CPN Practice 459 Questions with Verified Answer,100% CORRECT

CPN Practice 459 Questions with Verified Answer 2.1 Which is an example of cephalocaudal development? A. A child crawls before he walks; walks before he runs; runs before he jumps B. A child lifts his head before lifting his shoulders; sits with support before sitting without support C. A child rakes before developing pincer grasps; develops pincer grasps before feeding himself with a spoon D. A child first develops reflexive behaviors; then develops imitative behaviors - CORRECT ANSWER B. A child lifts his head before lifting his shoulders; sits with support before sitting without support Cephalocaudal development states that a child develops from head to toe 2.2 When assessing a school ages child's development, the nurse understands that a primary developmental task of his group is: A. Developing friends B. Learning to read C. Learning to trust others D. Developing independence - CORRECT ANSWER A. Developing friends Erikson's stage of a school age child is industry vs. inferiority; the primary job of a school age child is to develop competence through achievement in school and development of friendships; important nursing assessment of children in this stage is adjustment and success in school setting as well as the formation of friendships 2.3 Which nursing action would be most important in the psychosocial support of a 2 year old who is having an invasive procedure performed? A. Assuring her that it is not her fault B. Providing for parental presence C. Providing adequate pain control D. Performing the procedure quickly - CORRECT ANSWER B. Providing for parental presence 2 year olds are in Erikson's stage of autonomy vs. shame and doubt and Piaget's sensorimotor stage; toddlerhood is a time of heightened separation anxiety with fear of strangers; the most appropriate psychosocial support is to promote presence of the primary caregiver 2.4 Which of the following would be most helpful when assessing a child's bone age? A. Birth date B. Body mass index C. Blood test D. X-rays - CORRECT ANSWER D. X-rays Bone age is preformed by taking an x-ray of the child's hands and wrists for comparison against an atlas of standard x-rays categorized by age; the test predicts the remaining height growth based on bone age; typically a child's bone age should match their chronological age Delayed bone age: increased height growth prediction advanced bone age: decreased height growth prediction 2.5 Which of the following assessments would be most concerning in a 3 month old? A. Closed posterior fontanel B. In ability to roll over C. Failure to track object through visual fields D. Failure to laugh - CORRECT ANSWER C. Failure to track object through visual fields Infants develop the ability to track objects by 3 months The posterior fontanel closes by 2-3 months Infants do not roll over till 4 months Laughing typically occurs at 4 months 2.6 Which of the following developmental milestones of the 5 month old best reflects the principle of proximodistal growth and development? A. Babbling B. Raking objects C. Rolling over D. Eating solid foods - CORRECT ANSWER B. Raking objects Proximodistal growth and development states children develop from the trunk to the tips of the extremities; raking objects develops at 4 months, pincer grasps develops at 9 months 2.7 You are the nurse at a community health clinic; the mother of a 2 year old male expresses concern to you that her previously healthy child is nonverbal; which of the following responses is most appropriate? A "Try not to worry, language milestones vary, boys have tendency to lag behind girls" B. "Given your son's age, we should probably test his hearing to be sure that is the source of his delayed language skills" C. "Autism is the most frequent reason why children as old as 2 years of age - CORRECT ANSWER B. "Given your son's age, we should probably test his hearing to be sure that is the source of his delayed language skills" 2 year olds should be speaking 2-3 word sentences; hearing deficits are the most common cause for failure to speech development birth order does not affect failure to develop speech autism could explain failure to develop speech, but is far less common than a hearing deficit and would include over behavior abnormalities 2.8 The 5 year old uses how many words in a sentence? A. 3-4 B. 4-5 C. 5-6 D. 6-7 - CORRECT ANSWER C. 5-6 5 year olds typically use 5-6 word sentences typically preschool age children will speak a sentence in the number of words equal to the child's age to one more word than their age 2.9 The nurse would expect a 4 month old to: A. Sit alone B. Attempt to roll over C. Begin to crawl D. Grasp feet and pull them to mouth - CORRECT ANSWER B. Attempt to roll over Infants begin to roll over at 4 months (first from stomach to back then from back to stomach) Infants sit with support at 5 months and sit without support at 8 months Infants will push up from their stomach onto hands and knees at 6 months Crawling begins at 9 months Grasping feet and pulling to month begins at 5 months 2.10 A healthy 6 month old infant brought to the well-baby clinic for checkup; when assessing the infant's anterior fontanel, the nurse expects it to be: A. Open B. Sunken C. Closed D. Bulging - CORRECT ANSWER A. Open The anterior fontanel closes between 12-18 months, a healthy 6 month old should have an open anterior fontanel Sunken - dehydration Bulging - increased intracranial pressure 2.11 The nurse notes that an infant develops arm movements before fine-motor skills and interprets this as an example of which pattern of development? A. Cephalocaudal B. Proximodistal C. Differentiation D. Mass-to-specific - CORRECT ANSWER B. Proximodistal Proximodistal growth and development states children develop from the trunk to the tips of the extremities: this development is manifested in the progressing from gross motor large-muscle movement in the younger infant to fine motor movements in the older infant/toddler 2.12 What is the most important consideration when telling a 4 year old child about an upcoming procedure? A. Use simple terms B. Speak loudly and clearly C. Offer a toy to keep the child happy D. Include every detail - CORRECT ANSWER A. Use simple terms Lots of details can be confusing and lead to fear/anxiety Toys aren't the most important component of OR prep unless being used as a prop/teaching tool 2.13 When assessing a toddler's growth and development, the nurse understands that a child in this age group displays behavior that fosters which developmental task? A. Initiative B. Autonomy C. Trust D. Industry - CORRECT ANSWER B. Autonomy The toddler (1-2 years) is in Erikson's developmental stage of autonomy vs. shame and doubt; the virtue being developed is will: the toddler exerts his/her autonomy with statements like "me do" or "no" and "mine"; the toddler requires opportunities to accomplish independent tasks and respond to simple instructions 2.14 The nurse should expect a 3 year old child to be able to perform which action? A. Ride a tricycle B. Tie his shoelaces C. Roller skate D. Jump rope - CORRECT ANSWER A. Ride a tricycle Tying shoes and jumping rope are motor skills developed in early school age followed later by learning to roller skate 2.15 When performing a physical assessment of a 10 year old girl, the nurse keeps in mind that the first sign of sexual maturity in girls is: A. Breast bud development B. Pubic hair C. Axillary hair D. Menarche - CORRECT ANSWER A. Breast bud development The first sign of puberty in females is breast bud development (10 years) followed by axillary and pubic hair (11 years) then height spurt (around 12 years) and menarche (around 13-14 years) 2.16 A 6 month old infant is brought to the clinic for a well-baby visit, the mother reports that the infant weighed 7 lbs at birth; based on the nurse's knowledge of infant weight gain, which current weight would be considered the minimum weight expected for this infant to be within normal range for weight? A. 10 lbs B. 14 lbs C. 18 lbs D. 21 lbs - CORRECT ANSWER B. 14 lbs Infant doubles in birth weight by 6 months Triples in birth weight by one year 2.17 A parent calls the clinic to express concern over her child's eating habits, she says the child eats very little and consumes only a single type of food for weeks on end; the nurse knows this behavior is characteristic of: A. Toddlers B. Preschool aged children C. School aged children D. Adolescents - CORRECT ANSWER B. Preschool aged children Preschool age children are known for their relatively small appetites and food jag eating behavior; preschoolers have a slow growth rate requiring fewer calories it is recommended that caregivers avoid battles over food with toddlers and preschoolers 2.18 When developing a plan of care for an adolescent, the nurse considers the child's psychosocial needs; during adolescence, psychosocial development depends on: A. Becoming industrious B. Establishing an identity C. Achieving intimacy D. Developing initiative - CORRECT ANSWER B. Establishing an identity Erikson's stage for the adolescent is identity vs. identity confusion; if the adolescent successfully masters this phase, she will develop a sense of identity with regard to personal identity, beliefs/values, sexual identity and goals for a future job/vocation 2.19 What is the best way to prepare 4 year old boy for his admission to the hospital for same-day surgery? A. Allow him to play with the medical equipment at the preoperative office visit and explain that he will be staying in the hospital for a few days B. Do not mention anything to him until he arrives at the hospital on the morning of the operation C. Explain the details of the operation and what will happen D. Tell him that a hospital is a place where kids go and visit each other and eat i - CORRECT ANSWER A. Allow him to play with the medical equipment at the preoperative office visit and explain that he will be staying in the hospital for a few days Preschoolers are magic thinkers It is more developmentally appropriate to give brief and understandable information such as that the child will be staying in the hospital for a few days Allowing the child to handle equipment in a pre-op office visit is a good way to orient the child to the hospital equipment and involve the child in the pre-op teaching The child should be always told the truth while keeping in mind that concrete explanations without lots of detail are most appropriate 2.20 A 2 month old weighed 8 lbs at birth; based on your knowledge of pediatric growth, you know that his weight at 1 year should be at least: A. 16 lbs B. 20 lbs C. 24 lbs D. 32 lbs - CORRECT ANSWER C. 24 lbs Infants should minimally double their birth weight at 5-6 months and triple in weight at 1 year 2.22 Which developmental milestone would you expect to see the 9 month old developing? A. Pincer grasp B. Walking C. Speaking intelligible words D. Sitting up without support - CORRECT ANSWER A. Pincer grasp 9 month old are typically developing the pincer grasp Walking is developed at 12-15 months 9 month olds typically says "ma-ma" and 'da-da" correctly Sitting up without support is developed by 8 months 2.23 You are the nurse caring for a 12 year old, he shares with you that he is concerned about his short stature; based on your knowledge of growth and development you know that: A. In boys, the height spurt occurs later in puberty than in girls B. In boys, the height spurt occurs about the same time during puberty as in girls C. In boys, the height spurt occurs earlier in puberty than in girls D. It is impossible to predict how much more the child will grow - CORRECT ANSWER A. In boys, the height spurt occurs later in puberty than in girls In boys, the height spurt occurs late in puberty, occurring 2 years later than girls; boys have a longer time to grow and a higher rate of growth than girls 2.24 Which of the following assessments would be abnormal in a newborn? A. Closed anterior fontanel B. Red, flaky skin C. Crossed-eyes D. Vernix - CORRECT ANSWER A. Closed anterior fontanel The anterior fontanel closes between 12-18 months, an open anterior fontanel allows for brain growth and compensation of intracranial pressure change 2.25 Which of the following would likely pose the greatest fear for a 7 year old girl who was recently admitting for osteomyelitis treatment? A. Oral medications B. A visit from the doctor C. Having her mother leave for a few minutes D. A rectal temp - CORRECT ANSWER D. A rectal temp School age children are fearful of disruption of their body integrity Stranger anxiety subsides at the end of infancy and resolves after toddlerhood 2.26 Why does the nurse instruct the mother of an infant, who is being introduced to baby foods for the first time, to wait a few days before adding another new type of food to his diet? A. To determine if he has an allergies to the new foods B. To allow his stomach to adjust to the mixture of the various types of foods C. To determine what type of foods he really likes to eat D. To allow his digestive system to adjust to individual foods - CORRECT ANSWER A. To determine if he has an allergies to the new foods Baby foods are introduced intermittently to identify allergies; its best to wait 4-7 days between each new food type in order to identify a particular food 2.27 Which of the following developmental milestones would be most advanced for a 6 month old? A. Reaching for objects B. Rolling over from back to front C. Laughing out loud D. Sitting up unsupported for short periods - CORRECT ANSWER D. Sitting up unsupported for short periods Sitting up unassisted is the most advanced of the milestones listed; infants sit unassisted by 8 months Reaching for objects occurs at 4-6 months Rolling over back to front occurs at 5-6 months The social milestone of laughing out loud occurs at 4 months 2.28 Which of the following would be the most accurate information to share with the mother of an 8 year old girl who is asking about the onset of puberty? A. In girls, puberty begins on average at 10 years with the development of breast buds B. In girls, puberty begins on average at 10 years with the development of pubic hair C. In girls, puberty begins on average at 10 years with the onset of menses D. In girls, puberty begins on average at 10 years with a height spurt - CORRECT ANSWER A. In girls, puberty begins on average at 10 years with the development of breast buds On average, girls start puberty at 10 years with breast bud development then pubic hair at 11, height spurt at 12, menarche at 13 2.29 You expect which of the following developmental assessments of a 2 year old in your primary care clinic? A. Toilet training B. 2-3 word sentences C. Cooperative play D. Sharing willingly - CORRECT ANSWER B. 2-3 word sentences 2 year olds use 2-3 word sentences Toilet training starts around 2-3 years Cooperative play is a characteristic of the school age group Sharing willingly does not occur until children reach late preschool/early school age 2.30 A baby's length is 20 in at birth; you approximate her height at 4 years of age to be: A. 30 in B. 35 in C. 40 in D. 45 in - CORRECT ANSWER D. 40 in A baby birth length roughly doubles at four years of age 2.31 Which of the following assessment finding are normal in a healthy 6 month old? A. Closed anterior and posterior fontanel B. Open anterior and posterior fontanel C. Closed anterior and open posterior fontanel D. Open anterior and closed posterior fontanel - CORRECT ANSWER D. Open anterior and closed posterior fontanel Anterior fontanel closes between 12-18 months Posterior fontanel closes at 2 months 2.32 What is an 18 month old's biggest fear to anticipate for surgery? A. Pain B. Separation anxiety C. Death D. Body integrity - CORRECT ANSWER B. Separation anxiety Separation anxiety is greatest among toddlers Fear of pain/invasion of body integrity are issues with older preschoolers and school age children Fear of death is a more common concern for the adolescent due to abstract thinking 2.33 The mother of a 2 year old voices concern because her child does not share and uses the word "mine"; you know that this is typical of which developmental stage according to Erikson: A. Trust vs. mistrust B. Autonomy vs. shame and doubt C. Initiative vs. guilt D. Industry vs. inferiority - CORRECT ANSWER B. Autonomy vs. shame and doubt Toddlers are in Erikson's stage of autonomy vs. shame and doubt; they are egocentric It is normal for them to have difficulty sharing - this behavior will pass when the child becomes a preschooler and enters the preoperational stage where he/she learns the concepts of sharing and thoughts/feelings of others 2.34 You are the nurse caring for a 14 year old girl who experience menarche one year ago, she is concerned that she is short and wants to know if she will grow much taller; based on your knowledge of growth and development, you know that: A. In girls, menarche occurs early in puberty before the height spurt B. In girls, menarche occurs late in puberty after the height spurt C. In girls, the peak height velocity is usually around 15 years D. It is impossible to predict how much more she will gr - CORRECT ANSWER B. In girls, menarche occurs late in puberty after the height spurt Height spurt occurs earlier in puberty among girls compared to boys; average peak height velocity is 12 years for girls, after menarche girls have an average potential growth of 2.5cm, girls have a shorter growth period and a lower growth rate 2.35 When assessing the development of a 6 month old, which of the following would be most concerning? A. The child weighs twice as much as his birth weight B. The child does not look for hidden objects C. The child does not understand the word "no" D. The child does not transfer objects from one hand to the other - CORRECT ANSWER D. The child does not transfer objects from one hand to the other A 6 month old should weigh at least twice as much as his/her birth weight Looking for hidden objects is an example of object permanence - a phenomenon that occurs between 8-12 months Infants understand the word no by 9 months Infants transfer objects from one hand to another at 5 months - failure to achieve fine motor development task is considered a developmental delay in a 6 month old 2.36 A 4 year old girl is being admitted today, you know she is in which developmental stage according to Erikson? A. Initiative vs. guilt B. Identity vs. role confusion C. Industry vs. inferiority D. Autonomy vs. shame and doubt - CORRECT ANSWER A. Initiative vs. guilt Initiative vs. guilt is the stage for children ages 3-6; initiative is fostered through allowing the child to successfully achieve new skills and become independent 2.37 In which of the following age groups does the child experience the fastest rate of growth in the limbs? A. Infancy B. Preschool C. School age D. Adolescent - CORRECT ANSWER C. School age The limbs experience the fastest rate of growth during the school age years The head - infancy The trunk - toddler/preschool years The trunk, gonads, associated tissue, etc. - adolescent years 2.38 Which of the following statements concerning growth and development is true? A. Growth implies an increase in size an development B. Development refers to the maturation of structures of the body but does not include growth C. Growth and development usually progress from specific to general D. Development refers to the maturation of structures of the body and includes growth - CORRECT ANSWER D. Development refers to the maturation of structures of the body and includes growth Growth and development progress from general to specific; growth implies and increase in size but does not necessarily include development 2.39 The mother of an infant tells the nurse, "my child used to put her hands in her mouth but, now she is placing her feet in her mouth"; the nurse knows that this is an example of what concept of development A. Proximodistal B. Cephaocaudal C. General to specific D. Sterognosis - CORRECT ANSWER B. Cephaocaudal Cephaocaudal refers to het development that occurs from head to toe Proximodistal refers to development that occurs from the trunk to extremities Sterognosis - recognition of an object through the sense of touch 2.40 The father of a 9 month old brings his daughter to the clinic for a well-baby assessment, the father asks why it is important to record her length and weight on a growth chart; select the nurse's best response A. "The growth charts are used to plot her growth and we can see how she is growing compared to other 9 month old girls" B. "It is important to measure her to see if she is too heavy or small for her age" C. "We measure all babies" D. "The growth charts show how her length and weight - CORRECT ANSWER D. "The growth charts show how her length and weight compare to other infants her age as well as show us a pattern over time" Growth charts offer the ability to observe a pattern over time as well as comparison among other children of the same gender (only specific to the U.S.); they are used to assess the infant's growth over time but also the pattern of growth 2.41 A 7 month old infant lives with his parents, is kept clean and dry, and is picked up and comforted when he cries; by consistently meeting his basic needs, which psychological strength are his parents promoting? A. Will B. Hope C. Purpose D. Loyalty - CORRECT ANSWER B. Hope This virtue is developed during the infant years wterm-21hen the child is in the trust vs. mistrust stage The virtue will is developed during the toddler years when the child is in the autonomy vs. shame and doubt stage The purpose virtue is developed during the preschool years when the child is in the initiative vs. guilt stage Loyalty is a virtue developed during the adolescent years when the child is in the identity vs. role confusion 2.42 The nurse is teaching a parenting class when a mother asks when a child develops a conscience; basing her response on Erikson's theory of development, the nurse knows that this usually occurs during which of the following stages? A. By the end of the first year of life B. By the end of the toddler stage C. During the preschool stage D. During the school age years - CORRECT ANSWER C. During the preschool stage Children recognize an "inner voice" during the preschool years; the development of a conscience does not occur during the infant/toddler years Conscience development should occur before the school age years 2.43 The nurse is caring for a child who is very outgoing and likes to talk about his friends, he asks to play a board game and is very concerned about the rules of the game; when the nurse wins the game, he throws the game and says, "you cheated!"; how old is this child likely to be? A. 2 B. 4 C. 7 D. 13 - CORRECT ANSWER C. 7 School age children are very competitive, they focus on the rules and don't like to lose Toddlers are too young to participate in board games Preschool children do not focus on the rules of the board game Adolescents cope with competition in a more constructive manner than a school age child does 2.44 The nurse is caring for a 3 year old who is restricted to bed rest due to a femur fracture; which of the following toys should the nurse select for this child? A. A stuffed bear B. A large ball C. Dress up clothes D. A play hammer and pounding board - CORRECT ANSWER D. A play hammer and pounding board This toy will help develop gross motor skills and release frustration due to immobility 2.45 During the admission of a 15 year old with a history of asthma, the pt. admits that she is currently smoking; the nurse incorporates a long term goal of smoking cessation in her care plan; which of the following interventions would be most effective in helping her quit smoking? A. Ask her open ended questions about why she feels the need to smoke B. Have her attend a smoking cessation group led and attended by other teens C. Talk to her parents about restricting her activity until she stop - CORRECT ANSWER B. Have her attend a smoking cessation group led and attended by other teens An adolescent is likely to identify and share values with other teens; having her attend a peer led group is the most effective manner in influencing and changing her behavior 2.46 The nurse is caring for a 5 year old with leukemia; when planning care for this child, the nurse considers that the child is in which of the following of Erikson's stages? A. Trust vs. mistrust B. Industry vs. inferiority C. Initiative vs. guilt D. Identity vs role confusion - CORRECT ANSWER C. Initiative vs. guilt The 5 year old is in the initiative vs. guilt stage 2.47 According to Piaget, the child who is beginning to imitate behavior is in which of the following stages? A. Intuitive B. Preconceptual C. Sensorimotor D. Reflexive - CORRECT ANSWER C. Sensorimotor The child progresses from reflexive behavior to imitate behavior during the sensorimotor stage Preoperational stage begins at the age of 2, it occurs after the imitative behavior has begun Preconception stage is the first phase of the preoperational stage The intuitive stage is the second phase of the preoperational stage and begins at the age of 4 - represents a height level of development 2.48 You note that your patient's head circumference is now smaller than his chest circumference; his age is most likely: A. 3 months B. 9 months C. 15 months D. 30 months - CORRECT ANSWER D. 30 months The chest circumference is greater than the head circumference after the age of 24 months 2.49 Your patient's physical reveals that her BMI is at the 90th percentile; you correctly explain to her mother: A. "A BMI in the 90th percentile indicates that she is overweight, would you like to talk to a dietician?" B. She is very healthy and is taller than most children her age" C. "A BMI in the 90th percentile indicates a risk of becoming overweight, we can discuss ways to reduce this risk" D. "A BMI in the 90th percentile indicates that she is underweight, let's talk about her dietary i - CORRECT ANSWER A. "A BMI in the 90th percentile indicates that she is overweight, would you like to talk to a dietician?" BMI between 85-95% indicates that the child is overweight (25-29.9) Obesity - greater than 95% (30) Underweight - less than 5% (18.5) 2.50 The nurse measures the head circumference of a 6 month old boy and finds that it has changed from the 25th percentile to the 75th percentile; which of the following represents the nurse's best action? A. Immediately notify the physician as this may indicate increase intracranial pressure, a medical emergency B. Reassure his mother that this is a period of growth and changes in head circumference are to be expected C. Prepare his mother for the placement of a helmet as safety is a concern D - CORRECT ANSWER D. Measure his head again and check for accuracy Whenever a change in growth patterns are noted, both the measurement and plotting on the growth chart Chou led be rechecked to assure accuracy 2.51 A group of children are playing in the playroom, the children are tested on the concept of conservation; one child has just mastered this concept, how old is this child most likely to be? A. 4 years B. 6 years C. 8 years D. 12 years - CORRECT ANSWER C. 8 years An 8 year old child is considered to be in the concrete operations phase of cognitive development - an appropriate time to to understand the concept of conservation 4 year old - preoperational phase - not likely to understand the concept of conservation 6 year old - preoperational phase - not likely to understand the concept of conservation 12 year old - formal operations phase - likely to have mastered the concept of conservation 2.52 The nurse is playing with an infant, the nurse hides a toy rattle under a blanket, the infant looks for it while lifting up the blanket: how old is this infant most likely to be? A. 2 months B. 4 months C. 6 months D. 8 months - CORRECT ANSWER D. 8. Months Object permanence is a concept that usually develops between 8-9 months where the infant understands that even though an object can no longer be seen, it still exists 2.53 A 6 year old girl is being seen in the ER after a bike accident; the nurse is preparing to assist with suturing her scalp lacerations, the child cries out, "I'm sorry I didn't wear my helmet, I promise I'll be good next time, please don't hurt me!" which of the following is the nurse's best response? A. "Helmets are very important and protect your head, please make sure that you wear it in the future" B. "We need to fix your head, you are doing such a good job of trying to stay still" C. " - CORRECT ANSWER B. "We need to fix your head, you are doing such a good job of trying to stay still" Actions should be geared toward encouraging the child and helping her to cope with a stressful and potentially painful procedure 2.54 A 14 year old girl is being treated for acute renal failure, in order to help meet her development needs, which of the following is important to include in her plan of care? A. Provide privacy and respect her need for modesty B. Promptly respond to her call light and reassure her that needs will be met C. Encourage one of her parents to spend the night D. Provide opportunities for her to participate in her care and encourage a sense of achievement - CORRECT ANSWER A. Provide privacy and respect her need for modesty The adolescent is in Erickson's stage of identity vs. role confusion It is important to to respect the adolescent's need for privacy and modesty as the child's body is rapidly changing 2.55 A 2 year old boy admitted with RSV is in which of the following stages of psychosocial development? A. Trust vs. mistrust B. Autonomy vs. guilt C. Autonomy vs. shame and doubt D. Initiative vs. guilt - CORRECT ANSWER C. Autonomy vs. shame and doubt This is the developmental stage of toddlerhood 2.56 A 4 year old girl newly diagnosed with diabetes who is frightened of fingers stick; the nurse's best response is: A. Allow her to hold her favorite stuffed animal during finger sticks B. Encourage her mother to coach her during finger sticks C. Encourage her to count backward from 10 during finger stick D. Encourage her to play with the equipment and 'practice' on her dolls - CORRECT ANSWER D. Encourage her to play with the equipment and 'practice' on her dolls Play therapy uses the therapeutic powers of play to help children resolve various challenges 2.57 A teacher brings a 5 year old to a museum where children are encouraged to interact with the attractions, the teacher praises and helps the child explore the museum; what kind of play is this known as? A. Mutual play B. Imaginative play C. Solitary play D. Parallel play - CORRECT ANSWER A. Mutual play This occurs when a parent offers praise and support while encouraging a child to explore their environment 2.58 A group of preschool aged children are playing with dress up clothes; this kind of play in known as: A. Imaginative play B. Dramatic play C. Parallel play D. Team play - CORRECT ANSWER B. Dramatic play Dramatic play is typical of preschool aged children, it often involves dressing up in clothes, hat, and shoes 2.59 A preschooler's mother states she is concerned that her child has an imaginary playmate; which of the following is the nurse's best response? A. "Many 4 year olds have imaginary playmates, it really isn't a cause for concern" B. "This is unusual, has she had a stressful event lately?" C. "It really isn't any cause for concern, as long as she doesn't talk to her" D. "Most children don't develop imaginary playmates until much later in childhood; your child must be smart for her age" - CORRECT ANSWER A. "Many 4 year olds have imaginary playmates, it really isn't a cause for concern" Imaginary playmates are typical of preschool aged children, many children talk to their imaginary playmates - it's not a concern 2.60 The nurse is watching a group of toddlers in the playroom; which of the following type of play is typical of older toddlers? A. Solitary B. Parallel C. Team play D. Mutual play - CORRECT ANSWER B. Parallel Parallel play in which children play side-by-side is associated with toddler years Solitary - infancy Team play - school age Mutual - infancy to school age (caregiver and child, not groups of children) 2.61 The nurse is preparing to provide education to a 9 year old girl with asthma; which of the following should be taken into consideration? A. The child should be the focus of the education B. The parent should be the focus of education C. Information should be provided in written form only D. The parent should be encouraged to ask questions when the child is not present - CORRECT ANSWER B. The parent should be the focus of education Although the child should be included in the education, the parent should still be the focus 2.62 The nurse is teaching a parenting class to a group of expectant parents, one of them asks at what age a child typically begins to develop modesty; which of the following is the nurse's best answer? A. "Most children do not develop modesty until the adolescent years" B. "Most children develop modesty by age 4" C. "Most children develop modesty by age 10" D. "Most children develop modesty bu age 2" - CORRECT ANSWER B. "Most children develop modesty by age 4" Most children develop modesty by the age of 4; it is good idea to reinforce body safety at this time by teaching preschoolers and young school age children that "no one should look or touch where their bathing suit covers unless they are your mom, dad, doctor, or a nurse." 2.63 The nurse is caring for a 3 year old girl with diabetes; which of the following should be included in her plan of care? A. Allow her to handle and play with equipment being used in her care B. Avoid talking about the disease process C. Give her detailed explanations with pictures when possible D. Encourage participation in procedures such as finger sticks and insulin administration - CORRECT ANSWER A. Allow her to handle and play with equipment being used in her care It is important to allow a preschooler the opportunity to handle and play with equipment being used in her care Short simple explanations are most appropriate 2.64 A 9 year old diabetic boy tells the nurse that he is responsible for testing his own blood sugar and administering his own insulin; which of the following is the most appropriate action for the nurse? A. praise and encourage him to continue as he has done a good job with increased responsibility B. contact a social worker as he is assuming too much responsibility for his age C. gather more information about his diabetic care from his parents D. tell him that surely he is exaggerating - CORRECT ANSWER C. gather more information about his diabetic care from his parents It is essential to gather more information prior to forming a plan of care It seems he could be takin on too much responsibility for his age 2.65 The nurse is caring for a 2.5 year old, when selecting a toy for this child, which of the follow is the best? A. A simple board game B. A stuffed animal C. Crayons and coloring books D. Large dump and garbage trucks - CORRECT ANSWER D. Large dump and garbage trucks These will most likely encourage physical activity and are an appropriate choice for a toddler Board games are too advanced Stuffed animal can provide comfort, but not physical activity Toddlers don't have to attention span for crayons and coloring books 2.66 The nurse is caring for an infant who raises her chest when lying on her stomach, is beginning to babble, and follows an object 180 degrees with her eye; how old is this infant most likely to be? A. 4 weeks B. 3 months C. 4 months D. 5 months - CORRECT ANSWER B. 3 months The infant should have master these skills prior to 4 and 5 months The 4 week old cannot do these skills 2.67 Which of the following is a cause for concern in a 6 month old? A. The infant does not sit without support B. The infant does not clap his hands C. The infant does not grasp and hold objects D. The infant does not have a pincer grasp - CORRECT ANSWER C. The infant does not grasp and hold objects The infant should grasp and hold objects by 3 months Sit without support - 8 months Pincer grasp - 9 months Clap Hands - 10-12 months 2.68 The mother of a 3 year old is concerned that he doesn't turn his head toward her when she is talking to him; which of the following is the nurse's best response. A. "The hearing doesn't mature for almost a year, keep an eye on him and we'll talk about it at his next visit." B. "He can most likely hear you, but lacks the muscular maturity to turn his head. His muscles will continue to develop over the next few months." C. "It's not uncommon for an infant's hearing to lack maturity at this a - CORRECT ANSWER D. "The can be a concern, tell me more about things that you've noticed regarding his hearing." A 3 month old should turn his head in response to sound; it is appropriate for the nurse to gather more information since further evaluation is required 2.69 A 4 month old is being evaluated in the development clinic; which of the following would be most concerning? A. He doesn't hold objects in his hands B. He doesn't rake objects with his hands C. He doesn't transfer objects from hand to hand D. He doesn't clap his hands - CORRECT ANSWER A. He doesn't hold objects in his hands Infants should be able to grasp and hold objects by 3 months 2.70 The nurse is caring for a girl and notes that she pushes up from her stomach unto her knees and rocks back and forth; which of the following most likely represents this girls age? A. 4 weeks B. 3 months C. 6 months D. 8 months - CORRECT ANSWER C. 6 months This skill is usually developed between ages 5-6 months 2.71 The mother of an infant asks the nurse at what age should she give her daughter cheerios as a snack; when providing an answer to the mother the nurse remembers that the printer grasp is usually developed by which of the following ages? A. 3 months B. 6 months C. 9 months D. 12 months - CORRECT ANSWER C. 9 months The pincer grasp usually develops by 9 months 2.72 A boy measured 20 inches at birth, he now measures 30 inches; which of the following most likely represents his current age? A. 6 months B. 12 months C. 18 months D. 24 months - CORRECT ANSWER B. 12 months An infant's length usually increases by 50% by 12 months From years 1-2, a toddler grows an average of 5 inches 2-3 years to adolescent age - 2.5 inches on average per year 2.73 A father tells the nurse that he has concerns regarding the manner in which his 12 month old son plays with his toys, he says that his son throws anything that is handed to him; which of the following is the nurse's best response? A. "It sounds like he is going to be a ball player one day!" B. "I wouldn't worry. This is typical behavior for boys." C. "Try not to worry. This is normal behavior. He is learning about his world by feeling hitting, and throwing objects." D. Try not to worry. It - CORRECT ANSWER C. "Try not to worry. This is normal behavior. He is learning about his world by feeling hitting, and throwing objects." 12 month old infants learn about objects and their environments in a variety of ways that include hitting and throwing 2.74 A 2 year old's mother needs to briefly leave the hospital to pick up the patient's sister from preschool, the mother is worried how the 2 year old will react; the nurse's best suggestion is: A. "Tell her that you need to get her sister and you will be back when lunch is over and Dora the Explorer comes on TV." B. " Tell her that you need to leave to get her sister and if she doesn't cry you will bring her a surprise." C. " Wait until she starts her nap and quietly sneak out. You'll be back - CORRECT ANSWER A. "Tell her that you need to get her sister and you will be back when lunch is over and Dora the Explorer comes on TV." 2 year old children understand time in terms of routine A toddler would comprehend that her mother is returning after lunch and at the start of her favorite show It is best to be honest with the toddler and explain when the parent will return in terms that she is capable of comprehending 2.75 The nurse is caring for a child who knows his first and last name, speaks 3-4 word sentences, and knows his age; this child is at least how old? A. 3 years old B. 4 years old C. 5 years old D. 6 years old - CORRECT ANSWER A. 3 years old 3 year olds should be able to speak in 3-4 word sentances 2.76 The nurse is observing a group of children playing at a park; she notes that one child is running and overhears her mother say, "Look at her go! She just learned how to run!" The nurse correctly estimates her age to be which of the following? A. 12 months B. 18 months C. 24 months D. 36 months - CORRECT ANSWER C. 24 months Most children develop the skill of running at 24 months 2.77 The mother of 1 year old asks how many words she should have in her vocabulary; the nurse emphasizes that each child's vocabulary develops in a unique manner and tells the mother that most 12 month olds have a vocabulary consisting of: A. 1-2 words B. 5 words C. 20 words D. 50 words - CORRECT ANSWER B. 5 words Most 1 year old children have a vocabulary of approximately 5 words 50 words is not usually developed until 18 months 2.78 A newborn girl was 22 inches at birth and now measures 44 inches; which of the following ages most likely reflects this girl's age? A. 1 year old B. 2 years old C. 3 years old D. 4 years old - CORRECT ANSWER D. 4 years old The child's birth length typically doubles by the time the child reaches 4 years of age 2.79 The nurse is working in the developmental clinic evaluating a 4 year old girl; which of the following would be the greatest cause for concern? A. She cannot tie her shoes B. She does not have a best friend C. She owes not enjoy board games D. She cannot throw a ball overhand - CORRECT ANSWER D. She cannot throw a ball overhand A child should develop the skill of throwing a ball over hand by the age of 4 The other three skills are developed during the school age years 2.80 A boy enjoys copying shapes and can identify most colors, he draws a picture of the nurse with just two body parts; this boy is most likely to be how old? A. 2 years old B. 3 years old C. 4 years old D. 5 years old - CORRECT ANSWER C. 4 years old The described skills are typical of most 4 year olds 2.81 The nurse asks a child if it is ever OK to tell a fib, the child responds, "I think that telling a lie to get out of trouble is wrong, but telling your mom you like her hair cut when it's really ugly is OK." What age is this child likely to be? A. 7 years old B. 8 years old C. 9 years old D. 10 years old - CORRECT ANSWER D. 10 years old Most 10 year old children can recognize shades of gray and see beyond the firm concept of right and wrong Children ages 7-9 have a rigid concept of right and wrong 2.82 The school nurse is teaching a health education class to a group of adolescents, one of the in the class asks the nurse when she should expect her period to start; the nurse knows that the average age of the start of the menses is which of the following: A. 13 years B. 12 years C. 11 years D. 10 years - CORRECT ANSWER A. 13 years The average age of menarche is 13 years of age 2.83 Which of the following is accurate regarding puberty in females? A. The growth spurt occurs before menarche B. Pubic hair develops after menarche C. Breast development is the last sign of puberty D. Breast development begins between ages 12-13 years - CORRECT ANSWER A. The growth spurt occurs before menarche Profession of female puberty: Breast development at age 10 Pubic hair at age 11 Height spurt at age at age 12 Menarche at age 13 2.84 Which of the following is the first sign of puberty in males? A. Testicular enlargement B. Pubic hair development C. Growth spurt D. There is no specific order of events as puberty follows an individual development pattern - CORRECT ANSWER A. Testicular enlargement Progression of male puberty: Testicular enlargement at age 11 Pubic hair at age 12 Height spurt at age 13-14 2.85 In comparing the height growth spurt among males and females, which of the following is accurate? A. Girls tend to experience the growth spurt at a later age than boys B. Girls have a low potential for growth after the beginning of menarche C. The height growth spurt in males occurs 2 years earlier than girls D. Girls have a longer period in which to grow - CORRECT ANSWER B. Girls have a low potential for growth after the beginning of menarche Menarche is the last pubertal event for females (occurring after the height spurt), females will experience very little linear growth reaching adult height Since the female growth spurt occurs early in puberty, girls have a shorter time period in which to grow 2.86 Which of the following is an important nursing intervention to reduce the risk of sudden infant death syndrome? A. Allow only small stuffed animals, not pillows in the crib B. Encourage the use of a pacifier C. Only encourage infants with gastro-esophageal reflux to be placed on their stomachs for sleep D. Only allow co-sleeping in breast feeding infants - CORRECT ANSWER B. Encourage the use of a pacifier All infants should be placed on their backs to sleep in order to reduce the incidence of SIDS SIDS is associated with: soft crib mattresses, pillows/stuffed animals inside the crib, co-sleeping Recommendations for safe sleep: firm mattress, no soft items placed inside the crib, avoid co-sleeping (suffocation risk or crush risk), pacifier use while sleeping, breast feeding for the first 6 months, no positioning devices for sleep, routine childhood immunizations 2.87 A bottle-fed 3 month infant's is brought to the pediatrician's office for a well-child visit; during the previous visit, the nurse taught the mother about infant nutritional needs; which statement by the mother during the current visit indicates effective teaching? A. "I started the baby on cereals and fruits because he wasn't sleeping through the night." B. " I started putting cereal in the bottle with formula because the baby kept spitting up." C. "I will start my baby on infant cereal b - CORRECT ANSWER C. "I will start my baby on infant cereal between 4-6 months." Infant should begin solid foods in the form of rice cereal and fruits between 4-6 months 2.88 The nurse should begin lead screening when the child reaches what age? A. 6 months B. 12 months C. 18 months D. 24 months - CORRECT ANSWER A. 6 months Should start at the 6 month primary car visit using a standard lead screening questionnaire - then should be continued at regularly scheduled visits 2.89 A mother plans to provide her baby with breast milk postoperatively; the nurse instructs the mother in the use of a breast pump because: A. Pumping will maintain the mother's breast milk supply B. Bottle feeding pumped breast milk is a more accurate way of monitoring intake and output postoperatively C. Giving the mom a task that will help her baby postoperatively will help to promote mother-infant attachment D. Most infants are unable to breast feed postoperatively - CORRECT ANSWER A. Pumping will maintain the mother's breast milk supply Use of a breast milk pump when the infant is NPO will help the mother to maintain her milk supply so that it will be available for the baby postoperatively; pumped breast milk can be stored for use in the event that the mother is unavailable to breast feed the baby 2.90 You are the nurse working at a telephone triage hotline; the mother of a 2 year old reports her son has swallowed an unknown substance; you instruct the mother to call poison control and to: A. Give milk B. Give water C. Give syrup of ipecac D. Make the child NPO and avoid induction of vomiting - CORRECT ANSWER D. Make the child NPO and avoid induction of vomiting Keeping the child NPO and avoidance of vomiting is the treatment of choice for pediatric ingestion Syrup of ipecac is no longer recommended Vomiting could damage the upper GI tract 2.91 A mother is concerned about her healthy infant starting him on baby foods; you know the earliest time to start baby food is: A. 3 months B. 4 months C. 6 months D. When the infant starts waking up at night - CORRECT ANSWER B. 4 months The child is physiologically ready for the introduction of baby foods at 4 months when the tongue extrusion reflex disappears 2.92 Which of the following is not a risk factor for iron deficiency anemia in infants? A. Prematurity B. Multiple birth C. Drinking whole milk at 9 months D. Introduction to baby food - CORRECT ANSWER D. Introduction to baby food This is generally not associated with iron deficiency Prematurity - the majority of of maternal iron transfer to the fetus occurs during the third trimester Multiple birth - maternal iron stores (which are transferred during the third trimester) are shared among multiple fetuses and typically born prematurely Whole milk is a poor source of iron and therefore should not be introduced until 1 year when the infant is eat iron rich foods 2.93 Whole milk is essential in which of the following age groups: A. 9 to 11 months B. 1 to 2 years C. 2 to 3 years D. 3 years to puberty - CORRECT ANSWER B. 1 to 2 years Whole milk is essential for children 1 to 2 years of age because the body requires fat to myelinated the developing brain Children under 12 months of age should not receive whole milk because it is an inadequate source of iron - the should be given breast milk After 2 years of age children can drink 1% or 2% milk to reduces fat and calorie intake while still getting calcium, vit D, and some fat for body growth 2.94 Which of the follow formula feeding patterns would warrant further evaluation for a 1 year old infant? A. 4 feedings of 5oz each B. 5 feedings of 8oz each C. 3 feedings of 6oz each D. 4 feedings of 6oz each - CORRECT ANSWER B. 5 feedings of 8oz each The 1 year old should drink 16-24oz of whole milk 2.95 When you are instructing the mother of a healthy infant about the introduction of baby food to her baby, you know that the recommended order of progression for baby food introduction is: A. Fruit, vegetables, cereals B. Fruit, meat, cereals C. Cereals, fruit, meat D. Cereals, meat, vegetables - CORRECT ANSWER C. Cereals, fruit, meat The order of introduction is iron fortified, single grain cereals, then fruits or yellow/orange vegetables, and then meats 2.96 An 8 year old girl is being admitted today for a diagnostic evaluation; you know that she is in which of the following developmental stages according to Erikson A. Identity vs. role confusion B. Industry vs. inferiority C. Initiative vs. guilt D. Autonomy vs. doubt and shame - CORRECT ANSWER B. Industry vs. inferiority She is a school age child and in the developmental stage of industry vs. inferiority 2.97 A 3 year old is fearful of healthcare professionals; what would be most helpful while performing his assessment? A. Save uncomfortable procedures such as abdominal palpation for the end of the assessment B. Have the boy hold on to a favorite stuffed animal during the assessment C. Encourage him to put the blood pressure cuff on his stuffed bear and take the bear's blood pressure D. Attempt to obtain most of his assessment while he is asleep including painful procedures - CORRECT ANSWER C. Encourage him to put the blood pressure cuff on his stuffed bear and take the bear's blood pressure Play therapy is an effective way to help the child work through the stress of hospitalization 3.1 The parents of a 2 year old with chronic otitis media are concerned that this has affected the child's hearing; which suggests the child has a developed a hearing impairment? A. Stuttering B. Using gestures to express desires C. Babbling continuously D. Playing alongside rather than interacting with peers - CORRECT ANSWER C. Babbling continuously Most common cause for failure to speak/speech delay is a hearing impairment A 2 year old should be speaking in 2-3 word sentences 3.2 A 10 month old child with recurrent otitis media is brought in to clinic; to help determine cause, the nurse asks the parents: A. "Does water ever get into the baby's ears?" B. "Do you give the baby a bottle to take to bed?" C. "Have you noticed a lot of wax in the baby's ears?" D. "Can the baby combine two words when speaking?" - CORRECT ANSWER B. "Do you give the baby a bottle to take to bed?" Primary cause of otitis media is bottle propping and drinking from a bottle in recumbent position. Ear wax is not associated with otitis media. 3.3 Which of the following would be the most concerning finding for the child who has just had a tonsillectomy? A. Fever of 101 B. Increased swallowing C. Pain score of 4/10 D. Pain score of 7/10 - CORRECT ANSWER B. Increased Swallowing Priority nursing intervention is assessment for post-surgical bleeding - increased swallowing is a sign of bleeding 3.4 When planning care for a child with epiglottis is, the nurse should assign highest priority to which of the following interventions? A. Providing psychological support B. Ensuring respiratory patency C. Instituting infection control practices D. Administering prescribed drug therapy - CORRECT ANSWER B. Ensuring respiratory patency Epiglottis is a medical emergency in which the airway closes due to a progressive inflammation caused by infection of the epiglottis Typically effects toddlers and preschoolers Priority nursing intervention is to obtain intubation/tracheostomy equipment The airway should not be examined unless preparing for intubation/tracheostomy 3.5 The nurse is caring for a school age child with cystic fibrosis; which of the following sports would be most appropriate for this child? A. Basketball B. Golf C. Swimming D. Baseball - CORRECT ANSWER C. Swimming Children with cystic fibrosis benefit from exercise that promote deep breathing and adequate pulmonary toilet (hygiene) 3.6 When is the best time to administer pancreatic enzymes for the child with cystic fibrosis? A. 30 min before meals B. Immediately before meals C. In the middle of a meal D. 30 min after a meal - CORRECT ANSWER B. Immediately before meals Pancreatic enzymes for a child with cystic fibrosis should be given immediately before meals; they are given to improve absorption, particularly of fats 3.7 Which of the following respiratory conditions is a medical emergency? A. Asthma B. Cystic fibrosis C. Epiglottitis D. Laryngotracheobronchitis (LTB) - CORRECT ANSWER C. Epiglottitis This should always be treated as a medical emergency - its an infection causing inflammation of the epiglottis that causes an acute narrowing of the supraglottis which can cause acute respiratory arrest and eventually occlusion of the airway The nurse should gather equipment in preparation for an intubation/tracheostomy 3.8 The nurse knows that infants and children are more prone to otitis media because: A. The Eustachian tubes are short and in a horizontal position B. Children are always putting objects and fingers in their ears C. The have immature immune systems D. They eat by sucking, which increases susceptibility to ear infections - CORRECT ANSWER A. The Eustachian tubes are short and in a horizontal position 3.9 The nurse will do which of the following for the child with epiglottitis? A. Avoid using oropharyngeal suctioning due to potential airway obstruction B. Avoid using oropharyngeal suctioning due to contamination C. Use oropharyngeal suctioning to remove secretions D. Prepare to use bag-mask ventilation - CORRECT ANSWER A. Avoid using oropharyngeal suctioning due to potential airway obstruction Epiglottitis is commonly caused by bacteria Haemophilus Infuenzae Type B (HIB) Nurse should be quick to obtain emergency intubation and tracheostomy equipment Nurse should avoid manual assessment of airway or suctioning due to the risk of inducing complete airway obstruction 3.10 A nurse is caring for 5 year old who had a tonsillectomy; which of the following symptoms would indicate immediate postoperative complications? A. Spitting out brown, coffee-ground colored secretions B. Complaining of a sore throat and refusing liquids C. Vomiting bright red blood D. Crying - CORRECT ANSWER C. Vomiting bright red blood The greatest post-op complication of a tonsillectomy is risk of bleeding Tachycardia and increased swallowing are signs of potential bleeding at operative site 3.11 A 2 year old is in a pediatric unit with a diagnosis of pneumonia; in addition to albuterol, the patient is to receive chest physiotherapy, percussion, and postural drainage (PPD); which of the following represents the most effective way in which the treatment should be carried out? A. Administer albuterol immediately before preforming PPD, preform PPD 30 min before the patients next meal. B. Administer albuterol immediately after preforming PPD, preform PPD 30 min before the patients next - CORRECT ANSWER A. Administer albuterol immediately before preforming PPD, preform PPD 30 min before the patients next meal. To maximize the effectiveness of the respiratory treatment, aerosol-nebulized medications should be administered prior to PPD therapy; PPD should not be done after a meal as the child is at risk for vomiting 3.12 The nurse is caring for a 4 year old who is hospitalized with bronchiolitis, the patient has a tracheostomy in place which needs to be suctioned periodically; which of the following represents appropriate care of the child with a tracheostomy? A. Prior to suctioning, the catheter should be measured against the extra tracheostomy tube and not insert more than 0.5cm beyond the length of the tracheostomy tube. B. Instill 2-3 drops of sterile saline into the tracheostomy prior to suctioning to - CORRECT ANSWER A. Prior to suctioning, the catheter should be measured against the extra tracheostomy tube and not insert more than 0.5cm beyond the length of the tracheostomy tube. The will prevent trauma and subsequent inflammation to the tracheal wall Instillation of saline is not recommended as it encourages the colonization of bacteria and leads to infection It is essential that there are 2 additional tracheostomy tubes at the bedside, one that is the current size, and one that is one size SMALLER - the smaller one is used if the stoma can no longer accommodate the larger size 3.13 The nurse is reviewing the following results of a blood gas: pH 7.32; PaO2 88: PCO2 48 Which of the following best describes the results? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis - CORRECT ANSWER A. Respiratory acidosis Normal pediatric pH is: 7.35 - 7.45 Normal CO2 is: 35 - 45 The pH is less - acidosis; elevated CO2 - respiratory disturbance 3.14 Which of the following would be priority treatment for a child diagnosed with respiratory acidosis? A. Have the child slow his breathing down be breathing into a paper bag B. Administer O2 and monitor the child's work of breathing, preparing for intubation as necessary C. Administer bicarbonate via IV infusion D. Have the child's guardian attempt to help calm the child and slow his breathing down - CORRECT ANSWER B. Administer O2 and monitor the child's work of breathing, preparing for intubation as necessary The administration of O2 and preparation for intubation is the treatment for respiratory acidosis which indicates that the child's is in respiratory failure 3.15 The nurse is caring for a child who is noted to have inspiration stridor; the nurse know that is indicated which of the following? A. The child is attempting to prolong the exchange of O2 and CO2 B. Air within the lungs has been replaced by fluid C. There is edema within the upper airway D. There is inflammation within the narrow passages of the lungs - CORRECT ANSWER C. There is edema within the upper airway Stridor is heard wither audibly or on auscultation when there is edema within the upper airway (trachea) 3.16 The nurse is helping a nursing student who is caring for a 12 year old with cystic fibrosis, the patient has had problems with chronic hypoxemia most of his life; Which of the following would indicate that the patient is having acute respiratory distress? A. Barrel shapped chest B. Clubbing of the toes C. Intercostal retractions D. Having to take a breath after each sentence - CORRECT ANSWER C. Intercostal retractions Indicates that the child is having to work harder to maintain respiration's and indicates acute respiratory distress Clubbing of the toes and a having a barrel chests are both chronic findings Having to take a breath after each sentence is an expected finding 3.17 A 10 month old arrives to the clinic with difficulty breathing, the nurse assesses the infant has a respiratory rate of 45, the infant is using assessors muscles and occasionally grunts at the end of a respiration; the patient is awake and alert and appears pale but not cyanotic; which of the following is the most appropriate action fo the nurse to take? A. Allow the infant to remain in her mothers lap while the nurse obtains the patient's history B. Allow the mother to give the infant a b - CORRECT ANSWER D. Administer O2 and complete the assessment while the infant remains in the mother's lap The child is in respiratory distress and will benefit from supplemental O2, the remaining assessment should be obtained quickly and the nurse should call for assistance The child's anxiety should decrease if the infant remains in the mothers lap which could prevent worsening of the respiratory status 3.18 The parents of a 3 year old are concerned that the child may have allergies, they ask the nurse how they can differentiate between allergies and a cold. Which of the following is the nurse's best response? A. "Children with allergies always come from a family with a strong history of allergies." B. "Children with colds tend to sneeze more than children with allergies." C. "Children with colds always have yellow discharge from their noses." D. "Children with allergies tend to complain of it - CORRECT ANSWER D. "Children with allergies tend to complain of itchiness in their throats instead of pain." Allergies tend to cause pruritus of the throat instead of pain Allergies can occur without a familial history Allergies can cause more sneezing than upper respiratory infections 3.19 The nurse is caring for a 3 month old that has an upper respiratory infection and is congested with very thick secretions, the parents of the child are very anxious as this is the first time he has been ill; which of the following statements would be most helpful for the nurse to say to the parents? A. "Before each feeding, place a few drops of saline in each nostril and use the bulb syringe to suction the secretions." B. "Since the infant is so congested, he needs more fluids, replace one - CORRECT ANSWER A. "Before each feeding, place a few drops of saline in each nostril and use the bulb syringe to suction the secretions." In order to help the infant with an upper respiratory infection tolerate feeding, it is essential to help clear the nose so that the infant can breath while feeding The infant should be suctioned prior to feedings 3.20 A