A 1-year-old child is admitted to the hospital for control of tonic-clonic seizures. The
nurse would do which of the following in order to protect the child from injury? *SELECT
ALL THAT APPLY.* - Answer-*2. Remove toys that have bright, blinking lights on
them.* *3. Keep side rails and other hard objects padded.* *4. Turn the client to the side
during a seizure.*
/.A 1-year-old child is diagnosed with intussusception. The mother of the child asks the
nurse to describe the disorder. The nurse tells the mother that this disorder is: - Answer-
*2. A condition in which a proximal segment of the bowel prolapses into a distal
segment of the bowel*
/.A 1-year-old child is seen in the health care provider's office with complaints of an
elevated temperature that began the previous evening. When gathering subjective data
from the mother, the nurse notices that which of the following would most likely indicate
the child has acute otitis media? - Answer-*4. The mother states the child had purulent
discharge from the ear last night.*
/.A 1-year-old child with hypospadias is scheduled for surgery to correct this condition. A
nurse is asked to assist in preparing a plan of care for this child and makes suggestions,
knowing that this surgery is taking place at a time when: - Answer-*1. Fears of
separation and mutilation are present*
/.A 10-year-old child with asthma is treated for acute exacerbation. Which finding would
indicate that the condition is worsening? - Answer-*3. Decreased wheezing*
/.A 12-year-old child is seen in the clinic, and a diagnosis of Hodgkin's disease is
suspected. Several diagnostic studies are performed to determine the presence of this
disease. When evaluating the diagnostic results, the nurse would expect to note which
of the following if this child had Hodgkin's disease? - Answer-*2. The presence of Reed-
Sternberg cells*
/.A 13-year-old child is diagnosed with osteogenic sarcoma of the femur. Following a
course of chemotherapy, it is decided that leg amputation is necessary. Following the
amputation, the child becomes very frightened because of aching and cramping felt in
the missing limb. Which statement made by the nurse will best assist in alleviating the
child's fear? - Answer-*1. "This aching and cramping is normal and temporary and will
subside."*
/.A 2-year-old child is admitted to the hospital with a diagnosis of nephrotic syndrome. In
planning care for this child, which of the following nursing interventions would be of
highest priority? - Answer-*3. Dipstick the urine for protein every 4 hours.*
,/.A 2-year-old child is diagnosed with constipation. Which of the following describes a
characteristic of this disorder? - Answer-*3. The infrequent and difficult passage of dry
stools*
/.A 3-year-old child has returned to his room following a tonsillectomy. Which
assessment finding needs immediate notification of the registered nurse? - Answer-*2.
Nasal flaring and rib retractions*
/.A 3-year-old child is brought to the emergency department. The mother states that the
child has had flulike symptoms with vomiting and diarrhea for the past 2 days. On data
collection the nurse finds that the child's heart rate is slightly elevated and the blood
pressure is normal. The child is irritable and crying only a few tears. The mother states
that the child's weight before the illness was 33 pounds. The nurse finds the current
weight to be 31 pounds. The nurse correctly interprets this as what level of dehydration?
- Answer-*4. Moderate dehydration*
/.A 3-year-old child is seen in the health care clinic, and a diagnosis of encopresis is
made. The nurse reviews the record, expecting to note which of the following that is a
sign of this disorder? - Answer-*3. Evidence of soiled clothing*
/.A 4-year-old child is admitted to the hospital with suspected acute lymphocytic
leukemia (ALL). The nurse understands that which diagnostic study will confirm this
diagnosis? - Answer-*3. Bone marrow biopsy*
/.A 4-year-old child is being transported to the trauma center from a local community
hospital for treatment of a burn injury that is estimated as covering over 40% of the
body. The burns are partial- and full-thickness burns. The nurse is asked to prepare for
the arrival of the child and gathers supplies anticipating that which of the following will
be prescribed initially? - Answer-*2. Insertion of a Foley catheter*
/.A 4-year-old child is diagnosed with otitis media, and the mother asks the nurse about
the causes of this illness. The nurse responds, knowing that which of the following is an
unassociated risk factor related to otitis media? - Answer-*3. A history of urinary tract
infections*
/.A 4-year-old child is hospitalized for severe gastroenteritis. The child is crying and
clinging to the mother. The mother becomes very upset and is afraid to leave the child.
Which of the following nursing interventions would be most appropriate to alleviate the
child's fears and the mother's anxiety? - Answer-*3. Ask the mother if she would like to
stay overnight with the child.*
/.A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The
nurse assists with developing a plan of care. The nurse questions which intervention
that is written in the plan of care? - Answer-*1. Palpating the abdomen for a mass*
,/.A 4-year-old child sustains a fall at home and is brought to the emergency department
by the mother. After an x-ray, it is determined that the child has a fractured arm, and a
plaster cast is applied. The nurse provides instructions to the mother regarding cast
care for the child. Which statement by the mother indicates the need for further
instructions? - Answer-*2. "I can use lotion or powder around the cast edges to relieve
itching."*
/.A 4-year-old child sustains a fall at home and is brought to the emergency department
by the mother. Following x-ray examination, it has been determined that the child has a
fractured arm, and a plaster cast is applied. The nurse provides instructions to the
mother regarding cast care for the child. Which statement by the mother indicates a
need for further instruction? - Answer-*1. "The cast will feel warm when it is dried."*
/.A 4-year-old child with acute lymphocytic leukemia has been admitted to the hospital in
relapse. The priority concern is infection due to immunosuppression. Which of the
following interventions would the nurse include in the plan of care? - Answer-*1.
Perform oral hygiene four times a day.*
/.A 5-year-old child has been transferred to the pediatric unit after a cardiac
catheterization. Which of the following interventions has the highest priority in the care
of this child immediately following the procedure? - Answer-*1. Assess for any bleeding
on the dressing.*
/.A 5-year-old child is admitted to the hospital for heart surgery to repair tetralogy of
Fallot. The nurse notes that the child has clubbed fingers, and the nurse knows that this
symptom is likely a result of: - Answer-*1. Peripheral hypoxia*
/.A 6-month-old infant receives a diphtheria, tetanus, and acellular pertussis (DTaP)
immunization at the well-baby clinic. The mother returns home and calls the clinic to
report that the infant has developed swelling and redness at the site of injection. Which
instruction by the nurse is appropriate? - Answer-*3. Apply an ice pack to the injection
site.*
/.A 6-year-old child has just been diagnosed with localized Hodgkin's disease, and
chemotherapy is planned to begin immediately. The mother of the child asks the nurse
about radiation therapy because it was not prescribed as a part of treatment. The
appropriate response to the mother is: - Answer-*2. "The child is too young to have
radiation therapy."*
/.A 6-year-old child with leukemia is hospitalized and is receiving combination
chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse
prepares to implement protective isolation procedures. Which interventions would the
nurse initiate? *SELECT ALL THAT APPLY.* - Answer-*2. Place the child on a low-
bacteria diet.* *3. Change dressings using sterile technique.* *5. Perform meticulous
handwashing before caring for the child.*
, /.A 9-year-old child is diagnosed with chlamydial conjunctivitis. The nurse consults with
the primary health care provider regarding necessary follow-up because this infection
can be associated with: - Answer-*4. Possible sexual abuse*
/.A breast-feeding mother of an infant with lactose intolerance asks the nurse about
dietary measures. Which of the following foods would the nurse instruct the mother to
avoid? - Answer-*1. Hard cheeses*
/.A child has a basilar skull fracture. Which of the following health care provider's
prescriptions should the nurse question? - Answer-*4. Suction via the nasotracheal
route as needed.*
/.A child has been diagnosed with Reye's syndrome. The nurse understands that a
major symptom associated with Reye's syndrome is: - Answer-*1. Persistent vomiting*
/.A child has epistaxis. The nurse understands that an appropriate treatment for
epistaxis is which of the following? - Answer-*1. Have the child sit up and lean forward.*
/.A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome.
Which findings would the nurse expect to observe? *SELECT ALL THAT APPLY.* -
Answer-*1. Pallor* *2. Edema* *3. Anorexia* *4. Proteinuria*
/.A child is admitted to the hospital with sickle cell crisis. The nurse checks this child for
which frequent symptom of the disorder? - Answer-*1. Pain*
/.A child is admitted to the hospital, and a diagnosis of bacterial meningitis is suspected.
A lumbar puncture is performed, and the results reveal cloudy cerebrospinal fluid (CSF)
with high protein and low glucose levels. The nurse determines that these results are
indicative of: - Answer-*3. Confirmation of the diagnosis*
/.A child is admitted to the pediatric unit with a diagnosis of coarctation of the aorta
(COA). The health care provider prescribes that the child's blood pressure be taken
every 4 hours in the legs and arms. The nurse would expect the blood pressure in the
child's legs and arms to be: - Answer-*3. Decreased in the legs and increased in the
arms*
/.A child is brought to a clinic after developing a rash on the trunk and on the scalp. The
parents report that the child has had a low-grade fever, has not felt like eating, and has
been generally tired. The child is diagnosed with chickenpox. Which statement by the
nurse is accurate regarding chickenpox? - Answer-*4. The communicable period is 1 to
2 days before the onset of the rash to 6 days after the onset and crusting of lesions.*
/.A child is brought to the emergency department, and a fracture of the left lower arm is
suspected. The mother states that the child was rollerblading and attempted to break a
fall with an outstretched arm. The child receives diagnostic x-rays, from which it has
been determined that a fracture is present. A plaster of Paris cast is applied to the arm,
nurse would do which of the following in order to protect the child from injury? *SELECT
ALL THAT APPLY.* - Answer-*2. Remove toys that have bright, blinking lights on
them.* *3. Keep side rails and other hard objects padded.* *4. Turn the client to the side
during a seizure.*
/.A 1-year-old child is diagnosed with intussusception. The mother of the child asks the
nurse to describe the disorder. The nurse tells the mother that this disorder is: - Answer-
*2. A condition in which a proximal segment of the bowel prolapses into a distal
segment of the bowel*
/.A 1-year-old child is seen in the health care provider's office with complaints of an
elevated temperature that began the previous evening. When gathering subjective data
from the mother, the nurse notices that which of the following would most likely indicate
the child has acute otitis media? - Answer-*4. The mother states the child had purulent
discharge from the ear last night.*
/.A 1-year-old child with hypospadias is scheduled for surgery to correct this condition. A
nurse is asked to assist in preparing a plan of care for this child and makes suggestions,
knowing that this surgery is taking place at a time when: - Answer-*1. Fears of
separation and mutilation are present*
/.A 10-year-old child with asthma is treated for acute exacerbation. Which finding would
indicate that the condition is worsening? - Answer-*3. Decreased wheezing*
/.A 12-year-old child is seen in the clinic, and a diagnosis of Hodgkin's disease is
suspected. Several diagnostic studies are performed to determine the presence of this
disease. When evaluating the diagnostic results, the nurse would expect to note which
of the following if this child had Hodgkin's disease? - Answer-*2. The presence of Reed-
Sternberg cells*
/.A 13-year-old child is diagnosed with osteogenic sarcoma of the femur. Following a
course of chemotherapy, it is decided that leg amputation is necessary. Following the
amputation, the child becomes very frightened because of aching and cramping felt in
the missing limb. Which statement made by the nurse will best assist in alleviating the
child's fear? - Answer-*1. "This aching and cramping is normal and temporary and will
subside."*
/.A 2-year-old child is admitted to the hospital with a diagnosis of nephrotic syndrome. In
planning care for this child, which of the following nursing interventions would be of
highest priority? - Answer-*3. Dipstick the urine for protein every 4 hours.*
,/.A 2-year-old child is diagnosed with constipation. Which of the following describes a
characteristic of this disorder? - Answer-*3. The infrequent and difficult passage of dry
stools*
/.A 3-year-old child has returned to his room following a tonsillectomy. Which
assessment finding needs immediate notification of the registered nurse? - Answer-*2.
Nasal flaring and rib retractions*
/.A 3-year-old child is brought to the emergency department. The mother states that the
child has had flulike symptoms with vomiting and diarrhea for the past 2 days. On data
collection the nurse finds that the child's heart rate is slightly elevated and the blood
pressure is normal. The child is irritable and crying only a few tears. The mother states
that the child's weight before the illness was 33 pounds. The nurse finds the current
weight to be 31 pounds. The nurse correctly interprets this as what level of dehydration?
- Answer-*4. Moderate dehydration*
/.A 3-year-old child is seen in the health care clinic, and a diagnosis of encopresis is
made. The nurse reviews the record, expecting to note which of the following that is a
sign of this disorder? - Answer-*3. Evidence of soiled clothing*
/.A 4-year-old child is admitted to the hospital with suspected acute lymphocytic
leukemia (ALL). The nurse understands that which diagnostic study will confirm this
diagnosis? - Answer-*3. Bone marrow biopsy*
/.A 4-year-old child is being transported to the trauma center from a local community
hospital for treatment of a burn injury that is estimated as covering over 40% of the
body. The burns are partial- and full-thickness burns. The nurse is asked to prepare for
the arrival of the child and gathers supplies anticipating that which of the following will
be prescribed initially? - Answer-*2. Insertion of a Foley catheter*
/.A 4-year-old child is diagnosed with otitis media, and the mother asks the nurse about
the causes of this illness. The nurse responds, knowing that which of the following is an
unassociated risk factor related to otitis media? - Answer-*3. A history of urinary tract
infections*
/.A 4-year-old child is hospitalized for severe gastroenteritis. The child is crying and
clinging to the mother. The mother becomes very upset and is afraid to leave the child.
Which of the following nursing interventions would be most appropriate to alleviate the
child's fears and the mother's anxiety? - Answer-*3. Ask the mother if she would like to
stay overnight with the child.*
/.A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The
nurse assists with developing a plan of care. The nurse questions which intervention
that is written in the plan of care? - Answer-*1. Palpating the abdomen for a mass*
,/.A 4-year-old child sustains a fall at home and is brought to the emergency department
by the mother. After an x-ray, it is determined that the child has a fractured arm, and a
plaster cast is applied. The nurse provides instructions to the mother regarding cast
care for the child. Which statement by the mother indicates the need for further
instructions? - Answer-*2. "I can use lotion or powder around the cast edges to relieve
itching."*
/.A 4-year-old child sustains a fall at home and is brought to the emergency department
by the mother. Following x-ray examination, it has been determined that the child has a
fractured arm, and a plaster cast is applied. The nurse provides instructions to the
mother regarding cast care for the child. Which statement by the mother indicates a
need for further instruction? - Answer-*1. "The cast will feel warm when it is dried."*
/.A 4-year-old child with acute lymphocytic leukemia has been admitted to the hospital in
relapse. The priority concern is infection due to immunosuppression. Which of the
following interventions would the nurse include in the plan of care? - Answer-*1.
Perform oral hygiene four times a day.*
/.A 5-year-old child has been transferred to the pediatric unit after a cardiac
catheterization. Which of the following interventions has the highest priority in the care
of this child immediately following the procedure? - Answer-*1. Assess for any bleeding
on the dressing.*
/.A 5-year-old child is admitted to the hospital for heart surgery to repair tetralogy of
Fallot. The nurse notes that the child has clubbed fingers, and the nurse knows that this
symptom is likely a result of: - Answer-*1. Peripheral hypoxia*
/.A 6-month-old infant receives a diphtheria, tetanus, and acellular pertussis (DTaP)
immunization at the well-baby clinic. The mother returns home and calls the clinic to
report that the infant has developed swelling and redness at the site of injection. Which
instruction by the nurse is appropriate? - Answer-*3. Apply an ice pack to the injection
site.*
/.A 6-year-old child has just been diagnosed with localized Hodgkin's disease, and
chemotherapy is planned to begin immediately. The mother of the child asks the nurse
about radiation therapy because it was not prescribed as a part of treatment. The
appropriate response to the mother is: - Answer-*2. "The child is too young to have
radiation therapy."*
/.A 6-year-old child with leukemia is hospitalized and is receiving combination
chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse
prepares to implement protective isolation procedures. Which interventions would the
nurse initiate? *SELECT ALL THAT APPLY.* - Answer-*2. Place the child on a low-
bacteria diet.* *3. Change dressings using sterile technique.* *5. Perform meticulous
handwashing before caring for the child.*
, /.A 9-year-old child is diagnosed with chlamydial conjunctivitis. The nurse consults with
the primary health care provider regarding necessary follow-up because this infection
can be associated with: - Answer-*4. Possible sexual abuse*
/.A breast-feeding mother of an infant with lactose intolerance asks the nurse about
dietary measures. Which of the following foods would the nurse instruct the mother to
avoid? - Answer-*1. Hard cheeses*
/.A child has a basilar skull fracture. Which of the following health care provider's
prescriptions should the nurse question? - Answer-*4. Suction via the nasotracheal
route as needed.*
/.A child has been diagnosed with Reye's syndrome. The nurse understands that a
major symptom associated with Reye's syndrome is: - Answer-*1. Persistent vomiting*
/.A child has epistaxis. The nurse understands that an appropriate treatment for
epistaxis is which of the following? - Answer-*1. Have the child sit up and lean forward.*
/.A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome.
Which findings would the nurse expect to observe? *SELECT ALL THAT APPLY.* -
Answer-*1. Pallor* *2. Edema* *3. Anorexia* *4. Proteinuria*
/.A child is admitted to the hospital with sickle cell crisis. The nurse checks this child for
which frequent symptom of the disorder? - Answer-*1. Pain*
/.A child is admitted to the hospital, and a diagnosis of bacterial meningitis is suspected.
A lumbar puncture is performed, and the results reveal cloudy cerebrospinal fluid (CSF)
with high protein and low glucose levels. The nurse determines that these results are
indicative of: - Answer-*3. Confirmation of the diagnosis*
/.A child is admitted to the pediatric unit with a diagnosis of coarctation of the aorta
(COA). The health care provider prescribes that the child's blood pressure be taken
every 4 hours in the legs and arms. The nurse would expect the blood pressure in the
child's legs and arms to be: - Answer-*3. Decreased in the legs and increased in the
arms*
/.A child is brought to a clinic after developing a rash on the trunk and on the scalp. The
parents report that the child has had a low-grade fever, has not felt like eating, and has
been generally tired. The child is diagnosed with chickenpox. Which statement by the
nurse is accurate regarding chickenpox? - Answer-*4. The communicable period is 1 to
2 days before the onset of the rash to 6 days after the onset and crusting of lesions.*
/.A child is brought to the emergency department, and a fracture of the left lower arm is
suspected. The mother states that the child was rollerblading and attempted to break a
fall with an outstretched arm. The child receives diagnostic x-rays, from which it has
been determined that a fracture is present. A plaster of Paris cast is applied to the arm,
