Marking Scheme Current Update
If a medication is being administered by the otic route, it will be administered in which
way? - Answers -✔✔ Warmed to room temperature and dropped into the ear
A child has been diagnosed with strabismus. After further examination, the patient is
told that the resting position of the right eye is convergent. The nurse further explains
that this means which of the following? - Answers -✔✔ The resting position of the eye
is turned in.
The nurse is educating an 11-year-old child and her family about caring for her migraine
headaches. Which of the following would the nurse most likely include in the child's
teaching plan? - Answers -✔✔ "Use the triptan at the first sign of the headache."
A 17-year-old is brought to the emergency department with a fever, headache, and stiff
neck. Bacterial meningitis is suspected. The nurse would anticipate preparing the
adolescent for which test to confirm the diagnosis? - Answers -✔✔ Lumbar puncture
The nurse is assessing a 9-year-old child who is suspected of having meningitis. The
nurse assesses the child for meningeal irritation using the Kernig sign. Which result
would the nurse interpret as positive? - Answers -✔✔ Child reports pain behind the
knee when leg is extended.
Which nursing action should be included in the care plan to promote comfort in a 4-
year-old child hospitalized with meningitis? - Answers -✔✔ Avoid making noise when in
the child's room.
To detect complications as early as possible in a child with meningitis who's receiving IV
fluids, monitoring for which condition should be the nurse's priority? - Answers -✔✔
Cerebral edema
The nurse is performing a physical assessment on a toddler and suspects hearing loss.
What symptoms might indicate a problem? (Select all that apply.) - Answers -✔✔ 1.
Incomplete formed pinna
2. Child leaning forward
3. Unclear speech
White forelock on hair
A child has recently been diagnosed with cataracts. The treatment for cataracts is: -
Answers -✔✔ Surgery
, A child with a seizure disorder is being admitted to the inpatient unit. When preparing
the room for the child, what should be included? Select all that apply. - Answers -✔✔ 1.
Oxygen gauge and tubing
2. Suction at bedside
3. Padding for side rails
A young child in the clinic has watery eyes and reddened conjunctiva. The child keeps
the eyes closed a lot, because it hurts to have them open. Which problem does the
nurse suspect for this client? - Answers -✔✔ Conjunctivitis
During the physical examination, the nurse notes a positive Kernig and Brudzinski sign.
The nurse interprets these findings to suggest which condition? - Answers -✔✔
Meningeal irritation
The nurse is planning care for a preschool-age child diagnosed with meningitis. What
should the nurse identify as a priority goal for this patient's care? - Answers -✔✔
Reduce the pain related to nuchal rigidity.
A nurse suspects that a child has developed pneumococcal meningitis based on
assessment of which of the following? - Answers -✔✔ Nuchal rigidity
The nurse is preparing a care plan for a child who has a seizure disorder. The child
experiences tonic-clonic seizures. Which nursing diagnosis will the nurse identify as
having the highestpriority? - Answers -✔✔ Risk for injury
A nursing instructor is teaching about eye disorders in childhood. Which statement
made by a student indicates a need for further instruction? - Answers -✔✔ "Cataracts
are only present in adults."
The parents of a toddler have just learned that their child has profound hearing loss.
The parents are very upset and state to the nurse, "It just isn't fair. We did everything
right during our pregnancy all the way to this point." How should the nurse respond? -
Answers -✔✔ "I can't imagine how difficult this must be. When you're ready I would be
happy to arrange a meeting with a support group of other parents with children who
have hearing loss."
A child is brought to the emergency department after experiencing a series of
continuous seizures. The nurse is reviewing the orders for care and treatment. Which
order would be of the highest priority? - Answers -✔✔ Serum glucose level
The nurse is caring for a toddler who was just diagnosed with a hearing impairment.
What would the nurse expect to assess in the child? - Answers -✔✔ A delay or lack of
clear, understandable speech pattern