A 7-year-old receiving chemotherapy for leukemia presents with
fatigue, frequent nosebleeds, and a fever. The CBC reveals a low
white blood cell count, low red blood cell count, and low platelet
count. How should the nurse interpret these findings?
A. Neutropenia
B. Anemia
C. Thrombocytopenia
D. Pancytopenia - ANSWERS-D. Pancytopenia
A 2-month-old infant is diagnosed with coarctation of the aorta
(COA). While assessing the patient's vital signs, which action is most
appropriate for the nurse?
A. Measure pulse oximetry on the right hand only
B. Obtain blood pressure in the right arm and compare it to the left leg
C. Measure blood pressure in all four extremities
D. Record apical pulse and check capillary refill only - ANSWERS-C.
Measure blood pressure in all four extremities
During a well-baby visit, the nurse assesses the fine motor
development of a 9-month-old infant. Which milestone should the
nurse expect to observe?
A. Scribbles with a crayon
B. Builds a tower of two blocks
,C. Uses a pincer grasp to pick up small objects
D. Transfers objects from hand to hand - ANSWERS-C. Uses a pincer
grasp to pick up small objects
A 10-year-old child is admitted with signs of dehydration and
excessive urination. The healthcare provider suspects central diabetes
insipidus. The nurse explains that the condition is caused by a
deficiency of which hormone?
A. Aldosterone
B. Thyroid-stimulating hormone
C. Antidiuretic hormone (ADH)
D. Parathyroid hormone - ANSWERS-C. Antidiuretic hormone
(ADH)
The nurse is caring for a child diagnosed with central diabetes
insipidus (DI). Which medication should the nurse anticipate
administering?
A. Levothyroxine
B. Cortisone
C. Desmopressin (DDAVP)
D. Spironolactone - ANSWERS-C. Desmopressin (DDAVP)
A 6-year-old child with a history of epilepsy is admitted for
evaluation of recurrent clonic seizures. During a seizure, which
nursing action takes highest priority?
A. Restrain the child to prevent injury
,B. Administer oral lorazepam immediately
C. Ensure a safe environment and maintain airway patency
D. Place a tongue blade in the mouth to prevent biting - ANSWERS-
C. Ensure a safe environment and maintain airway patency (seizure
precautions)
A 6-year-old child with autism spectrum disorder is being admitted
for evaluation. Which room assignment is most appropriate?
A. A room with another child of the same age to promote socialization
B. A room near the nurses' station to allow frequent observation
C. A private room with minimal stimulation and consistency in
caregivers
D. A playroom setting where they can be observed while interacting
with peers - ANSWERS-C. A private room with minimal stimulation
and consistency in caregivers
The nurse is assessing pain in a 5-year-old who is post-op from an
appendectomy. Which pain scale is most appropriate for this child?
A. FLACC scale
B. Numeric rating scale (0-10)
C. FACES pain rating scale
D. COMFORT scale - ANSWERS-C. FACES pain rating scale
A nurse is assessing a 10-month-old infant with suspected
dehydration. Which of the following findings would indicate severe or
late-stage dehydration?
, A. Low blood pressure
B. Sunken anterior fontanel
C. Dry mucous membranes
D. Capillary refill of 2 seconds - ANSWERS-A. Low blood pressure
A nurse is assessing a 1-year-old child admitted with vomiting and
diarrhea. Which of the following would the nurse recognize as an
early sign of dehydration?
A. Decreased blood pressure
B. Cold, mottled extremities
C. Dry mucous membranes
D. Loss of consciousness - ANSWERS-C. Dry mucous membranes
A 7-year-old with newly diagnosed Type 1 Diabetes is being
discharged. Which teaching point is most appropriate?
A. "You will need oral medications to manage your blood sugar."
B. "Daily insulin injections will be needed because your body cannot
make insulin."
C. "Type 1 diabetes is usually caused by being overweight."
D. "Exercise should be avoided to keep blood sugar levels stable." -
ANSWERS-B. "Daily insulin injections will be needed because your
body cannot make insulin."
A school-age child is being evaluated for congenital hypothyroidism.
Which finding would concern the nurse?