QUESTIONS AND ANSWERS WITH
RATIONALE 2024
1. A nurse is caring for a 7-year-old child who is in skeletal traction following a
complete fracture of the femur. Which of the following diversional activities should
the nurse offer the child?
A. Puzzle with large pieces
B. Building blocks
C. Finger paints
D. Chapter books: D. Chapter books
The nurse should offer chapter books as an appropriate diversional activity for a school-
age child who has limited movement due to skeletal traction.
2. A nurse is providing teaching to the family of a child who has autism spectrum
disorder. Which of the following statements indicates that the family understands the
teaching?
A. "Donepezil might slow the progression of the disorder."
B. "My child will prefer group therapy with other children."
C. "We can help our child by structuring our daily routine."
D. "Our child probably has this condition as a result of prematurity.": C. "We can
help our child by structuring our daily routine."
,Children who have autism spectrum disorder benefit from a structured routine. This
environment can minimize the anxiety the child might have with sudden schedule changes
and socialization requirements and satisfy a preference for ritualistic behavior.
3. A nurse is assessing a 24-month-old toddler who has a new diagnosis of autism
spectrum disorder (ASD). Which of the following findings should the nurse expect?
A. Wanting to be held frequently
B. Ability to build a tower of 10 cubes
C. Impaired language skills
D. Ability to stand on 1 foot: C. Impaired language skills
The nurse should expect a 24-month-old toddler who has ASD to exhibit impaired
language skills (e.g. failing to respond to his or her name, pointing to objects instead of
speaking).
4. A nurse on a pediatric unit is caring for a child who has autism spectrum disorder.
Which of the following actions should the nurse take?
A. Provide activities to stimulate the child's interest in the environment
B. Make frequent eye contact when talking to the child
C. Offer the child choices when scheduling planned care
D. Ensure that staff visits with the child are kept short
Check Answer: D. Ensure that staff visits with the child are kept short
Children who have autism spectrum disorders have difficulty adjusting to new situations.
The staff members should keep interactions with the child as brief as possible.
5. A nurse is providing teaching to an adolescent who has scoliosis and a new
prescription for a Boston brace. Which of the following responses by the adolescent
, indicates an understanding of the teaching? A. "I can take my brace off to sleep every
night at bedtime."
B. "I can take my brace off for about an hour daily to shower."
C. "I should loosen the straps on my brace if it is rubbing against my skin."D. "I
should place the pads of the brace against my skin with a t-shirt over them.": B. "I
can take my brace off for about an hour daily to shower."
The nurse should instruct the child to wear the brace for 23 hours each day and only to
remove it for showering or participating in physical therapy.
6. A nurse is assessing an adolescent who has sustained a broken tibia. Following the
application of a fiberglass cast, the adolescent reports pain and a tingling feeling in
the limb. Which of the following actions should the nurse take first?
A. Give the adolescent ibuprofen
B. Elevate the adolescent's leg on pillows
C. Place an ice pack on the cast
D. Assess for manifestations of circulatory impairment: D. Assess for manifestations of
circulatory impairment
The nurse should apply the ABC priority-setting framework, which emphasizes the basic
core of human functioning: having an open airway, being able to breathe in adequate
amounts of oxygen, and circulating oxygen to the body's organs via the blood. An
alteration in any of these can indicate a threat to life, and is therefore the nurse's priority
concern.