1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
nursing intervention is appropriate for this child?
5t 5t 5t 5t 5t 5t 5t
A) Make certain the child is maintained in correct body alignment.
5t 5 t 5t 5 t 5 t 5t 5t 5 t 5t
B) Be sure the traction weights touch the end of the bed.
5t 5t 5t 5 t 5t 5t 5t 5t 5t 5t
C) Adjust the head and foot of the bed for the child's comfort
5t 5t 5t 5 t 5t 5t 5t 5t 5 t 5t 5t
D) Release the traction for 15-20 minutes every 6 hours PRN.
5t 5t 5 t 5t 5t 5 t 5t 5t 5t
The correct answer isA: Make certain the child is maintained in correct body alignment.
5t 5t 5 t 5t 5t 5t 5t 5t 5 t 5t 5t 5t 5 t 5t
,2. The nurse is assessing a healthy child at the 2 year check up. Which of the following should
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
the nurse report immediately to the health care provider?
5t 5t 5t 5t 5t 5t 5t 5t 5t
A) Height and weight percentiles vary widely 5t 5t 5 t 5t 5t
B) Growth pattern appears to have slowed 5t 5t 5t 5t 5t
C) Recumbent and standing height are different 5t 5t 5 t 5t 5t
D) Short term weight changes are uneven 5t 5t 5t 5t 5t
The correct answer isA: Height and weight percentiles vary widely
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
3. The parents of a 2 year-old child report that he has been holding his breath whenever he has
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
temper tantrums. What is the best action by the nurse?
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
A) Teach the parents how to perform cardiopulmonary resuscitation
5t 5t 5t 5t 5t 5t 5t
B) Recommend that the parents give in when he holds his breath to prevent anoxia 5t 5t 5t 5 t 5t 5t 5t 5t 5t 5 t 5t 5t 5t
C) Advise the parents to ignore breath holding because breathing will begin as a reflex
5t 5t 5t 5t 5t 5t 5t 5t 5 t 5t 5t 5t 5t
D) Instruct the parents on how to reason with the child about possible harmful effects The
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
correct answer is C:Advise the parents to ignore breath holding because breathing will begin
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
as a reflex
5t 5t 5t
4. The nurse is assessing a client in the emergency room. Which statement suggests that the
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
problem is acute angina?
5t 5t 5t 5t
A) "My pain is deep in my chest behind my sternum."
5t 5t 5t 5 t 5t 5t 5t 5t 5t
B) "When I sit up the pain gets worse." 5t 5t 5t 5t 5t 5t 5t
C) "As I take a deep breath the pain gets worse."
5t 5t 5t 5t 5t 5 t 5t 5t 5t
D) "The pain is right here in my stomach area."
5t 5t 5t 5t 5t 5t 5t 5t
The correct answer isA: "My pain is deep in my chest behind my sternum."
5t 5t 5 t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
.
5. The nurse is assessing the mental status of a client admitted with possible organic brain
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
disorder. Which of these questions will best assess the function of the client's recent
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
,memory?
A) "Name the year." "What season is this?" (pause for answer after each question)
5t 5t 5t 5 t 5t 5t 5t 5t 5t 5t 5t 5t
B) "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
continue to subtract 7 from the new number."
5t 5t 5t 5t 5t 5t 5t 5t
C) "I am going to say the names of three things and I want you to repeat them after me: blue,
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
ball, pen."
5t 5t
D) "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?"
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
The correct answer is C: "I am going to say the names of three things and I want you to repeat them
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
after me: blue, ball, pen."
5t 5t 5t 5t 5t
6. In planning care for a 6 month-old infant, what must the nurse provide to assist in the
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
development of trust?
5t 5t 5t
A) Food
B) Warmth
C) Security
D) Comfort
The correct answer is C: Security
5t 5t 5t 5t 5t
7. Anurse has just received a medication order which is not legible. Which statement best
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
reflects assertive communication?
5t 5t 5t
A) "I cannot give this medication as it is written. I have no idea of what you mean."
5t 5t 5t 5 t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5 t 5t
B) "Would you please clarify what you have written so I am sure I am reading it
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
correctly?"
5t
C) "I am having difficulty reading your handwriting. It would save me time if you would be
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
more careful."
5t 5t
D) "Please print in the future so I do not have to spend extra time attempting to read your
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
writing."
5t
The correct answer is B) "Would you please clarify what you have written so I am sure I am
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
reading it correctly?" 5t 5t
8. What is the most important consideration when teaching parents how to reduce risks in the
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
home?
5t
A) Age and knowledge level of the parents
5t 5t 5t 5t 5t 5t
B) Proximity to emergency services 5t 5t 5 t
C) Number of children in the home 5t 5t 5t 5t 5t
D) Age of children in the home 5t 5t 5t 5t 5t
The correct answer is D:Age of children in the home
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
, 9. A35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
enters the room to request something for pain. The nurse should
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
A) Administer a placebo 5t 5t
B) Encourage increased fluid intake 5t 5t 5t
C) Administer the prescribed analgesia 5t 5t 5t
D) Recommend relaxation exercises for pain control 5t 5 t 5t 5t 5t
The correct answer is C:Administer the prescribed analgesia
5t 5t 5t 5t 5t 5t 5t 5t
10. While caring for a toddler with croup, which initial sign of croup requires the nurse's
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
immediate attention?
5t 5t
A) Respiratory rate of 42 5t 5t 5t
B) Lethargy for the past hour 5t 5t 5t 5t
C) Apical pulse of 54 5t 5t 5t
D) Coughing up copious secretions 5t 5t 5 t
The correct answer isA: Respiratory rate of 30
5t 5t 5t 5t 5t 5t 5t 5t
11. Aclient is admitted with low T3 andT4 levels and an elevated TSH level. On initial
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
assessment, the nurse would anticipate which of the following assessment findings?
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
A) Lethargy
B) Heat intolerance 5t
C) Diarrhea
D) Skin eruptions 5t
The correct answer isA: Lethargy
5t 5t 5t 5t 5t
12. The emergency room nurse admits a child who experienced a seizure at school.The father
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
comments that this is the first occurrence, and denies any family history of epilepsy. What is
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
the best response by the nurse?
5t 5t 5t 5t 5t 5t
A) "Do not worry. Epilepsy can be treated with medications."
5t 5t 5t 5t 5t 5t 5t 5t
B) "The seizure may or may not mean your child has epilepsy."
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
C) "Since this was the first convulsion, it may not happen again."
5t 5t 5t 5t 5t 5t 5t 5t 5 t 5t
D) "Long term treatment will prevent future seizures." 5t 5t 5 t 5t 5t 5 t
The correct answer is B: "The seizure may or may not mean your child has epilepsy."
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5 t 5t
13. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
nursing diagnosis best applies?
5t 5t 5t 5t
A) Risk for injury 5t 5t
B) Risk for knowledge deficit 5t 5t 5t
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
nursing intervention is appropriate for this child?
5t 5t 5t 5t 5t 5t 5t
A) Make certain the child is maintained in correct body alignment.
5t 5 t 5t 5 t 5 t 5t 5t 5 t 5t
B) Be sure the traction weights touch the end of the bed.
5t 5t 5t 5 t 5t 5t 5t 5t 5t 5t
C) Adjust the head and foot of the bed for the child's comfort
5t 5t 5t 5 t 5t 5t 5t 5t 5 t 5t 5t
D) Release the traction for 15-20 minutes every 6 hours PRN.
5t 5t 5 t 5t 5t 5 t 5t 5t 5t
The correct answer isA: Make certain the child is maintained in correct body alignment.
5t 5t 5 t 5t 5t 5t 5t 5t 5 t 5t 5t 5t 5 t 5t
,2. The nurse is assessing a healthy child at the 2 year check up. Which of the following should
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
the nurse report immediately to the health care provider?
5t 5t 5t 5t 5t 5t 5t 5t 5t
A) Height and weight percentiles vary widely 5t 5t 5 t 5t 5t
B) Growth pattern appears to have slowed 5t 5t 5t 5t 5t
C) Recumbent and standing height are different 5t 5t 5 t 5t 5t
D) Short term weight changes are uneven 5t 5t 5t 5t 5t
The correct answer isA: Height and weight percentiles vary widely
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
3. The parents of a 2 year-old child report that he has been holding his breath whenever he has
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
temper tantrums. What is the best action by the nurse?
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
A) Teach the parents how to perform cardiopulmonary resuscitation
5t 5t 5t 5t 5t 5t 5t
B) Recommend that the parents give in when he holds his breath to prevent anoxia 5t 5t 5t 5 t 5t 5t 5t 5t 5t 5 t 5t 5t 5t
C) Advise the parents to ignore breath holding because breathing will begin as a reflex
5t 5t 5t 5t 5t 5t 5t 5t 5 t 5t 5t 5t 5t
D) Instruct the parents on how to reason with the child about possible harmful effects The
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
correct answer is C:Advise the parents to ignore breath holding because breathing will begin
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
as a reflex
5t 5t 5t
4. The nurse is assessing a client in the emergency room. Which statement suggests that the
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
problem is acute angina?
5t 5t 5t 5t
A) "My pain is deep in my chest behind my sternum."
5t 5t 5t 5 t 5t 5t 5t 5t 5t
B) "When I sit up the pain gets worse." 5t 5t 5t 5t 5t 5t 5t
C) "As I take a deep breath the pain gets worse."
5t 5t 5t 5t 5t 5 t 5t 5t 5t
D) "The pain is right here in my stomach area."
5t 5t 5t 5t 5t 5t 5t 5t
The correct answer isA: "My pain is deep in my chest behind my sternum."
5t 5t 5 t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
.
5. The nurse is assessing the mental status of a client admitted with possible organic brain
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
disorder. Which of these questions will best assess the function of the client's recent
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
,memory?
A) "Name the year." "What season is this?" (pause for answer after each question)
5t 5t 5t 5 t 5t 5t 5t 5t 5t 5t 5t 5t
B) "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
continue to subtract 7 from the new number."
5t 5t 5t 5t 5t 5t 5t 5t
C) "I am going to say the names of three things and I want you to repeat them after me: blue,
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
ball, pen."
5t 5t
D) "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?"
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
The correct answer is C: "I am going to say the names of three things and I want you to repeat them
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
after me: blue, ball, pen."
5t 5t 5t 5t 5t
6. In planning care for a 6 month-old infant, what must the nurse provide to assist in the
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
development of trust?
5t 5t 5t
A) Food
B) Warmth
C) Security
D) Comfort
The correct answer is C: Security
5t 5t 5t 5t 5t
7. Anurse has just received a medication order which is not legible. Which statement best
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
reflects assertive communication?
5t 5t 5t
A) "I cannot give this medication as it is written. I have no idea of what you mean."
5t 5t 5t 5 t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5 t 5t
B) "Would you please clarify what you have written so I am sure I am reading it
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
correctly?"
5t
C) "I am having difficulty reading your handwriting. It would save me time if you would be
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
more careful."
5t 5t
D) "Please print in the future so I do not have to spend extra time attempting to read your
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
writing."
5t
The correct answer is B) "Would you please clarify what you have written so I am sure I am
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
reading it correctly?" 5t 5t
8. What is the most important consideration when teaching parents how to reduce risks in the
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
home?
5t
A) Age and knowledge level of the parents
5t 5t 5t 5t 5t 5t
B) Proximity to emergency services 5t 5t 5 t
C) Number of children in the home 5t 5t 5t 5t 5t
D) Age of children in the home 5t 5t 5t 5t 5t
The correct answer is D:Age of children in the home
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
, 9. A35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
enters the room to request something for pain. The nurse should
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
A) Administer a placebo 5t 5t
B) Encourage increased fluid intake 5t 5t 5t
C) Administer the prescribed analgesia 5t 5t 5t
D) Recommend relaxation exercises for pain control 5t 5 t 5t 5t 5t
The correct answer is C:Administer the prescribed analgesia
5t 5t 5t 5t 5t 5t 5t 5t
10. While caring for a toddler with croup, which initial sign of croup requires the nurse's
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
immediate attention?
5t 5t
A) Respiratory rate of 42 5t 5t 5t
B) Lethargy for the past hour 5t 5t 5t 5t
C) Apical pulse of 54 5t 5t 5t
D) Coughing up copious secretions 5t 5t 5 t
The correct answer isA: Respiratory rate of 30
5t 5t 5t 5t 5t 5t 5t 5t
11. Aclient is admitted with low T3 andT4 levels and an elevated TSH level. On initial
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
assessment, the nurse would anticipate which of the following assessment findings?
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
A) Lethargy
B) Heat intolerance 5t
C) Diarrhea
D) Skin eruptions 5t
The correct answer isA: Lethargy
5t 5t 5t 5t 5t
12. The emergency room nurse admits a child who experienced a seizure at school.The father
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
comments that this is the first occurrence, and denies any family history of epilepsy. What is
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
the best response by the nurse?
5t 5t 5t 5t 5t 5t
A) "Do not worry. Epilepsy can be treated with medications."
5t 5t 5t 5t 5t 5t 5t 5t
B) "The seizure may or may not mean your child has epilepsy."
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
C) "Since this was the first convulsion, it may not happen again."
5t 5t 5t 5t 5t 5t 5t 5t 5 t 5t
D) "Long term treatment will prevent future seizures." 5t 5t 5 t 5t 5t 5 t
The correct answer is B: "The seizure may or may not mean your child has epilepsy."
5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5 t 5t
13. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t 5t
nursing diagnosis best applies?
5t 5t 5t 5t
A) Risk for injury 5t 5t
B) Risk for knowledge deficit 5t 5t 5t
