Answer: B Your Response: C 48. The nurse is assessing the coping behaviors of the parents whose child has been recently diagnosed with a chronic illness. What reaction by the parents is a positive step in the ability to cope with this new situation? A. Endowing the illness with meaning. B. Refusing to believe the child is ill. C. Entertaining an unrealistic future plan for the child. D. Placing complete faith in religion to the point of relinquishing own responsibility. Coping mechanisms are behaviors directed at reducing the tension elicited by a crisis. Approach behaviors are coping mechanisms resulting in movement toward adjustment and resolution of the crisis. The parents' ability to assign the illness meaning within an existing medical, scientific, or spiritual philosophy of life is a long-term coping strategy significantly related to successful family functioning (A). Avoidance behaviors (B, C, and D) result in movement away from adjustment or maladaptation to the crisis. Points Earned: 1/1 Correct Answer: A Your Response: A 49. A child with a penetrating eye injury comes to the school clinic. What action should the nurse implement? A. Remove the object impaled in the eye and then apply a regular eye patch. B. Place an ice bag over the eye until the healthcare provider is seen. C. Irrigate the affected eye copiously with a cool sterile saline solution. D. Apply a Fox shield to the affected eye and any type of patch to the other eye. 21 | P a g eThe treatment for a penetrating eye injury is the application of a Fox shield, if available (not a regular eye patch) with another eye patch placed over the unaffected eye (D) to prevent bilateral movement, and the child transported to the emergency department immediately. (A) is contraindicated because removal of a penetrating object from the eye can cause vitreous leakage, eyeball collapse, and blindness. (B) is used for periorbital ecchymosis (black eye), and (C) is the treatment for a chemical burn of the eye. Points Earned: 0/1 Correct Answer: D Your Response: C 50. A 5-year-old child who is one day postoperative has bilateral eye patches in place and should be out of bed. What nursing intervention should be implemented first before leaving the bedside? A. Speak to the child when entering the room. B. Allow the child to assist in feeding himself. C. Orient the child to the immediate surroundings. D. Allow the parents to stay in the room with the child. When sighted children temporarily lose their vision, many aspects of the environment become bewildering and frightening. To minimize the effects of temporary loss of vision, the child should be oriented immediately to the surroundings (C) and should be told about the nurse's actions and any experiences that are felt or heard during procedures. The child and family should be reassured throughout every phase of treatment and encouraged to be independent (with assistance) in self-care activities, such as eating and bathing. Although (A, B, and D) should also be implemented, (C) is priority. Points Earned: 0/1 Correct Answer: C Your Response: A 51. A 4-year-old child who is ventilator-dependent is receiving tube feedings in the home setting. The family wants to begin oral feeding of the child, and asks the home health nurse to feed the child baby food orally. After explaining the risks for aspiration to the family, list in order which actions the nurse should implement. (Rank in the priority order from first action to last action.) A. Refuse to feed the child orally, because the risk is too high. B. Ask the parents to negotiate a change in feeding methods with the healthcare provider. C. Set additional goals for feeding the child with the parents. D. Acknowledge the request and then explore with the family the available options for care. Nurses should respect parental preferences that do not pose a risk for the child, but the risks of aspiration should be explained. Then, the request for oral feeding should be acknowledged, and options should be explored. The nurse and parents should set goals in an atmosphere of mutual respect. If an agreement cannot be reached, written medical prescriptions should be implemented and refusal to feed the child orally substantiated 22 | P a g ewith the risks involved. Lastly, the parents should be directed to negotiate a change in feeding with the healthcare provider. Points Earned: 2/4 Correct Answer: A:3, B:4, C:2, D:1 Your Response: A:2, B:4, C:3, D:1 52. What sign of malignant hyperthermia should the nurse assess for during the perioperative period in a child receiving general anesthesia? A. Apnea. B. Tachypnea. C. Bradycardia. D. Decreased blood pressure. Malignant hyperthermia, a potentially fatal genetic myopathy, can cause a change in vital signs that demands immediate attention in the perioperative period. Early symptoms of the disorder include tachycardia and tachyarrhythmias, tachypnea (B), hypercarbia, and metabolic and respiratory acidosis. An elevated temperature is a late sign of the disorder. (A, C, and D) are not indicators for the onset of this condition. Points Earned: 1/1 Correct Answer: B Your Response: B 53. When administering a gavage feeding to a school-age child, which action should the nurse implement? A. Administer feedings over 5 to 10 minutes. B. Position the child on the right side after administering the feeding. C. Check the placement of the tube by inserting 20 ml of sterile water. D. Lubricate the tip of the feeding tube with petroleum jelly to facilitate passage. The child should be positioned on the right side after administering the feeding (B) to facilitate gastric emptying and prevent gastric reflux. Gavage feedings should be given to allow slow gastric filling over 15 to 30 minutes, not (A). Verification of tube placement by instilling water (C) places the child at risk for aspiration. Sterile water or water-soluble lubricant, not petroleum jelly (D), should be used as the lubricant. Points Earned: 0/1 Correct Answer: B Your Response: A 54. The nurse is assessing an infant with diarrhea and lethargy. Which finding should the nurse identify that is consistent with early dehydration? A. Tachycardia. B. Bradycardia. C. Dry mucous membranes. D. Increased skin turgor. 23 | P a g eIn early dehydration (during the first 2 days), fluid loss occurs first from the extracellular and intravascular fluid spaces. so blood pressure falls and heart rate increases (A) in response to a diminished blood volume. As dehydration progresses from minimal, mild, moderate to severe, cellular fluid loss increases and is manifested as (C, B, and D). Points Earned: 0/1 Correct Answer: A Your Response: C 55. The mother of a 2-month-old infant who just received the first DTaP asks the nurse what symptoms to expect. What is the best response for the nurse to provide? A. Most children do not experience any reaction. B. Seizures are common and require anticonvulsant medication. C. Mild reactions are common and most frequently include low-grade fever. D. The most common reaction is a whole-body rash that develops into itchy vesicles. The most common mild reactions to DTaP include low-grade fever, drowsiness, anorexia, local pain, swelling, and redness (C). These mild reactions to DTaP are common, not (A), and are usually managed symptomatically with acetaminophen. Uncommon reactions following DTaP administration, such as seizures (B) and rash (D), which is more likely to occur after the varicella virus vaccine, should be reported to the healthcare provider. Points Earned: 0/1 Correct Answer: C Your Response: D 56. During a well-baby check, the nurse hides a block under the baby's blanket, and the baby looks for the block. Which normal growth and development milestone is the baby developing? A. Associative play. B. Object prehension. C. Object permanence. D. Separation anxiety. Object permanence (C), learning that objects and people continue to exist even when they are no longer in sight, starts around the age of 7 months, when the infant learns to search for an object that is partially hidden but does not search for one that is completely out of sight. (A) is found in preschoolers when they engage in group play or similar activities. (B) is the development of fine motor skills, or the act of grasping. (D) occurs between the ages of 4 and 8 months, when the infant begins to have some awareness of the self and the parent as separate beings. Points Earned: 0/1 Correct Answer: C Your Response: A 24 | P a g e57. While assessing an 18-month-old during a well-child visit, the nurse notes that the toddler has a rounded pot-belly abdomen, marked lordosis or swayback, short, slightly bowed legs, and a large head. Based on these findings, what action should the nurse implement? A. Refer the findings to the healthcare provider for diagnostic studies for hydrocephalus. B. Document general physical appearance of a normally developed toddler. C. Plot the findings on the growth chart within the parameters of delayed physical maturation. D. Review the dietary intake for indications of a vitamin deficiency or malnutrition. Toddler lordosis describes the normal upright posture (B) found at this age, which is characterized by a pot belly, swayback, and short, slightly bowed legs. There are no findings indicative of hydrocephalus (A), malnutrition (D), or delayed physical maturation (C). Points Earned: 0/1 Correct Answer: B Your Response: C 58. The parents of a toddler brought to the clinic for a well-child visit tell the nurse that their child becomes upset if even the smallest things change in the environment. What information should the nurse provide the parents? A. A child is insecure because trust is not fostered and developed during infancy. B. A toddler should be exposed to different routines to promote adapting to new experiences. C. Children of this age are comfortable with ritualism and display global thinking. D. Objects should be frequently moved in the environment to teach the child to acclimate to change. A 2-year-old is ritualistic and wants consistency and routine, so changes in the toddler's environment or schedule is upsetting. Another mark of the toddler's sensitivity to change is global thinking (change in one small part, such as a minor shift in room arrangement or changes in the whole environment), and the 2-year-old's equanimity disintegrates (C). There is not enough information to make the assumption the child did not develop trust (A). Frequent changes (B and D) in the schedule or the environment can lead to insecurity on the part of the toddler. Points Earned: 0/1 Correct Answer: C Your Response: B 59. The nurse at the well-child clinic is advising the parents of an 8-month-old child about health and safety. What information should the nurse provide? 25 | P a g eA. Install stair guards or gates in the home. B. Use of a car seat is optional if a lap/shoulder belt is in place. C. Start toilet training with a child-sized potty. D. Give syrup of ipecac in case of accidental ingestion or poisoning. By the age of 8 months, a child is crawling and may be able to pull up to a standing position. The use of stair guards or gates is necessary to prevent accidents (A), which are the most common cause of injury among children of this age. The use of a car seat is necessary for children under the age of 5 years (B). The child is not old enough for toilet training (C). Administration of syrup of ipecac is not recommended in cases of poisoning in children (D). Points Earned: 1/1 Correct Answer: A Your Response: A 60. An infant weighs 7 lb at birth. How much should the nurse expect the infant to weigh at age 6-months? A. 12 lb. B. 14 lb. C. 17 lb. D.21 lb. Infancy growth spurts double the birthweight by 4 to 6 months and triple it by one year. Twelve pounds (A) represents a lower-than-expected weight. A weight of 17 (C) or 21 (D) pounds is greater than expected. Points Earned: 1/1 Correct Answer: B Your Response: B 61. The nurse observes the interactions of a 2-year-old child who says, No, even when Yes is what the child really wants to say. The parent says to the nurse, We, as parents, are such positive people, why is our child so negative? How should the nurse respond? A. A 2-year-old often acts in the opposite way to get attention. B. This age child is testing the limits of the parent's patience. C. D. The toddler is exhibiting an example of ritualistic behavior. The child is trying to assert autonomy through negativism. As a toddler tests autonomy and ego boundaries, young children sometimes clash with parental restrictions, and responds with recital of prompts that parents often say. No is a favorite, repeated word and is the child's way of exploring autonomy through negativism (D). This behavior does not indicate (A, B, or C). Points Earned: 0/1 Correct Answer: D Your Response: C 62. The mother of a 2-month-old reports that she often lets the baby cry in the middle of the night instead of going to pick up or sooth the infant. What information should the nurse provide the mother? 26 | P a g eA. Picking up the infant in the middle of the night fosters dependency on the mother. B. A sense of trust is developed in an infant when others respond to the infant's cry. C. An infant is learning to manipulate others when the infant is picked up unnecessarily. D. A 2-month-old who does not sleep through the night should be evaluated further. According to Erikson, a crucial element in the developmental stage of the infant is, Trust versus mistrust, which is nurtured when the mother or the primary caregiver is responsive and consistent in responding to the infant's needs and cries (B). Responding by picking up the infant to cuddle or soothe does not cause (A or C). Infants adapt to sleep cycles at different rates, so (D) does not imply a need for further evaluation. Points Earned: 1/1 Correct Answer: B Your Response: B 63. The father of an 8-year-old tells the nurse he is interested in seeing his child succeed in soccer. The nurse talks with the boy, who expresses a sincere interest in playing chess and feels like a failure at soccer. How should the nurse respond to this father? A. The father should decrease his expectations to give the son a chance to succeed. B. The child has an introverted personality and should be encouraged to play isolated games. C. The father should encourage the son to participate in team sports instead of less physical activities. D. The child should be given opportunities to achieve a sense of competency in an area he chooses. According to Erickson, the developmental stage Industry versus inferiority builds feelings of confidence, competence, and industry if there is achievement in an area of interest. If a child believes that he or she cannot measure up to society's expectations, the child loses confidence and may not find pleasure in the activity. Children should be encouraged to do the things they enjoy and succeed in (D). The father does not need to decrease his expectations (A), but should be encouraged to shift the expectation to an activity the child takes pleasure in. (B) does not encourage autonomy. (C) can cause a feeling of inadequacy. Points Earned: 0/1 Correct Answer: D Your Response: B 64. During the well-child assessment, the parents of a 4-year-old express concern that their child often chatters while playing alone. What information should the nurse provide the parents? A. 27 | P a g e The child is attempting to formulate a secondary language.B. C. tool. D. This is an attempt by the child to form an imaginary social base. Private speech is normal at this age and serves as a problem-solving Concern for psychological development is warranted so further testing is required. Children chatter to themselves between the ages of 4 and 6 years, and this private speech serves as a problem-solving tool for the preschoolers as they try new tasks or work through unfamiliar situations (C). This behavior does not indicate that the child that is formulating a new language (A) or needs a social base (B). (D) is incorrect and may worry the parents. Points Earned: 0/1 Correct Answer: C Your Response: A 65. After discussing the introduction of solid foods with the mother of a 6-month- old infant, the nurse determines that the mother understands the information when she states that the first food she gives the infant is from which food group? A. B. C. Fruits. Egg yolks. Rice cereal. D. Yellow vegetables. Solid foods are usually introduced at about 6-months of age starting with rice cereal (C), which is the least allergenic. New foods should be started one at a time with about 5 days in between each food. The next food group to be introduced should be vegetables (D), followed by fruits (A). Egg yolks (B) should be last because they tend to produce allergies. Points Earned: 0/1 Correct Answer: C Your Response: A 66. The nurse plans to mix a medication with food to make it more palatable for a pediatric client. Which food should the nurse choose? A. Syrup. B. C. D. Applesauce. Orange juice. Formula or milk. In order to prevent the child from developing a negative association with an essential food, a nonessential food such as applesauce is best for mixing with medications (B). Syrup is not used to mix with medications because of its high sugar content (A). Medications may alter the flavor of the food and cause the child to avoid those foods in the future, so orange juice (C), which provides essential nutritional elements, and formula or milk (D), which are essential foods in a child's diet, should not be mixed with medications. Points Earned: 1/1 28 | P a g eCorrect Answer: B Your Response: B 67. What intervention should the nurse implement to help keep a 6-month-old infant calm during a physical assessment? A. Give the infant a soft cuddly toy to hold. B. Remove the pacifier from the infant's mouth. C. D. Encourage the parent to hold the infant. Distract the infant with noise or bright lights. Parents should be encouraged to participate by holding the infant (C) as much as possible during an examination to calm and help the infant feel secure. Holding a soft cuddly toy for long periods of time (A) may not be a developmental capability of a 6- month-old. Pacifiers offer comfort to an infant and should not be taken away (B). Distraction with noise or bright lights (D) is best employed for a preschool-age child. Points Earned: 1/1 Correct Answer: C Your Response: C 68. A 14-year-old is brought to the emergency room after a biking accident. How should the nurse interact with the adolescent? A. B. C. D. Furnish rewards for cooperation during procedures. Have the parents remain with the adolescent at all times. Provide clear explanations while encouraging questions. Limit the number of choices to be made by the adolescent. Adolescents are capable of abstract thinking and understand explanations, so the opportunity to ask questions (C) should be provided. Giving rewards (A), such as stickers for cooperation with treatments or procedures are best used with a younger child. An adolescent's modesty should be respected, so the presence of the parents (B) at the bedside should be a choice made by the adolescent. An adolescent's ability to think abstractly engages problem solving, so the 14-yearold should be allowed to make decisions about care, not (D). Points Earned: 0/1 Correct Answer: C Your Response: A 69. The nurse is caring for an irritable, lethargic 18-month-old child who swallowed several over-the-counter (OTC) antihistamine tablets an hour ago. What intervention should the nurse implement? A. B. Initiate gastric lavage. Administer naloxone. C. Give a dose of ipecac syrup. D. Encourage oral intake of water or milk. 29 | P a g eGastric lavage (A) should be implemented within 2 hours of ingestion to ensure gastric removal of a non-corrosive substance, such as an OTC antihistamine. Naloxone (Narcan) (B) is the antidote for an opioid overdose. Inducing vomiting using ipecac syrup (C), which is no longer available, or the administration of oral fluids to dilute the caustic substances (D) are contraindicated in a client with an altered level of consciousness. Points Earned: 0/1 Correct Answer: A Your Response: B 70. The nurse is triaging a child with a fever who is brought to the emergency department by the parents. Which finding requires the nurse's immediate intervention? A. B. C. D. Prolonged exhalations. Thick yellow rhinorrhea. Frequent nonproductive cough. Oxygen saturation is 95% by pulse oximeter. Prolonged exhalation (A) indicates breathing difficulty, and intervention for this should be taken immediately. Nasal discharge (B) and a productive cough (C) are not findings that indicate the child is in immediate distress. An oxygen saturation of 95% is a normal finding (D). Points Earned: 0/1 Correct Answer: A Your Response: D 71. When assessing the breath sounds of an 18-month-old child who is crying, what action should the nurse take? A. B. Ask the parent to quiet the child so breath sounds can be auscultated. Auscultate and document breath sounds, noting that the child was crying at the time. C. Document that the assessment is not available because the child is crying. D. Allow the child to initially play with the stethoscope, and distract during auscultation. Engaging the child with an interesting activity, such as playing with the stethoscope before its use, often distracts the child long enough to stop crying (D) so breath sounds can be accurately obtained. Asking a parent to