ATI Quiz 2 Practice Questions with Rationales

ATI Quiz 2 Practice Questions with Rationales 1. A nurse is collecting data from a 9-month-old infant. Which of the following findings would require further intervention? a. Positive Babinski reflex R The Babinski reflex disappears after 1 year of age. Therefore, a 9-month-old infant with a positive Babinski reflex is a finding that does not require further intervention b. Positive Moro reflex R The Moro reflex disappears approximately at 3-4 months of age. Therefore, a 9-month-old infant with a positive Moro reflex is a findings that requires further intervention c. Negative Doll’s eye reflex R A negative Doll’s eye reflex is a normal finding. Therefore, a 9-month-old infant w/ a negative Doll’s eye reflex is a finding that doesn’t require further intervention d. Negative Crawl reflex R A negative Crawl reflex disappears after 6 months of age. Therefore, a 9-month-old infant with a negative Crawl reflex is a finding that does not require further intervention 2. During a routine well child check-up, a nurse is reinforcing teaching to a parent who reports having difficulty getting a preschool-age child to go to bed. Which of the following statements indicates to the nurse that the parent understands how to foster a consistent bedtime for the preschooler? a. "I will allow my child to cry himself to sleep each night.” R While crying for brief periods of time is not harmful to the child, it may promote a sense of fear and insecurity and discourage the child from going to sleep. b. "I will let my child fall asleep with me, and then move him to his own bed.” R Allowing the child to routinely come into the parent’s bed fosters the idea that this will be the norm. The child may then be unwilling to sleep alone. c. "I will make sure the room is dark when placing my child in bed.” R Darkened rooms may elicit fear in a preschooler. d. "I will encourage my child to fall asleep with his favorite toy.” R Transitional objects, such as a blanket or toy, will provide a sense of comfort and allow the child to fall asleep more quickly. 3. A nurse is collecting data about a 6-year-old client. Which statement by the client's parent should concern the nurse? a. "The teacher says my child has to squint to see the board." R Squinting to see the board may indicate a vision problem. It is essential to check children for hearing and vision problems. If not identified and corrected early, they lead to frustration and a decreased ability to learn. b. "My child has recently lost both front top teeth." R Children of this age begin to lose their deciduous teeth to accommodate the emergence of their permanent teeth. This is an expected finding. c. "My child often cheats when we play board games." R Children of this age often cheat to win at games because they feel winning is most important. This is an expected finding. d. "Sometimes my child acts bossy with his friends." R Children of this age are often bossy and are learning how to interact with peers. This is an expected finding. 4. A nurse is talking to a parent who is concerned about her hospitalized 5-year-old child's behavior and asks the nurse if it is "normal." The nurse explains that regression is common in hospitalized children and may manifest by which of the following? a. Bedwetting several times a day R Bedwetting by a preschooler who does not usually do so is a sign of regression in preschoolers. b. Crying when the parent leaves R This behavior is expected with preschoolers and is not a sign of regression. c. Eating only food from home R Preschoolers are reluctant to make changes in their dietary habits when ill. This is not a sign of regression. d. Cuddling a threadbare blanket at bedtime R Transitional objects are helpful in any situation where a child feels anxiety or stress. This is not a sign of regression. 5. A school nurse is talking with a 13-year-old female at her annual health screening visit. Which of the following client comments should concern the nurse? a. "My parents treat me like a baby sometimes." R This is an expected comment. Adolescence can be a time of great struggle between independence and dependence for both the child and the parents. b. "I haven't gotten my period yet, and all my friends have theirs." R Adolescents constantly compare themselves to their peers and feel very isolated if there are any differences. Onset of menses varies and this client is still within the appropriate time frame. c. "None of the kids at this school like me, and I don't like them either." R This statement should concern the nurse, as the peer group is critical to adolescent development and sense of self-esteem. This comment needs to be explored in greater depth. d. "There's a pimple on my face, and I worry that everyone will notice it." R Adolescents constantly compare themselves to their peers and feel very isolated if there are any differences. 6. The nurse is caring for a hospitalized adolescent. The nurse understands that which major developmental task is important during adolescence? a. Building a sense of trust R Building a sense of trust is not an appropriate developmental task of adolescence. b. Learning to utilize creative energies R Learning to utilize creative energies is not a developmental task of adolescence. c. Learning to defer gratification R Learning to defer gratification is not an appropriate developmental task of adolescence. d. Defining a sense of self R Establishing an identity or defining a sense of self is the major adolescent developmental task. 7. A nurse is talking to the parents of an 8-month-old who will be hospitalized for surgery. Which of the following actions should the nurse explain to the parents will help prepare the infant for the hospital? a. Buy a new toy and give it to the infant at the hospital. R This action could be an effective anxiety-reduction strategy with a preschooler or school-age child, as a new toy could provide the child with distraction. This is not an appropriate action to take for a hospitalized infant. b. Bring the infant’s favorite blanket to the hospital. R Infants of this age have separation anxiety and often need a transitional object, such as a blanket or toy, that brings them comfort. The transitional object is especially important when the child is in unfamiliar surroundings, or the parent is not there to provide comfort. Having the object will help to provide the infant with a sense of security. c. Purchase new loose-fitting, soft pajamas for the child. R This action could be an effective anxiety-reduction strategy with an older school-age child or adolescent, as new clothes could help with the child’s anxiety about body image. This is not an appropriate action to take for a hospitalized infant. d. Read the child a story about hospitalization. R This action could be an effective anxiety-reduction strategy with a preschooler or school-age child because it will help to prepare the child for a new, anxiety- producing experience. This is not an appropriate action to take for a hospitalized infant. 8. A nurse is planning care for a hospitalized 4-year-old child. The nurse should include providing a a. plastic stethoscope. R Preschool play centers on imitation of adults. Providing a stethoscope allows the child to imitate the staff and helps ease the fear of unfamiliar equipment. b. brightly colored mobile. R A brightly colored mobile is appropriate for a very young infant. It would not meet the activity needs of a preschooler. c. jigsaw puzzle. R A jigsaw puzzle is too difficult for most preschoolers and will frustrate rather than entertain the child. d. helium-filled latex balloon. R Helium balloons might entertain the child, but the rubber in a deflated latex balloon presents a choking hazard. 9. At the preoperative visit before an elective surgery, the nurse is planning to prepare a 9-year-old client for IV catheter insertion. When reinforcing teaching, the nurse will first a. explain to the client's parents what they can expect during and after IV insertion. R While this is both important and appropriate, this is not the first action the nurse should take. b. provide an opportunity for the client to see and touch IV tubing and supplies. R While this is important and appropriate, it is best initiated at the conclusion of the visit. c. describe the insertion procedure to the client, emphasizing sensory aspects. R While this is important and appropriate, it is not the first action the nurse should take. d. ask the client what he knows about having an IV infusion. R A key principle of teaching/learning theory is to first determine the learner's prior knowledge and readiness to learn. The child's perception of the anticipated experience illuminates any misconceptions that require clarification. In addition, it is possible that the child has had experience with IV therapy, and the nurse can build on this knowledge. 10. A nurse is reinforcing teaching to an assistive personnel to count respiration rate on a newborn. Which of the following statements indicate understanding of why the respiratory rate should be counted for a complete minute? a. “Newborns are abdominal breathers.” R Newborns are abdominal breathers. However, this has no impact on obtaining a respiratory rate. b. “Newborns do not expand their lungs fully with each respiration.” R The labor of breathing in a newborn will vary. However, this has no impact on obtaining a respiratory rate. c. “Activity will increase the respiration rate.” R Activity will increase the respiration rate. However, this has no impact on obtaining a respiratory rate. d. “The rate and rhythm are irregular in newborns.” R Newborns have an irregular respiratory rate and rhythm. Therefore, counting the respiratory rate for a complete minute is recommended to obtain an accurate rate. 11. A nurse is collecting data from a 7-month-old infant. Which of the following would indicate the need for further evaluation? a. Uses a unidextrous grasp R A 7-month-old infant should exhibit a unidextrous approach and grasp, therefore this would not indicate the need for further evaluation. b. Has a fear of strangers R A 7-month-old infant should exhibit a fear of strangers, therefore this would not indicate the need for further evaluation. c. Shows preferences towards foods R A 7-month-old infant should exhibit a preference towards food likes and dislikes, therefore this would not indicate the need for further evaluation. d. Babbles one-syllable sounds R A 7-month-old infant should babble in changed syllables, therefore this would indicate the need for further evaluation. 12. A nurse is collecting data regarding the pain level of a 4-year-old client on the second postoperative day. Which of the following actions should the nurse take? a. Ask the client what number the pain is on a scale from 1 to 10. R An ordinal scale is not appropriate to use with a 4-year-old client. b. Tell the client to point to a face on a FACES Pain Rating Scale. R The FACES Pain Rating Scale is an age appropriate pain assessment tool for a 4- year-old client. c. Have the parent report the pain level for the client. R The nurse should use an age appropriate pain rating scale for a 4-year-old client. The parent may not be able to accurately report the client's pain level. d. Request an assistive personnel to evaluate the client's pain level. R Determining a 4-year-old client's pain level is not within the scope of practice of an assistive personnel. 13. A nurse is caring for an infant after surgical repair of a cleft lip. The nurse should comfort the infant by a. rocking her with a favorite blanket. R After a cleft lip repair, the nurse should try to minimize crying. Crying pulls on the incision line, causing inflammation and increasing the risk of scar tissue formation. b. offering her a pacifier. R A pacifier is contraindicated for this client. c. placing her in a play yard at the nurses' station. R This intervention is not likely to calm the client. d. positioning her on her abdomen. R The infant should be placed on her side when in the crib. 14. A nurse is caring for a toddler who is experiencing separation anxiety. Which of the following is an appropriate action for the nurse to take? a. Explain to the toddler that her parents will return in one hour. R Toddlers have limited concept of time. Therefore, explaining to the toddler that her parents will return in one hour is not an appropriate action for the nurse to take. b. Assist the parents to sneak out of the toddler’s room. R Parents are encouraged to tell their toddler that they are leaving to prevent the uncertainty of their absence. Therefore, assisting the parents to sneak out of the room is not an appropriate action for the nurse to take. c. Tell the parents about the reaction of the toddler while they were gone. R Telling the parents about the reaction of the toddler will ease the stress of the separation. d. Leave the toddler alone for five minutes to cry it out. R Toddlers that experience separation anxiety should not be left alone. Therefore, this is not an appropriate action for the nurse to take. 15. A nurse is caring for a 3-year-old client whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse contribute to the child’s plan of care? (Select all that apply.) a. Have a parent stay with the child during procedures. R Have a parent stay with the child during procedures is correct. Maintaining parent- child contact is one of the most supportive interventions for toddlers and preschoolers undergoing painful procedures. b. Cluster invasive procedures whenever possible. R Cluster invasive procedures whenever possible is incorrect. This creates an unnecessarily lengthy painful period for the client, which is likely to increase her fear. c. Perform the procedure as quickly as possible. R Perform the procedure as quickly as possible is correct. Moving quickly through the procedure is one of the most supportive interventions for toddlers and preschoolers undergoing painful procedures. d. Allow the child to keep a toy from home with her. R Allow the child to keep a toy from home with her is correct. Having familiar and cherished objects nearby are therapeutic for children during their hospitalization. e. Use mummy restraints during painful procedures. R Use mummy restraints during painful procedures is incorrect. This helps immobilize very young children and keep them safe during procedures, but it is likely to increase terror in toddlers and preschoolers. 16. A nurse is collecting data on a child who is descending stairs by placing both feet on each step while holding on to the railing. This is developmentally appropriate at which of the following ages? a. 3 years R At age 3, children can typically go up stairs using alternating feet, but still descend by placing both feet on each step b. 4 years R By age 4, they descend using alternating feet and holding the railing. c. 5 years R By age 5, children’s balance improves and they continue going up and down stairs using alternating feet and holding the railing d. 6 years R At age 6, balance is improved and children are proficient at going up and down stairs 17. A nurse is caring for a 4-year-old client following abdominal surgery. Which of the following statements is appropriate for the nurse to use to encourage the child to take deep breaths? a. "You can't go to the playroom until you finish doing your deep breathing." This is a punitive remark that the child could perceive as a threat or a challenge. b. "Let's play a game of blowing cotton balls across your table." R By engaging the child in a form of play, the nurse may distract him from the discomfort of deep breathing. c. "I'll leave your blow bottle here on your table, so you can use it yourself like a big kid." R Since deep breathing will be uncomfortable, it is unlikely that the child will perform it without coaching. d. "I will give you a sticker each time you take a deep breath." R This action is going to be painful, and the child may not respond to positive reinforcement after the pain. 18. A nurse is assessing a toddler in the well-child clinic. At what point in the physical examination should the nurse examine the tympanic membrane? a. At the end R When examining the toddler, the nurse should follow a modified head-to-toe approach, starting at the head but deferring anything that the toddler is likely to view as invasive and traumatic to the very end. The toddler is likely to resist not only having the ears examined, but also anything that follows. b. At the beginning R The nurse should not examine the tympanic membranes first because the toddler is likely to view examination of the ear canal as invasive and traumatic. The toddler is likely to resist not only having the ears examined, but also anything that follows. c. Before the head and neck are examined R The nurse should not examine the tympanic membrane before the head and neck. d. Before the chest and abdomen are auscultated R The nurse should not examine the tympanic membrane before the chest and abdomen are auscultated 19. A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs? a. Call the family and ask them to stay with the client. R It is the nurse's responsibility, not the family's, to ensure the client's during his time in the facility. b. Move the client to a room closer to the nurses' station. R This will make it easier for the staff to observe the client, should the client behave in an unsafe manner. c. Apply wrist and leg restraints to the client. R Restraints are a last resort, plus they can increase the client's risk for injury. d. Administer medication to sedate the client. R Sedating an older adult client can worsen confusion. 20. A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) a. Inspection b. Superficial palpitation c. Deep palpitation d. Auscultation R Answer: a, d, b, c 21. A nurse is caring for a 4-year-old child who has croup and wet the bed overnight. When the parents visit the next day, the nurse explains the situation and one of the parents says, "She never wets the bed at home. I am so embarrassed." Which of the following responses should the nurse make? a. "It is expected for children who are hospitalized to regress. The toileting skills will return when your child is feeling better." b. "I know this can really be embarrassing. I have kids myself, so I understand, and it doesn't bother me." c. "Your child did not seem upset, so I wouldn't worry about it if I were you." d. "Why does it bother you that your child has wet the bed?" 22. A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with contact precautions in place. Which of the following toys should the nurse recommend in order to meet the developmental needs of the client? a. Large building blocks b. Hanging crib toys c. Modeling clay d. Crayons and a coloring book 23. A nurse is caring for an 18-month-old toddler who has been hospitalized for 10 days. After the toddler's mother leaves the room, the nurse observes the toddler sitting quietly in the corner of the crib, sucking her thumb. When the nurse approaches the crib, the toddler turns away from the nurse. The nurse should understand that these behaviors indicate which of the following developmental reactions? a. An anxiety reaction b. Regression c. Resentment toward the mother d. Developing autonomy 24. A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect? a. Closed posterior fontanel b. Uses thumb and index fingers in a pincer grasp c. Lateral incisors d. Sitting steadily without support 25. A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson? a. Arrange for a teacher to provide lesson plans. b. Allow the client to select his own food from the menu. c. Discourage visits from the client's friends. d. Provide a daily session with a play therapist. 26. A parent of a toddler asks a nurse at a well-child visit how the child's frequent temper tantrums can best be handled. Which of the following actions should the nurse suggest to the parent? a. Restrain the child physically. b. Ignore the temper tantrums. c. Tell the child that temper tantrums are not acceptable. d. Distract the child by offering to play a game. 27. A nurse is assessing a female child in an area struck by an earthquake. The child, who is crying, walks well, can state her first name, and repeatedly says "All done" and "Go bye-bye now" during the assessment. The child has 24 deciduous teeth and her anterior fontanel is closed. Based on these observations, the nurse should estimate that the child is how many months old? a. 12 b. 18 c. 24 d. 30 28. The parent of a 4-year-old child tells a nurse that the child believes there are monsters hiding in the closet at bedtime. Which one of the following statements should the nurse make? a. "Let your child sleep in your bed with you." b. "Keep a night light on in your child's room." c. "Tell your child that monsters are not real." d. "Stay with your child until the child is asleep." 29. A nurse is developing a health program for the parents of school-age boys. Which of the following information about pubescent changes should the nurse include in the program? a. Changes in the voice signal the beginning of puberty. b. Gynecomastia commonly occurs during late puberty. c. Puberty might be delayed if scrotal changes have not occurred by the age of 11 years. d. Growth spurts in height occur toward the end of midpuberty. 30. A nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a heart rate? a. Carotid artery b. Apex of the heart c. Brachial artery d. Radial artery 31. A nurse is assessing the psychosocial development of a toddler. The nurse should recognize that this stage is characterized by which of the following? a. Imaginary playmates b. Erikson's stage of initiative versus guilt c. Demonstrations of sexual curiosity d. Negative behaviors characterized by the need for autonomy 32. A nurse is providing health promotion teaching to an adolescent. Which of the following information should the nurse include in the teaching? a. "Share piercing needles only with close friends you trust." b. "Limit your caloric intake to avoid becoming overweight." c. "Your need for sleep will increase during periods of growth." d. "Tanning beds are much safer than lying in the sun." 33. A nurse is providing health promotion teaching to the parents of a toddler. Which of the following information should the nurse include in the teaching? (Select all that apply.) a. Management of tantrums b. How to establish trust c. How to encourage cooperative play d. Dental care e. Need for increased caloric intake 34. A nurse has accepted a position on a pediatric unit and is learning about psychosocial development. Place Erikson's stages of psychosocial development in order from birth to adolescence. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) a. Autonomy vs. shame and doubt b. Industry vs. inferiority c. Identity vs. role confusion d. Initiative vs. guilt e. Trust vs. mistrust R Answer: e, a, d, b, c 35. A nurse is collecting data from an infant at a well-child visit. The nurse should understand that birth weight typically doubles by what age? a. 3 months b. 6 months c. 9 months d. 12 months 36. A nurse is assessing a 3-month-old infant. Which of the following findings should the nurse report to the provider? a. Inability to raise head when in prone position b. Inability to sit without support c. Inability to pick up an object with her fingers d. Inability to bring an object to her mouth 37. A nurse is collecting data from an infant. Which of the following sites is the most reliable location to check the infant's pulse? a. Carotid b. Apical c. Dorsalis pedis d. Temporal 38. A nurse is selecting a toy for a 7 month old infant. Which of the following toys should the nurse choose? a. A set of blocks to build a block tower b. A colorful crib mobile that plays music c. A soft toy that squeaks or crackles when squeezed d. A wooden farm animal puzzle with large pieces 39. A nurse is preparing to administer an IM injection to a preschool-age child. Which of the following actions should the nurse take? a. Ask the parents to hold the child b. Allow the child to hold a favorite toy. c. Administer the medication the child's room d. Tell the child the medicine will make him feel better. 40. A nurse is caring for a 4-year old child who refuses to take his medication because of the bad taste. Which of the following strategies should the nurse use to administer the medication? a. Offer the child an ice pop prior to administering the medication R This numbs the tongue b. Tell the child the medicine tastes like candy c. Hide the medication in apple slices. d. Inform the child that if he does not take the medication he will need a shot. 41. A nurse is planning care for a 4-year old child who has been admitted to the hospital. Which of the following toys. Should the nurse plan to provide the child? a. Modeling Clay b. Brightly Colored mobile c. 100- piece jigsaw puzzle d. Checkerboard and Checkers 42. A parent asks a nurse about toys to provide for a 10-month old infant. Which of the following toys should the nurse suggest? a. Push- Pull Toy b. Crib Gym c. Large-Piece puzzles d. Coloring book with crayons Wong 43. When discussing discipline with the mother of a 4-year-old child, the nurse should include which instruction? a. Children as young as 4 years old rarely need to be punished. b. Parental control should be consistent. R For effective discipline, parents must be consistent and must follow through with agreed-on actions. Realistic goals should be set for this age group. Parents should structure the environment to prevent unnecessary difficulties. Requests for behavior change should be phrased in a positive manner to provide direction for the child. Withdrawal of love and approval is never appropriate or effective. Discipline strategies should be appropriate to the child’s age, temperament, and severity of the misbehavior. Following rules rigidly and unquestioningly is beyond the developmental capabilities of a 4-year-old. c. Withdrawal of love and approval is effective at this age. d. One should expect rules to be followed rigidly and unquestioningly. 44. A nurse is planning care for a Spanish-speaking child and family. The nurse speaks limited Spanish. Which interventions should the nurse plan when caring for this child and family? (Select all that apply.) a. Ask a visitor to interpret. b. Use a language-line telephone interpreter if a hospital interpreter is not available. c. Use written cards with common phrases in the Spanish language. d. Ask the family to provide an interpreter. e. When using a hospital interpreter, speak to the family not the interpreter. R If a live interpreter is not available, the nurse should use a language line telephone interpreter. The nurse should use cards with common greetings, phrases, and names of body parts in the family’s language. When using a hospital interpreter, the nurse should speak directly to the family and allow the interpreter to translate. Visitors or other family members should not be used as interpreters because of the risk of misinterpretation of medical terms. 45. An infant gains head control before sitting unassisted. The nurse recognizes that this is which type of development? a. Cephalocaudal R The pattern of development that is head-to-tail, or cephalocaudal, direction is described by an infant’s ability to gain head control before sitting unassisted. The head end of the organism develops first and is large and complex, whereas the lower end is smaller and simpler, and development takes place at a later time. Proximodistal, or near to far, is another pattern of development. Limb buds develop before fingers and toes. Postnatally, the child has control of the shoulder before achieving mastery of the hands. Mass to specific is not a specific pattern of development. In all dimensions of growth, a definite, sequential pattern is followed. R b. Proximodistal c. Mass to specific d. Sequential 46. An infant who weighs 7 pounds at birth would be expected to weigh how many pounds at age 1 year? a. 14 b. 16 c. 18 d. 21 R In general, birth weight triples by the end of the first year of life. For an infant who was 7 pounds at birth, 21 pounds would be the anticipated weight at the first birthday; 14, 16, or 18 pounds is below what would be expected for an infant with a birth weight of 7 pounds. 47. By what age does birth length usually double? a. 1 year b. 2 years c. 4 years R Linear growth or height occurs almost entirely as a result of skeletal growth and is considered a stable measurement of general growth. On average, most children have doubled their birth length at age 4 years. One and 2 years are too young for doubling of length. Most children will have achieved the doubling by age 4 years. d. 6 years 48. Parents of an 8-year-old child ask the nurse how many inches their child should grow each year. The nurse bases the answer on the knowledge that after age 7 years, school-age children usually grow what number of inches per year? a. 1 b. 2 R The growth velocity after age 7 years is approximately 5 cm (2 inches) per year. One inch is too small an amount. Three and 4 inches are greater than the average yearly growth after age 7 years. c. 3 d. 4 49. Parents express concern that their pubertal daughter is taller than the boys in her class. The nurse should respond with which statement regarding how the onset of pubertal growth spurt compares in girls and boys? a. It occurs earlier in boys. b. It occurs earlier in girls. R Usually, the pubertal growth spurt begins earlier in girls. It typically occurs between the ages of 10 and 14 years for girls and 11 and 16 years for boys. The average earliest age at onset is 1 year earlier for girls. There does not appear to be a relation to growth during infancy. c. It is about the same in both boys and girls. d. In both boys and girls, the pubertal growth spurt depends on growth in infancy. 50. A 13-year-old girl asks the nurse how much taller she will get. She has been growing about 2 inches per year but grew 4 inches this past year. Menarche recently occurred. The nurse should base her response on which statement? a. Growth cannot be predicted. b. Pubertal growth spurt lasts about 1 year. c. Mature height is achieved when menarche occurs. d. Approximately 95% of mature height is achieved when menarche occurs. R At the time of the beginning of menstruation or the skeletal age of 13 years, most girls have grown to about 95% of their adult height. They may have some additional growth (5%) until the epiphyseal plates are closed. Although growth cannot be definitively predicted, on average, 95% of adult height has been reached with the onset of menstruation. Pubertal growth spurt lasts about 1 year does not address the girl’s question. Young women usually will grow approximately 5% more after the onset of menstruation. 51. Which statement is true about the basal metabolic rate (BMR) in children? a. It is reduced by fever. b. It is slightly higher in boys than in girls at all ages. R The BMR is the rate of metabolism when the body is at rest. At all ages, the rate is slightly higher in boys than in girls. The rate is increased by fever. The BMR is highest in infancy and then closely relates to the proportion of surface area to body mass. As the child grows, the proportion decreases progressively to maturity. c. It increases with age of child. d. It decreases as proportion of surface area to body mass increases. 52. A 12-year-old child enjoys collecting stamps, playing soccer, and participating in Boy Scout activities. The nurse recognizes that the child is displaying which developmental task? a. Identity b. Industry R Industry is engaging in tasks that can be carried through to completion, learning to compete and cooperate with others, and learning rules. Industry is the developmental task characteristic of the school-age child. Identity is the developmental task of adolescence. Integrity and intimacy are not developmental tasks of childhood. c. Integrity d. Intimacy 53. The nurse is observing parents playing with their 10-month-old child. Which should the nurse recognize as evidence that the child is developing object permanence? a. Looks for the toy that parents hide under the blanket R Object permanence is the realization that items that leave the visual field still exist. When the infant searches for the toy under the blanket, it is an indication that object permanence has developed. Returning the blocks to the same spot on the table is not an example of object permanence. Recognizing that a ball of clay is the same when flattened out is an example of conservation, which occurs during the concrete operations stage from 7 to 11 years. Banging two cubes together is a simple repetitive activity characteristic of developing a sense of cause and effect. b. Returns the blocks to the same spot on the table c. Recognizes that a ball of clay is the same when flattened out d. Bangs two cubes held in her hands 54. A father tells the nurse that his child is “filling up the house with collections” like seashells, bottle caps, baseball cards, and pennies. The nurse should recognize that the child is developing: a. object permanence. b. preoperational thinking. c. concrete operational thinking. R During concrete operations, children develop logical thought processes. They are able to classify, sort, order, and otherwise organize facts about the world. This ability fosters the child’s ability to create collections. Object permanence is the realization that items that leave the visual field still exist. This is a task of infancy and does not contribute to collections. Preoperational thinking is concrete and tangible. Children in this age group cannot reason beyond the observable, and they lack the ability to make deductions or generalizations. Collections are not typical for this developmental level. The ability to use abstract symbols is a characteristic of formal operations, which develops during adolescence. These children can develop and test hypotheses. d. ability to use abstract symbols. 55. Which behavior is most characteristic of the concrete operations stage of cognitive development? a. Progression from reflex activity to imitative behavior b. Inability to put oneself in another’s place c. Increasingly logical and coherent thought processes R During the concrete operations stage of development, which occurs approximately between ages 7 and 11 years, increasingly logical and coherent thought processes occur. This is characterized by the child’s ability to classify, sort, order, and organize facts to use in problem solving. The progression from reflex activity to imitative behavior is characteristic of the sensorimotor stage of development. The inability to put oneself in another’s place is characteristic of the preoperational stage of development. The ability to think in abstract terms and draw logical conclusions is characteristic of the formal operations stage of development. d. Ability to think in abstract terms and draw logical conclusions 56. The nurse observes some children in the playroom. Which play situation exhibits the characteristics of parallel play? a. Kimberly and Amanda sharing clay to each make things b. Brian playing with his truck next to Kristina playing with her truck R Playing with trucks next to each other but not together is an example of parallel play. Both children are engaged in similar activities in proximity to each other; however, they are each engaged in their own play. Sharing clay to make things is characteristic of associative play. Friends playing a board game together is characteristic of cooperative play. A child playing with something by herself on her mother’s lap is an example of solitary play. c. Adam playing a board game with Kyle, Steven, and Erich d. Danielle playing with a music box on her mother’s lap 57. A nurse is planning play activities for school-age children. Which type of a play activity should the nurse plan? a. Solitary b. Parallel c. Associatived. d. Cooperative R School-age children engage in cooperative play where it is organized and interactive. Playing a game is a good example of cooperative play. Solitary play is appropriate for infants, parallel play is an activity appropriate for toddlers, and associative play is an activity appropriate for preschool-age children. 58. Which following function of play is a major component of play at all ages? a. Creativity b. Socialization c. Intellectual development d. Sensorimotor activity R Sensorimotor activity is a major component of play at all ages. Active play is essential for muscle development and allows the release of surplus energy. Through sensorimotor play, children explore their physical world by using tactile, auditory, visual, and kinesthetic stimulation. Creativity, socialization, and intellectual development are each functions of play that are major components at different ages. 59. Parents are asking the clinic nurse about an appropriate toy for their toddler. Which response by the nurse is appropriate? a. “Your child would enjoy playing a board game.” b. “A toy your child can push or pull would help develop muscles.” R Toys should be appropriate for the child’s age. A toddler would benefit from a toy he or she could push or pull. The child is too young for a board game, action figure, or 25-piece puzzle. c. “An action figure toy would be a good choice.” d. “A 25-piece puzzle would help your child develop recognition of shapes.” 60. Which is probably the single most important influence on growth at all stages of development? a. Nutrition R Nutrition is the single most important influence on growth. Dietary factors regulate growth at all stages of development, and their effects are exerted in numerous and complex ways. Adequate nutrition is closely related to good health throughout life. Heredity, culture, and environment contribute to the child’s growth and development. However, good nutrition is essential throughout the lifespan for optimal health. b. Heredity c. Culture d. Environment 61. A nurse is counseling an adolescent, in her second month of pregnancy, about the risk of teratogens. The adolescent has understood the teaching if she makes which statement? a. “I will be able to continue taking isotretinoin (Accutane) for my acne.” b. “I can continue to clean my cat’s litter box.” c. “I should avoid any alcoholic beverages.” R Teratogens are agents that cause birth defects when present in the prenatal period. Avoidance of alcoholic beverages is recommended to prevent fetal alcohol syndrome. Isotretinoin (Accutane) and phenytoin (Dilantin) have been shown to have teratogenic effects and should not be taken during pregnancy. Cytomegalovirus, an infection agent and a teratogen, can be transmitted through cat feces, and cleaning the litter box during pregnancy should be avoided. d. “I will ask my physician to adjust my phenytoin (Dilantin) dosage.” 62. What should the nurse consider when discussing language development with parents of toddlers? a. Sentences by toddlers include adverbs and adjectives. b. The toddler expresses himself or herself with verbs or combination words. R The first parts of speech used are nouns, sometimes verbs (e.g., “go”), and combination words (e.g., “bye-bye”). Responses are usually structurally incomplete during the toddler period. The preschool child begins to use adjectives and adverbs to qualify nouns followed by adverbs to qualify nouns and verbs. Pronouns are not added until the later preschool years. By the time children enter school, they are able to use simple, structurally complete sentences that average five to seven words. c. The toddler uses simple sentences. d. Pronouns are used frequently by the toddler. 63. Play serves many purposes. In teaching parents about appropriate activities, the nurse should inform them that play serves which of the following function? (Select all that apply.) a. Intellectual development b. Physical development c. Socialization d. Creativity R A common statement is that play is the work of childhood. Intellectual development is enhanced through the manipulation and exploration of objects. Socialization is encouraged by interpersonal activities and learning of social roles. In addition, creativity is developed through the experimentation characteristic of imaginative play. Physical development depends on many factors; play is not one of them. Temperament refers to behavioral tendencies that are observable from the time of birth. The actual behaviors, but not the child’s temperament attributes, may be modified through play. e. Temperament development 64. What factors indicate parents should seek genetic counseling for their child? (Select all that apply.) a. Abnormal newborn screen b. Family history of a hereditary disease c. History of hypertension in the family d. Severe colic as an infant e. Metabolic disorder R Factors that are indicative parents should seek genetic counseling for their child include an abnormal newborn screen, family history of a hereditary disease, and a metabolic disorder. A history of hypertension or severe colic as an infant is not an indicator of a genetic disease. 65. A nurse is preparing to administer a Denver II. Which is a correct statement about the Denver II? (Select all that apply.) a. All items intersected by the age line should be administered. b. There is no correction for a child born prematurely. c. The tool is an intelligence test. d. Toddlers and preschoolers should be prepared by presenting the test as a game. e. Presentation of the toys from the kit should be done one at a time. R To identify “cautions,” all items intersected by the age line are administered. Toddlers and preschoolers should be tested by presenting the Denver II as a game. Because children are easily distracted, perform each item quickly and present only one toy from the kit at a time. Before beginning the screening, ask whether the child was born preterm and correctly calculate the adjusted age. Up to 24 months of age, allowances are made for preterm infants by subtracting the number of weeks of missed gestation from their present age and testing them at the adjusted age. Explain to the parents and child, if appropriate, that the screenings are not intelligence tests but rather are a method of showing what the child can do at a particular age. 66. Place in order the sequence of cephalocaudal development that the nurse expects to find in the infant. Begin with the first development expected, sequencing to the final. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d). a. Crawl b. Sit unsupported c. Lift head when prone d. Gain complete head control e. Walk R Answer: c, d, b, a, e R Cephalocaudal development is head-to-tail. Infants achieve structural control of the head before they have control of their trunks and extremities, they lift their head while prone, obtain complete head control, sit unsupported, crawl, and walk sequentially. 67. What is the single most important factor to consider when communicating with children? a. The child’s physical condition b. Presence or absence of the child’s parent c. The child’s developmental level R The nurse must be aware of the child’s developmental stage to engage in effective communication. The use of both verbal and nonverbal communication should be appropriate to the developmental level. Although the child’s physical condition is a consideration, developmental level is much more important. The parents’ presence is important when communicating with young children but may be detrimental when speaking with adolescents. Nonverbal behaviors will vary in importance, based on the child’s developmental level. d. The child’s nonverbal behaviors 68. Which approach would be best to use to ensure a positive response from a toddler? a. Assume an eye-level position and talk quietly. R It is important that the nurse assume a position at the child’s level when communicating with the child. By speaking quietly and focusing on the child, the nurse should be able to obtain a positive response. The nurse should engage the child and inform the toddler what is going to occur. If the nurse picks up the child without explanation, the child is most likely going to become upset. The toddler may not understand the meaning of the phrase, “I’m your nurse.” If a positive response is desired, the nurse should assume the child’s level when speaking if possible. b. Call the toddler’s name while picking him or her up. c. Call the toddler’s name and say, “I’m your nurse.” d. Stand by the toddler, addressing him or her by name. 69. A nurse is preparing to assess a 3-year-old child. What communication technique should the nurse use for this child? a. Focus communication on child. R Because children of this age are able to see things only in terms of themselves, the best approach is to focus communication directly on them. Children should be provided with information about what they can do and how they will feel. With children who are egocentric, experiences of others, analogies, and assurances that the communication is private will not be effective because the child is not capable of understanding. b. Explain experiences of others to child. c. Use easy analogies when possible. d. Assure child that communication is private. 70. The nurse’s approach when introducing hospital equipment to a preschooler should be based on which principle? a. The child may think the equipment is alive. R Young children attribute human characteristics to inanimate objects. They often fear that the objects may jump, bite, cut, or pinch all by themselves without human direction. Equipment should be kept out of sight until needed. The child should be given simple concrete explanations about what the equipment does and how it will feel to the child. Simple, concrete explanations will help alleviate the child’s fear. The preschooler will need repeated explanations as reassurance. b. The child is too young to understand what the equipment does. c. Explaining the equipment will only increase the child’s fear. d. One brief explanation will be enough to reduce the child’s fear. 71. A nurse is assigned to four children of different ages. In which age group should the nurse understand that body integrity is a concern? a. Toddler b. Preschooler c. School-age child R School-age children have a heightened concern about body integrity. They place importance and value on their bodies and are oversensitive to anything that constitutes a threat or suggestion of injury. Body integrity is not as important a concern to toddlers, preschoolers, or adolescents. d. Adolescent 72. An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is to: a. ask her why she wants to know. b. determine why she is so anxious. c. explain in simple terms how it works. R School-age children require explanations and reasons for everything. They are interested in the functional aspect of all procedures, objects, and activities. It is appropriate for the nurse to explain how equipment works and what will happen to the child. A nurse should respond positively for requests for information about procedures and health information. By not responding, the nurse may be limiting communication with the child. The child is not exhibiting anxiety, just requesting clarification of what will be occurring. The nurse must explain how the blood pressure cuff works so that the child can then observe during the procedure. d. tell her she will see how it works as it is used. 73. When the nurse interviews an adolescent, which is especially important? a. Focus the discussion on the peer group. b. Allow an opportunity to express feelings. R Adolescents, like all children, need an opportunity to express their feelings. Often they will interject feelings into their words. The nurse must be alert to the words and feelings expressed. Although the peer group is important to this age group, the focus of the interview should be on the adolescent. The nurse should clarify which information will be shared with other members of the health care team and any limits to confidentiality. The nurse should maintain a professional relationship with adolescents. To avoid misinterpretation of words and phrases that the adolescent may use, the nurse should clarify terms frequently. c. Emphasize that confidentiality will always be maintained. d. Use the same type of language as the adolescent. 74. The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique might be most helpful? a. Suggest that the child keep a diary. b. Suggest that the parent read fairy tales to the child. c. Ask the parent if the child is always uncommunicative. d. Ask the child to draw a picture. R Drawing is one of the most valuable forms of communication. Children’s drawings tell a great deal about them because they are projections of the child’s inner self. It would be difficult for a 6-year-old child who is most likely learning to read to keep a diary. Parents reading fairy tales to the child is a passive activity involving the parent and child. It would not facilitate communication with the nurse. The child is in a stressful situation and is probably uncomfortable with strangers. 75. The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change. The nurse decides to do a simple magic trick using gauze. This should be interpreted as: a. inappropriate, because of child’s age. b. a way to establish rapport. R A magic trick or other simple game may help alleviate anxiety for a 5-year-old. It is an excellent method to build rapport and facilitate cooperation during a procedure. Magic tricks appeal to the natural curiosity of young children. The nurse should establish rapport with the child. Failure to do so may cause the procedure to take longer and be more traumatic. c. too distracting, when cooperation is important. d. acceptable, if there is adequate time. 76. The nurse must assess 10-month-old infant. The infant is sitting on the father’s lap and appears to be afraid of the nurse and of what might happen next. Which initial action by the nurse would be most appropriate? a. Initiate a game of peek-a-boo. R Peek-a-boo is an excellent means of initiating communication with infants while maintaining a safe, nonthreatening distance. The child will most likely become upset if separated from his father. As much of the assessment as possible should be done on the father’s lap. The nurse should have the father undress the child as needed for the examination. b. Ask father to place the infant on the examination table. c. Undress the infant while he is still sitting on his father’s lap. d. Talk softly to the infant while taking him from his father. 77. When interviewing the mother of a 3-year-old child, the nurse asks about developmental milestones such as the age of walking without assistance. This should be considered: a. unnecessary information because child is age 3 years. b. an important part of the family history. c. an important part of the child’s past history. R Information about the attainment of developmental milestones is important to obtain. It provides data about the child’s growth and development that should be included in the past history. Developmental milestones provide important information about the child’s physical, social, and neurologic health and should be included in the history for a 3-year-old child. If pertinent, attainment of milestones by siblings would be included in the family history. The review of systems does not include the developmental milestones. d. an important part of the child’s review of systems. 78. The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active? a. Ask her, “Are you sexually active?” b. Ask her, “Are you having sex with anyone?” R Asking the adolescent girl whether she is having sex with anyone is a direct question that is well understood. The phrase sexually active is broadly defined and may not provide specific information to the nurse to provide necessary care. The word anyone is preferred to using gender-specific terms such as boyfriend or girlfriend. Because homosexual experimentation may occur, it is preferable to use gender-neutral terms. Questioning about sexual activity should occur when the adolescent is alone. c. Ask her, “Are you having sex with a boyfriend?” d. Ask both the girl and her parent whether she is sexually active. 79. A nurse is preparing to perform a physical assessment on a toddler. Which approach should the nurse use for this child? a. Always proceed in a head-to-toe direction. b. Perform traumatic procedures first. c. Use minimal physical contact initially. R Parents can remove clothing, and the child can remain on the parent’s lap. The nurse should use minimal physical contact initially to gain the child’s cooperation. The head-to-toe assessment can be done in older children but usually must be adapted in younger children. Traumatic procedures should always be performed last. These will most likely upset the child and inhibit cooperation. The nurse should introduce the equipment slowly. The child can inspect the equipment, but demonstrations are usually too complex for toddlers. d. Demonstrate use of equipment. 80. The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother either staying in the room or leaving. This action should be considered: a. appropriate because of child’s age. R The older school-age child should be given the option of having the parent present or not. During the examination, the nurse should respect the child’s need for privacy. Although the question was appropriate for the child’s age, the mother is responsible for making decisions for the child. It is appropriate because of the child’s age. During the examination, the nurse must respect the child’s privacy. The child should help determine who is present during the examination. b. appropriate because mother would be uncomfortable making decisions for child. c. inappropriate because of child’s age. d. inappropriate because child is same sex as mother. 81. A nurse is counseling parents of a child beginning to show signs of being overweight. The nurse accurately relates which body mass index (BMI)-for-age percentile indicates a risk for being overweight? a. 10th percentile b. 9th percentile c. 85th percentile R Children who have BMI-for-age greater than or equal to the 85th percentile and less than the 95th percentile are at risk for being overweight. Children in the 9th and 10th percentiles are within normal limits. Children who are greater than or equal to the 95th percentile are considered overweight. d. 95th percentile 82. Which tool measures body fat most accurately? a. Stadiometer b. Calipers R Calipers are used to measure skin-fold thickness, which is an indicator of body fat content. Stadiometers are used to measure height. Cloth tape measures should not be used because they can stretch. Paper or metal tape measures can be used for recumbent lengths and other body measurements that must be made. c. Cloth tape measure d. Paper or metal tape measure 83. The nurse is using calipers to measure skin-fold thickness over the triceps muscle in a school-age child. What is the purpose of doing this? a. To measure body fat R Measurement of skin-fold thickness is an indicator of body fat. Arm circumference is an indirect measure of muscle mass. The accuracy of weight measurement should be verified with a properly balanced scale. Body fat is just one indicator of weight. b. To measure muscle mass c. To determine arm circumference d. To determine accuracy of weight measurement 84. A nurse notes that a 10-month-old infant has a larger head circumference than chest. The nurse interprets this as a normal finding because the head and chest circumference become equal at which age? a. 1 month b. 6 to 9 months c. 1 to 2 years R Head circumference begins larger than chest circumference. Between ages 1 and 2 years, they become approximately equal. Head circumference is larger than chest circumference before age 1. Chest circumference is larger than head circumference at 2 1/2 to 3 years. d. 2 1/2 to 3 years 85. Which would be best for the nurse to use when determining the temperature of a preterm infant under a radiant heater? a. Axillary sensor R The axillary sensor measures the infrared heat energy radiating from the axilla. It can be used on wet skin, in incubators, or under radiant warmers. Ear thermometry does not show sufficient correlation with established methods of measurement. It should not be used when body temperature must be assessed with precision. Mercury thermometers should never be used. The release of mercury, should the thermometer be broken, can cause harmful vapors. Rectal temperatures should be avoided unless no other suitable way exists for the temperature to be measured. b. Tympanic membrane sensor c. Rectal mercury glass thermometer d. Rectal electronic thermometer 86. What is the earliest age at which a satisfactory radial pulse can be taken in children? a. 1 year b. 2 years R Satisfactory radial pulses can be used in children older than 2 years. In infants and young children, the apical pulse is more reliable. The apical pulse can be used for assessment at these ages. c. 3 years d. 6 years 87. Pulses can be graded according to certain criteria. Which is a description of a normal pulse? a. 0 b. +1 c. +2 d. +3 R A normal pulse is described as +3. A pulse that is easy to palpate and not easily obliterated with pressure is considered normal. A pulse graded 0 is not palpable. A pulse graded +1 is difficult to palpate, thready, weak, and easily obliterated with pressure. A pulse graded +2 is difficult to palpate and may be easily obliterated with pressure. 88. When palpating the child’s cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. What is the best explanation for this? a. Some form of cancer b. Local scalp infection common in children c. Infection or inflammation distal to the site d. Infection or inflammation close to the site R Small nontender nodes are normal. Tender, enlarged, and warm lymph nodes may indicate infection or inflammation close to their location. Tender lymph nodes are not usually indicative of cancer. A scalp infection would usually not cause inflamed lymph nodes. The lymph nodes close to the site of inflammation or infection would be inflamed. 89. During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which is the nurse’s most appropriate action? a. Teach parents appropriate exercises. b. Recheck head control at next visit. c. Refer child for further evaluation. R Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation. Reduction of head lag is part of normal development. Exercises will not be effective. The lack of achievement of this developmental milestone must be evaluated. d. Refer child for further evaluation if anterior fontanel is still open. 90. At what age should the nurse expect the anterior fontanel to close? a. 2 months b. 2 to 4 months c. 6 to 8 months d. 12 to 18 months R The anterior fontanel normally closes between ages 12 and 18 months. Two to 8 months is too early. The expected closure of the anterior fontanel occurs between ages 12 and 18 months; if it closes between ages 2 and 8 months, the child should be referred for further evaluation. 91. During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is a(n): a. normal finding. R A brilliant, uniform red reflex is an important normal finding. It rules out many serious defects of the cornea, aqueous chamber, lens, and vitreous chamber. b. abnormal finding, so child needs referral to ophthalmologist. c. sign of possible visual defect, so child needs vision screening. d. sign of small hemorrhages, which will usually resolve spontaneously. 92. Parents of a newborn are concerned because the infant’s eyes often “look crossed” when the infant is looking at an object. The nurse’s response is that this is normal based on the knowledge that binocularity is normally present by what age? a. 1 month b. 3 to 4 months R Binocularity is usually achieved by ages 3 to 4 months. 1 month is too young. If binocularity is not achieved by ages 6 to 12 months, the child must be observed for strabismus. c. 6 to 8 months d. 12 months 93. A nurse is preparing to test a school-age child’s vision. Which eye chart should the nurse use? a. Denver Eye Screening Test b. Allen picture card test c. Ishihara vision test d. Snellen letter chart R The Snellen letter chart, which consists of lines of letters of decreasing size, is the most frequently used test for visual acuity for school-age children. Single cards (Denver—letter E; Allen—pictures) are used for children ages 2 years and older who are unable to use the Snellen letter chart. The Ishihara vision test is used for color vision. 94. Which is the most appropriate vision acuity test for a child who is in preschool? a. Cover test b. Ishihara test c. HOTV chart R The HOTV test consists of a wall chart of these letters. The child is asked to point to a corresponding card when the examiner selects one of the letters on the chart. The cover test determines ocular alignment. The Ishihara test is used for the detection of color blindness. The Snellen letter chart is usually used for older children. d. Snellen letter chart 95. The nurse is testing an infant’s visual acuity. By what age should the infant be able to fix on and follow a target? a. 1 month b. 1 to 2 months c. 3 to 4 months R Visual fixation and following a target should be present by ages 3 to 4 months. One to 2 months is too young for this developmental milestone. If the infant is not able to fix and follow by 6 months, further ophthalmologic evaluation is needed. d. 6 months 96. The appropriate placement of a tongue blade for assessment of the mouth and throat is: a. center back area of tongue. b. side of the tongue. R Side of the tongue is the correct position. It avoids the gag reflex yet allows visualization. Placement in the center back area of the tongue will elicit the gag reflex. Against the soft palate and on the lower jaw are not appropriate places for the tongue blade. c. against the soft palate. d. on the lower jaw. 97. An appropriate screening test for hearing that can be administered by