2024-2025 QUESTIONS AND ANSWERS 100%
CORRECT!!
,A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the
following actions should the nurse take?
a. Perform the assessment in a head to toe sequence.
b. Minimize physical contact with the child initially.
c. Explain procedures using medical terminology.
d. Stop the assessment if the child becomes uncooperative. - ANSWER B
Rationale: The nurse should initially minimize physical contact with the toddler, and then
progress from the least traumatic to the most traumatic procedures.
A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and
is
planning to attend college. The nurse should inform the client that he should receive
which of the
following immunizations prior to moving into a campus dormitory?
a. Pneumococcal polysaccharide
b. Meningococcal polysaccharide
c. Rotavirus
d. Herpes zoster - ANSWER B
Rationale: The meningococcal polysaccharide immunization is used to prevent infection
by
certain groups of meningococcal bacteria. Meningococcal infection can cause life-
threatening
illnesses, such as meningococcal meningitis, which affects the brain, and
meningococcemia,
which affects the blood. Both of these conditions can be fatal. College freshmen,
particularly
those who live in dormitories, are at an increased risk for meningococcal disease
relative to other
persons their age. Therefore, the Centers for Disease Control and Prevention has
issued a
recommendation that all incoming college students receive the meningococcal
immunization.
A nurse is teaching the parent of an infant about food allergens. Which of the following
foods should the nurse include as being the most common food allergy in children?
a. Cow's milk
b. Wheat bread
,c. Corn syrup
d. Egg - ANSWER A
Rationale: According to evidence-based practice, the nurse should instruct the parent
that cow's
milk is the most common food allergy in children. Some children are sensitive to the
protein,
called casein, found in cow's milk. They have difficulty metabolizing the casein and are,
therefore, allergic to cow's milk.
A nurse is preparing to administer recommended immunizations to a 2-month-old infant.
Which of the following immunizations should the nurse plan to administer?
a. Human papillomavirus (HPV) and hepatitis A
b. Measles, mumps, rubella (MMR) and tetanus, diphtheria, and acellular pertussis
(TDaP)
c. Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV)
d. Varicella (VAR) and live attenuated influenza vaccine (LAIV) - ANSWER C
Rationale: The recommended immunizations for a 2-month-old infant include Hib and
IPV. The
Hib immunization series consists of 3 to 4 doses, depending on the immunization used,
and at a
minimum is administered at the ages of 2 months, 4 months, and 12 to 15 months. The
IPV
immunization series consists of 4 doses and is administered at the ages of 2 months, 4
months, 6
to 18 months, and 4 to 6 years.
A nurse is developing a plan of care for a school-age child who underwent a surgical
procedure that resulted in temporary loss of vision. Which of the following interventions
should the nurse include in the plan of care?
a. Assign an assistive personnel to feed the child.
b. Explain sounds the child is hearing.
c. Have the child use a cane when ambulating.
d. Rotate nurses caring for the child. - ANSWER B
Rationale: The noises in a facility can be frightening to a child who is experiencing a
sensory
loss. It is important to explain these noises to allay the child's fears.
A nurse is assessing a 3-year-old child who is 1 day postoperative following a
tonsillectomy.
Which of the following methods should the nurse use to determine if the child is
experiencing pain?
, a. Ask the parents.
b. Use the FACES scale.
c. Use the numeric rating scale.
d. Check the child's temperature. - ANSWER B
Rationale: Pain is a subjective experience even for a 3-year-old child. The FACES scale
can be
used to accurately determine the presence of pain in children as young as 3 years of
age.
12. A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following
findings indicates the need for further assessment?
a. Grabs feet and pulls them to her mouth
b. Posterior fontanel is closed
c. Legs remain crossed and extended when supine
d. Birth weight has doubled - ANSWER C
Rationale: Legs crossed and extended when supine is an unexpected finding and
requires further
assessment. At 6 months of age, the legs flex at the knees when the infant is supine.
Crossed and
extended legs when supine is a finding associated with cerebral palsy.
A nurse is observing a mother who is playing peek-a-boo with her 8-month-old child.
The
mother asks if this game has any developmental significance. The nurse should inform
the
mother that peek-a-boo helps develop which of the following concepts in the child?
a. Hand-eye coordination
b. Sense of trust
c. Object permanence
d. Egocentrism - ANSWER C
Rationale: Object permanence refers to the cognitive skill of knowing an object still
exists even
when it is out of sight. In discovering a hidden object while playing peek-a-boo, the
infant
experiences validation of this concept.
A nurse is caring for a 15-month-old toddler who requires droplet precautions. Which of
the
following actions should the nurse take?
a. Have the toddler wear a disposable gown when in the unit's playroom.
b. Wear sterile gloves when changing the toddler's diapers.