Pediatric Drill 10 answers

1.) Ans: D
R: Infant developmental milestone, generally grouped in 3-month increments, include the gain or loss of certain reflexes and the mastery of increasingly sophisticated motor skills. The ability to lift the head and chest from a prone position is characteristic of a 3-month old infant and demonstrates a cephalocaudal principle of growth and development---that is, the infant’s ability to raise his head, then his chest, and then his trunk. The moro and tonic-neck reflexes usually begin fading at 3 months; a persistently strong Moro or tonic-neck reflex is abnormal. Rolling over also occurs incrementally: The infant begins by rolling from back to side, then from side to back, and then over completely. Rolling over intentionally usually occurs at ages 5-6 months.
2.) Ans: D
R: Birth weight typically doubles by 6 months, triples by 12 months and quadruples by 30 months
3.) Ans: D
R: All these statements demonstrate positive development in the infant-caregiver relationship, but only the last one exemplifies the concept of mutuality: the special sensing—mutual exchange of unique cues and responses—between an infant and his caregiver that cannot be replicated with a substitute caregiver, such as a nurse. For mutuality to occur, the caregiver must think of the infants as an active participant in the relationship, not as a passive vessel.
4.) Ans: C
R: Individuation—the process whereby an infant realizes he is a distinct individual with a will of his own—usually occurs at age 8 or 9 months, after the infant has established a trusting relationship with his caregivers. This realization appears to be related to cognitive development.
5.) Ans. C
R: Stranger anxiety (also called 8-month anxiety) is the most important criterion in determining an infant’s ability to distinguish himself from his primary caregiver. Typically, the infant experiencing this type of anxiety cries when the caregiver leaves or a stranger approaches. This behavior usually dissipates by the end of the first year but reappears to a stronger degree at 18 months.
6.) Ans: B
R: Between ages 2 and 3, most children undergo significant changes in the development of fine motor skills. According to studies based on results of the Denver Developmental Screening Test (DDST), approximately 90% of US children are capable of washing their hands and brushing their teeth with minimal supervision by age 3.
7.) Ans: C
R: Parallel play refers to noninteractive, side-by-side play in which toddlers engage, as exemplified by two toddlers seated next to each other playing with separate dolls. The situations involving two toddlers sharing crayons or playing a board game do not demonstrate this behavior because toddlers typically do not share and cooperate and because such activity connotes interaction. Also, in the case of two toddlers playing a board game with the play therapist, the play involves interaction with an adult. The situation involving a toddler playing with a music box while seated on the play therapist’s lap also does not demonstrate parallel play because the play involves only one toddler, who is interacting with an adult.
8.) Ans: A
R: A young infant enjoys feeling various textures and is capable of holding a lightweight object, such as a soft cube. A book would hold little interest for an infant so young. An activity box and wooden blocks are too sophisticated for a 3-month old infant, who has not yet developed the fine and gross motor skills needed for reaching, holding, pulling, and stacking.
9.) Ans: B
R: Toddlers expend most of their energy walking and enjoy pulling things behind them. A 2-year-old child lacks the gross motor skills necessary to ride a bicycle. Miniature cars require fine motor coordination and are more appropriate for a preschooler. A 10-piece puzzle requires fine motor coordination and higher cognitive development and is therefore too complex for a 2 year old child.
10.) Ans: C
R: The initial step in health education involves assessing an individual’s needs, motivation, developmental level, knowledge base, and learning ability. BY asking such open-ended questions as, “What do you know about toilet training?” the nurse can elicit information and provide a basis for more specific questions that can lead to teaching. Questions involving the caregiver’s previous experience and motivation and the child’s readiness for toilet training should be part of the assessment phase, but these questions are too specific to be of value initially.
11.) Ans: A
R: Toddlers require simple, clear, and nondetailed instructions and explanations to complete a task. Toilet-training sessions should last no longer than 10minutes because the toddler’s attention span typically ranges from 5 to 10 minutes. Praise for cooperation or successful elimination is more effective than using negative control such as spanking, which may hinder toilet-training efforts. A stool stability and sense of security for the child.
12.) Ans: C
R: Although individuals mature sexually at different rates, most follow a normal development rhythm and order. The typical order of female sexual maturity---breast enlargement, followed by appearance of pubic hair, and, finally, menarche—commonly occur between ages 9 and 17
13.) Ans: B
R: Male sexual development commonly occurs between ages 10 and 17, characteristically beginning with testicular enlargement and scrotal skin reddening. Pubic hair development,, nocturnal emissions, and deepening voice—the most notable changes during adolescence—typically follow
14.) Ans: D
R: Regarding inanimate objects as alive (animism) is characteristic of Piaget’s preoperational stage of cognitive development, which occurs between ages 2 and 7, reflexive behavior, intentional reaching or grasping, and habitual, repetitive behavior are characteristic of the sensorimotor stage, which occurs from birth to about age 2
15.) Ans: C
R: Menarche usually occurs in Tanner’s stage IV, a latent stage of puberty, characterized in girls by protrusion of the areola and nipple, presence of axillary hair, growth of pubic hair, and beginning of menses (menarche). It does not occur at the onset of puberty or senescence, the stage associated with old age. Tanner’s stage II, the stage of early puberty, is marked by the beginning development of secondary sex characteristics, such as breast buds and early pubic hair.
16.) Ans: C
R: Tanner’s stage IV is characterized in boys by increased genital development thicker and coarser pubic hair, and increased axillary hair. Stage II is characterized by increased testicular size, as noted by an increased pendulous appearance of the scrotum and the onset of penile growth and pubic hair development. Stage V is marked by fully mature genitalia and pubic hair.
17.) Ans: D
R: A child with a receptive language problem has trouble decoding information because he does not understand verbal symbols. He also may have limited comprehension and ability to organize ideas. Poor grammar, speech pattern and sound alterations, and environmental deprivation are associated with expensive speech difficulties
18.) Ans: A
R: The inability to process symbols and abstract ideas usually results from aphasia, a central nervous system dysfunction commonly caused by trauma or inadequate language development. Expressive language problems, such as articulation defects, dysfluency (speech hesitancy), and voice disorders; are symptoms
19.) Ans: B
R: Stuttering is the most common form of dysfluency (speech hesitancy), a normal characteristic of speech development during the preschool years. More common in boys, stuttering typically occurs because the child’s vocabulary does not keep pace with his advancing mental ability and comprehension level. In many cases a child under age 3 is unaware that he is stuttering. Stuttering that persists beyond age 5 usually requires caregiver assistance, such as reinforcement of fluent speech periods that occur with singing or repeating nursery rhymes. With proper attention, dysfluency can be reversed early in the child’s development. An articulation error involves the incorrect pronunciation of a sound or the omission of a sound, particularly at the end of a word. A voice disorder involves a deviation in the pitch; loudness, or quality of speech. A decoding problem involves difficulty processing and interpreting information in the brain.
20.) Ans: C
R: Continuous babbling is not an indication of hearing impairment in an infant or a young child. Hearing impairment usually becomes noticeable when the child exhibits a problem in one or more of the following areas: orientation responses (such as unresponsiveness to simple oral commands), vocalization and sound production (such as absence of babbling or vocal play by age 7 months), visual attentiveness (such as avoidance of social interaction), and emotional behaviors (such as frequent stubbornness or inattentiveness).
21). Ans: D
R: Infant developmental milestone, generally grouped in 3-month increments, include the gain or loss of certain reflexes and the mastery of increasingly sophisticated motor skills. The ability to lift the head and chest from a prone position is characteristic of a 3-month old infant and demonstrates a cephalocaudal principle of growth and development---that is, the infant’s ability to raise his head, then his chest, and then his trunk. The moro and tonic-neck reflexes usually begin fading at 3 months; a persistently strong Moro or tonic-neck reflex is abnormal. Rolling over also occurs incrementally: The infant begins by rolling from back to side, then from side to back, and then over completely. Rolling over intentionally usually occurs at ages 5-6 months.

22.) Ans: D
R: Birth weight typically doubles by 6 months, triples by 12 months and quadruples by 30 months

33.) Ans: D
R: All these statements demonstrate positive development in the infant-caregiver relationship, but only the last one exemplifies the concept of mutuality: the special sensing—mutual exchange of unique cues and responses—between an infant and his caregiver that cannot be replicated with a substitute caregiver, such as a nurse. For mutuality to occur, the caregiver must think of the infants as an active participant in the relationship, not as a passive vessel.

24.Ans: C
R: Individuation—the process whereby an infant realizes he is a distinct individual with a will of his own—usually occurs at age 8 or 9 months, after the infant has established a trusting relationship with his caregivers. This realization appears to be related to cognitive development.

25.) Ans. C
R: Stranger anxiety (also called 8-month anxiety) is the most important criterion in determining an infant’s ability to distinguish himself from his primary caregiver. Typically, the infant experiencing this type of anxiety cries when the caregiver leaves or a stranger approaches. This behavior usually dissipates by the end of the first year but reappears to a stronger degree at 18 months.

26.) Ans: B
R: Between ages 2 and 3, most children undergo significant changes in the development of fine motor skills. According to studies based on results of the Denver Developmental Screening Test (DDST), approximately 90% of US children are capable of washing their hands and brushing their teeth with minimal supervision by age 3.

27.) Ans: C
R: Parallel play refers to noninteractive, side-by-side play in which toddlers engage, as exemplified by two toddlers seated next to each other playing with separate dolls. The situations involving two toddlers sharing crayons or playing a board game do not demonstrate this behavior because toddlers typically do not share and cooperate and because such activity connotes interaction. Also, in the case of two toddlers playing a board game with the play therapist, the play involves interaction with an adult. The situation involving a toddler playing with a music box while seated on the play therapist’s lap also does not demonstrate parallel play because the play involves only one toddler, who is interacting with an adult.

28.) Ans: A
R: A young infant enjoys feeling various textures and is capable of holding a lightweight object, such as a soft cube. A book would hold little interest for an infant so young. An activity box and wooden blocks are too sophisticated for a 3-month old infant, who has not yet developed the fine and gross motor skills needed for reaching, holding, pulling, and stacking.

29.) Ans: B
R: Toddlers expend most of their energy walking and enjoy pulling things behind them. A 2-year-old child lacks the gross motor skills necessary to ride a bicycle. Miniature cars require fine motor coordination and are more appropriate for a preschooler. A 10-piece puzzle requires fine motor coordination and higher cognitive development and is therefore too complex for a 2 year old child.

30.) Ans: C
R: The initial step in health education involves assessing an individual’s needs, motivation, developmental level, knowledge base, and learning ability. BY asking such open-ended questions as, “What do you know about toilet training?” the nurse can elicit information and provide a basis for more specific questions that can lead to teaching. Questions involving the caregiver’s previous experience and motivation and the child’s readiness for toilet training should be part of the assessment phase, but these questions are too specific to be of value initially.

31.) Ans: A
R: Toddlers require simple, clear, and nondetailed instructions and explanations to complete a task. Toilet-training sessions should last no longer than 10minutes because the toddler’s attention span typically ranges from 5 to 10 minutes. Praise for cooperation or successful elimination is more effective than using negative control such as spanking, which may hinder toilet-training efforts. A stool stability and sense of security for the child.

32.) Ans: C
R: Although individuals mature sexually at different rates, most follow a normal development rhythm and order. The typical order of female sexual maturity---breast enlargement, followed by appearance of pubic hair, and, finally, menarche—commonly occur between ages 9 and 17

33.) Ans: B
R: Male sexual development commonly occurs between ages 10 and 17, characteristically beginning with testicular enlargement and scrotal skin reddening. Pubic hair development,, nocturnal emissions, and deepening voice—the most notable changes during adolescence—typically follow

34.) Ans: D
R: Regarding inanimate objects as alive (animism) is characteristic of Piaget’s preoperational stage of cognitive development, which occurs between ages 2 and 7, reflexive behavior, intentional reaching or grasping, and habitual, repetitive behavior are characteristic of the sensorimotor stage, which occurs from birth to about age 2

35.) Ans: C
R: Menarche usually occurs in Tanner’s stage IV, a latent stage of puberty, characterized in girls by protrusion of the areola and nipple, presence of axillary hair, growth of pubic hair, and beginning of menses (menarche). It does not occur at the onset of puberty or senescence, the stage associated with old age. Tanner’s stage II, the stage of early puberty, is marked by the beginning development of secondary sex characteristics, such as breast buds and early pubic hair.

36.) Ans: C
R: Tanner’s stage IV is characterized in boys by increased genital development thicker and coarser pubic hair, and increased axillary hair. Stage II is characterized by increased testicular size, as noted by an increased pendulous appearance of the scrotum and the onset of penile growth and pubic hair development. Stage V is marked by fully mature genitalia and pubic hair.

37.) Ans: D
R: A child with a receptive language problem has trouble decoding information because he does not understand verbal symbols. He also may have limited comprehension and ability to organize ideas. Poor grammar, speech pattern and sound alterations, and environmental deprivation are associated with expensive speech difficulties

38.) Ans: A
R: The inability to process symbols and abstract ideas usually results from aphasia, a cetral nervous system dysfunction commonly caused by trauma or inadequate language development. Expressive language problems, such as articulation defects, dysfluency (speech hesitancy), and voice disorders; are symptoms

39.) Ans: B
R: Stuttering is the most common form of dysfluency (speech hesitancy), a normal characteristic of speech development during the preschool years. More common in boys, stuttering typically occurs because the child’s vocabulary does not keep pace with his advancing mental ability and comprehension level. In many cases a child under age 3 is unaware that he is stuttering. Stuttering that persists beyond age 5 usually requires caregiver assistance, such as reinforcement of fluent speech periods that occur with singing or repeating nursery rhymes. With proper attention, dysfluency can be reversed early in the child’s development. An articulation error involves the incorrect pronunciation of a sound or the omission of a sound, particularly at the end of a word. A voice disorder involves a deviation in the pitch; loudness, or quality of speech. A decoding problem involves difficulty processing and interpreting information in the brain.

40.) Ans: C
R: Continuous babbling is not an indication of hearing impairment in an infant or a young child. Hearing impairment usually becomes noticeable when the child exhibits a problem in one or more of the following areas: orientation responses (such as unresponsiveness to simple oral commands), vocalization and sound production (such as absence of babbling or vocal play by age 7 months), visual attentiveness (such as avoidance of social interaction), and emotional behaviors (such as frequent stubbornness or inattentiveness).

Pediatric Drill 9 answers

Question 1. Which of the following should the nurse do next after noting that an 8-month-old child's posterior fontanel is slightly open?

1. Check the child's head circumference
2. Document this as a normal finding
3. Question the mother about the child's delivery
4. Schedule an x-ray of the child's head

Looking for answers(s):1
Explanation: RATIONALE: The posterior fontanel usually closes by 6 weeks to 2 months. Therefore, the nurse should measure the head circumference to determine if the child's head is larger than the established norms because hydrocephalus can cause separation of the cranium sutures. This is not a normal finding because the posterior fontanel usually closes by age 2 months. Because the child is 8 months old, the delivery history probably would not be a significant factor. An x-ray (radiologic) examination is not necessary until other data are collected.

Question 2. Which of the following nursing diagnoses would the nurse identify as the priority for a 4-month-old infant with heart failure and congenital heart disease?

1. Activity Intolerance
2. Risk for Infection
3. Impaired Mobility
4. Ineffective Health Maintenance

Looking for answers(s):1
Explanation: RATIONALE: An infant with congenital heart disease and congestive heart failure usually tires easily, leading to a priority nursing diagnosis of Activity Intolerance. Nursing care needs to focus on allowing the infant to have frequent rest periods. Infants with congenital heart disease and congestive heart failure are not necessarily at risk for more infections than other infants. Impaired Mobility usually is not a problem because an infant with congenital heart disease usually exhibits normal physical mobility. Ineffective Health Maintenance usually is not a problem because these infants still need regular and routine health check-ups.

Question 3. When developing a plan of care that includes interventions aimed at preventing complications of a low platelet count in a child with leukemia, which of the following is most appropriate?

1. Consulting with a physician about the use of a stool softener
2. Placing the child in protective isolation
3. Using heparin instead of saline to flush an intermittent IV access device
4. Eliminating raw vegetables and fruits from the child's diet

Looking for answers(s):1
Explanation: RATIONALE: A stool softener would assist in preventing damage to the rectal mucosa due to hard stool, thereby decreasing the chances of rectal bleeding. Placing the child in protective isolation would be appropriate for the child if the neutrophil count was low. The use of heparin is contraindicated in situations in which there is a possibility of increased bleeding due to low platelets. Avoiding raw vegetables or fruits would be indicated if the child's neutrophil count were low.

Question 4. The nurse teaches the parent about the normal reaction that an infant may experience 12 to 24 hours after DTaP immunization. The nurse determines that the teaching is effective when the parent asks which of the following?

1. "Will the lethargy make it harder to breast-feed?"
2. "How much acetaminophen (Tylenol) can I give for the fever?"
3. "Can you give loperamide (Imodium) to an infant?"
4. "What kind of nose spray can I use for the baby's congestion?"

Looking for answers(s):2
Explanation: RATIONALE: Mild fever is common in an infant at 12 to 24 hours after administration of a DTaP vaccine. The mother should be taught to give the infant acetaminophen for the fever. Temperature above 102 degrees F (measured rectally) should be reported to the physician. After DTaP immunization, a mild fever is common. Typically an infant with a fever is restless rather than lethargic. Diarrhea (for which loperamide [Imodium] is given in adults, not infants) is not associated with administration of the DTaP vaccine. Nasal congestion is not associated with the DTaP vaccine.

Question 5. Which of the following would indicate effective therapy in a neonate born at 38 weeks gestation and given oxygen as a treatment for cold stress?

1. Heart rate is 200 bpm at rest
2. Respiratory rate is 48 breaths/minute at rest
3. Axillary temperature is 98 c
4. Blood pressure is 56/30 mm Hg

Looking for answers(s):3
Explanation: RATIONALE: Oxygen is given to a neonate experiencing cold stress to support an increase in the metabolic rate through a complex process of increasing metabolism. Axillary temperature readings are used because the initial response to cold stress is vasoconstriction, resulting in a decreased skin temperature. A heart rate of 200 bpm is above the normal range for a neonate at rest, possibly reflecting the need for more oxygen at the cellular level. A respiratory rate of 48 breaths per minute is above the normal range for a neonate at rest, possibly reflecting the need for more oxygen at the cellular level. A blood pressure reading of 56/30 mm Hg is normal for a neonate at 38 weeks' gestation. Thus, it is not a reliable indicator of effective therapy.

Question 6. After uncomplicated abdominal surgery, which of the following would be most appropriate when determining if an alert school-aged child is ready to drink oral fluids?

1. Ask if the child wants something to drink
2. Auscultate the child's abdomen for bowel sounds
3. Determine that the child has a gag reflex
4. Palpate the epigastric area for discomfort

Looking for answers(s):2
Explanation: RATIONALE: After uncomplicated abdominal surgery, fluid intake is resumed early in the postoperative period. However, before fluids are given, the nurse needs to auscultate the child's abdomen for bowel sounds indicating the return of peristalsis and a functioning gastrointestinal tract. Fluids are withheld until bowel sounds are heard. Asking the child if he or she wants something to drink is inappropriate because medications used before and during surgery may cause thirst. Additionally, the child's degree of thirst is not an indicator for peristalsis. Determining if a gag reflex is present would be more appropriate for the child having undergone upper gastrointestinal procedures such as gastroscopy. Having a gag reflex is usually not a concern in a child who is alert and has had uncomplicated abdominal surgery. Palpating the epigastric area or abdomen for discomfort provides no information about the function of the gastrointestinal tract. Complaints of pain are likely because the client has had abdominal surgery.

Question 7. A young child who has undergone a tonsillectomy refuses to let the nurse look at the tonsillar beds to check for bleeding. To assess whether the child is bleeding from the tonsillar beds, which of the following would be most appropriate?

1. Assess capillary refill
2. Force open the mouth with a tongue blade
3. Monitor for decreased blood pressure
4. Observe for frequent swallowing

Looking for answers(s):4
Explanation: RATIONALE: By observing for frequent swallowing, the nurse can evaluate whether the child is bleeding because blood will go down the back of the throat causing the child to swallow frequently. Decreased peripheral perfusion as evidenced by assessing capillary refill may be a sign of blood loss. In children, however, it is a late sign. Forcing the mouth open with a tongue blade can result in broken teeth, tissue damage, and psychological damage. Although a drop in blood pressure is a sign of blood loss, in children it occurs late.

Question 8. Which of the following interventions would be included in the plan of care for the child with juvenile rheumatoid arthritis to reduce joint pain in the morning just after arising?

1. Having the child sleep in a sleeping bag
2. Increasing pain medication at bedtime
3. Having the child sleep with the joints flexed
4. Awakening the child once nightly to exercise the joints

Looking for answers(s):1
Explanation: RATIONALE: Sleeping in a sleeping bag keeps the joints warm, therefore more flexible. Thus, joint pain in the morning would be lessened. Increasing bedtime pain medications may help the child sleep but will not decrease early morning stiffness. The child's joints should be kept in an extended position during sleep to maintain function. Lack of sleep, such as from awakening the child at night for exercises, is a stressor that can lead to exacerbation of juvenile rheumatoid arthritis.

Question 9. A mother brings her 18-month-old child to the clinic because the child "eats ashes, crayons, and paper." Which of the following information would be most important to obtain first about this toddler?

1. Currently cutting large teeth
2. Experiencing a growth spurt
3. Experiencing changes in the home environment
4. Eating a soft, low-roughage diet

Looking for answers(s):3
Explanation: RATIONALE: It is important to determine if the child is experiencing any change in the home environment that could cause anxiety that is relieved through oral gratification. A craving to eat nonfood substances is known as pica. Nutritional deficiencies, especially iron deficiency, were once thought to cause pica but research has not substantiated this theory. The child is demonstrating a craving to eat nonfood substances, known as pica. The cutting of large teeth is an unlikely cause of pica. The child is demonstrating a craving to eat nonfood substances, known as pica. Growth spurts are considered to be an unlikely cause of pica. The child is demonstrating a craving to eat nonfood substances, known as pica. Eating a low-roughage diet is considered to be an unlikely cause of pica.

Question 10. While examining a 12-month-old child, the nurse notes that the child can stand independently but cannot walk without support. Which of the following actions would be most appropriate?

1. Ask the mother if the child uses a walker at home
2. Do nothing because this is a normal finding in a child this age
3. Initiate a consultation with a developmental specialist
4. Tell the mother that the child may have a developmental delay

Looking for answers(s):2
Explanation: RATIONALE: A child aged 12 months is expected to cruise but not necessarily walk without support. Using or not using a walker at home does not significantly affect independent walking. A developmental specialist consult is not necessary. Even if the child's development in walking is slow, this fact is not sufficient data to make the nurse suspect developmental delay. Even if the child's development in walking is slow, this fact is not sufficient data to make the nurse suspect developmental delay.

Question 11. Which of the following laboratory values would the nurse interpret as associated with cold stress in a 1-day-old preterm neonate?

1. Bilirubin level of 13 mg/dL
2. Glucose level of 15 mg/dL
3. Hematocrit of 65%
4. Hemoglobin level of 23.5 g/dL

Looking for answers(s):2
Explanation: RATIONALE: A common finding in neonates with cold stress is low serum glucose level. The normal range for this infant is 20 to 60 mg/dL. Thus, a level of 15 mg/dL suggests hypoglycemia. Bilirubin levels typically do not exceed 5 mg/dL. At 13 mg/dL, the infant would be jaundiced owing to hyperbilirubinemia. A hematocrit of 65% suggests polycythemia, not cold stress. Normally, hemoglobin is below 22 g/dL. A hemoglobin level of 23.5 mg/dL is associated with polycythemia, not cold stress.

Question 12. An 18-month-old child with acquired immunodeficiency syndrome (AIDS) is seen in the clinic for health maintenance. Which of the following vaccines would the nurse anticipate administering to this toddler?

1. Diphtheria-tetanus-acellular pertussis
2. Varicella
3. Measles, mumps, and rubella
4. Hemophilus influenza

Looking for answers(s):1
Explanation: RATIONALE: Diphtheria, acellular pertussis, and tetanus are killed vaccines and may be given to this toddler. Live virus vaccines are not routinely administered to anyone with an altered immune system because multiplication of the virus may be enhanced, causing a severe vaccine-induced illness. Varicella virus vaccine is a live virus vaccine and is not routinely administered to anyone with an altered immune system because multiplication of the virus may be enhanced, causing a severe vaccine-induced illness Measles, mumps, and rubella are live virus vaccines and are not routinely administered to anyone with an altered immune system because multiplication of the virus may be enhanced, causing a severe vaccine-induced illness. Hemophilus influenza vaccine is a live virus vaccine and is not routinely administered to anyone with an altered immune system because multiplication of the virus may be enhanced, causing a severe, vaccine-induced illness

Question 13. A 2-month-old child returns from a cardiac catheterization. The child's fontanel is flat. The diaper is dry. The respiratory rate is 20 breaths/minute and breath sounds are decreased bilaterally. The child is limp although she moves all extremities when stimulated. The dressing over the insertion site is intact, clean, and dry. The pedal pulses are palpable bilaterally and equal to the heart rate. Which of the following nursing diagnoses would be most appropriate?

1. Ineffective Tissue Perfusion related to thrombus formation
2. Deficit Fluid Volume related to inability to take in fluids
3. Risk for Injury related to disruption of vessel integrity
4. Ineffective Breathing Pattern related to sedation

Looking for answers(s):4
Explanation: RATIONALE: The defining characteristics of Ineffective Breathing Pattern include a decrease in respiratory rate and chest expansion, limpness or unresponsiveness, and changes in mental status. In this situation, sedation used during the catheterization is the most probable cause of the Ineffective Breathing Pattern. Because the child's pedal pulses are palpable, Ineffective Tissue Perfusion from a thrombus is unlikely. Because fluids are administered during the procedure, Deficit Fluid Volume is unlikely. A disruption in vessel integrity would lead to bleeding at the site and circulatory or neurologic deficit in the affected leg. The child's dressing is dry and intact and the child is able to move all extremities so Risk for Injury is an inappropriate nursing diagnosis.

Question 14. Which of the following would the nurse most likely assess in a child who has sustained full-thickness burns?

1. Blanching to the touch
2. Excessive bleeding
3. Minimal complaints of pain
4. Blistering, moist appearance

Looking for answers(s):3
Explanation: RATIONALE: Full-thickness burns are serious injuries in which all the skin layers are destroyed. Lack of pain is characteristic of full-thickness burns. With full-thickness burns, blanching and bleeding are absent because blood supply is destroyed. With full-thickness burns, blanching and bleeding are absent because blood supply is destroyed. Blisters and moist appearance characterize partial-thickness burns.

Question 15. Which of the following would be the priority nursing diagnosis for a 4-week-old infant with a diagnosis of pyloric stenosis?

1. Constipation
2. Deficient Fluid Volume
3. Imbalanced Nutrition, less than body requirements
4. Impaired Swallowing

Looking for answers(s):2
Explanation: RATIONALE: Infants with pyloric stenosis generally have a history of spitting up, which progresses to projectile vomiting, weight loss, decrease in number of stools, and some degree of dehydration. Infants with dehydration need fluid and electrolyte replacement before surgery. A decrease in the number of stools, not constipation, is associated with pyloric stenosis. Although the infant's nutrition may be affected, a fluid volume deficit is the priority. Infants have a greater percentage of water per body weight and are at high risk for fluid imbalances. Pyloric stenosis is not associated with difficulty in swallowing.

Question 16. Immediately after the return of an 18-month-old child to his room following insertion of a ventriculoperitoneal shunt, which of the following would the nurse do first?

1. Ask the child to state his name and where he is
2. Palpate his anterior fontanel
3. Position him on the side opposite the shunt site
4. Check his pupil size and reactivity to light

Looking for answers(s):3
Explanation: RATIONALE: As soon as the child returns to his room, he needs to be positioned appropriately, in this case on the side opposite the shunt placement to avoid pressure on the operative site. Developmentally, the child at this age may or may not be able to state his name or where he is. Palpating his fontanel and checking pupils are part of the neurologic assessment that would be done once the child is positioned properly. Checking the child's pupils is part of the neurologic assessment that would be done once the child is positioned properly.

Question 17. When performing a physical assessment on an 18-month-old child, which of the following would be best?

1. Have the mother hold the toddler on her lap
2. Assess the respiratory and cardiac systems first
3. Carry out the assessment from head to toe
4. Assess motor function by having the child run and walk

Looking for answers(s):1
Explanation: RATIONALE: The best strategy for assessing a toddler is to have the parent hold the toddler. Doing so is comforting to the toddler. Assessment should begin with noninvasive assessments first while the child is quiet. Typically these include assessments of the cardiac and respiratory systems. The ears and throat are often examined last. Using a head-to-toe approach is more appropriate for an older child. For a toddler, assessment should begin with noninvasive assessments first while the child is quiet. Having a toddler run and be active may make it difficult to settle the child down after the physical exertion.

Question 18. At 3 AM, the mother of a 3-year-old child calls the emergency room nurse and reports the child has a temperature of 101.1 degreess f, a runny nose, and a barky cough that "gets going and won't stop." The mother states that she just gave the child acetaminophen (Tylenol). Which of the following should the nurse recommend next?

1. Sitting with the child in a steamy warm bathroom
2. Running a steam vaporizer near the child's bedside
3. Giving the child an over-the-counter decongestant
4. Administering aspirin in 2 hours

Looking for answers(s):1
Explanation: RATIONALE: Based on the mother's description, the child most likely is exhibiting signs and symptoms of laryngotracheal bronchitis. The mother should try to decrease the inflammation in the upper airway by exposing her child to a warm, steamy environment. The safest method is to steam up the bathroom and stay with the child. Steam vaporizers work by boiling water. Their use is to be avoided because they can cause severe burns if the child comes in close contact with the steam or if the vaporizer spills. A decongestant may assist in decreasing the rhinorrhea (runny nose) but it will not decrease the inflammation in the upper airway. Laryngotracheal bronchitis is caused by a virus. Aspirin is contraindicated in children with viral infections because this combination is implicated in Reye's syndrome.

Question 19. When developing a seminar on injury prevention to be presented to a group of parents of children from 2 to 18 years, the nurse would place the first priority on discussing the use of which of the following?

1. Child restraints in automobiles
2. Helmets for biking and skating
3. Special locks for cabinets
4. Topical bug repellent in summer

Looking for answers(s):1
Explanation: RATIONALE: Motor vehicle injuries are the leading cause of death in children older than 1 year of age. Most fatalities are related to nonuse of child restraints and seat belts. Although using helmets for biking and skating safety is important, it is not the priority. Special locks for cabinets are important in the prevention of poisoning, but this is not the priority. Topical bug repellant in summer is important for the prevention of Lyme disease. However, this is not the priority.

Question 20. The mother of a 9-month-old infant asks about adding new foods to his diet. The child is being breast-fed and takes formula and cereal when at the sitter's. Which of the following would the nurse instruct the mother to do?

1. Mix new foods with formula or breast milk
2. Mix new foods with more familiar foods
3. Offer new foods one at a time
4. Offer new foods after giving formula or breast milk

Looking for answers(s):3
Explanation: RATIONALE: Infants should be offered new foods one at a time. This gives the infant the chance to become gradually familiar with a variety of food tastes and textures and also helps identify any allergies or adverse reactions to a specific food. Mixing new foods with formula, breast milk, or other familiar foods would make it impossible to satisfactorily detect allergic or other unfavorable reactions. Mixing new foods with formula, breast milk, or other familiar foods would make it impossible to satisfactorily detect allergic or other unfavorable reactions. This practice may also cause the infant to refuse familiar foods. If a new food is offered after the infant's appetite is satisfied with formula or breast milk, the infant is not likely to eat the new food.

Question 21. After the nurse instructs the parents of a 5-month-old infant about the purpose of the Denver Developmental Screening Test (DDST), which of the following statements by the parents about what the test measures would indicate that the teaching was effective?

1. Intelligence quotient
2. Emotional development
3. Social and physical abilities
4. Potential for future development

Looking for answers(s):3
Explanation: RATIONALE: The Denver Developmental Screening Test (DDST) measures a child's social, language, and fine and gross motor skills by testing abilities that usually occur at a given age. The DDST is not designed to measure intelligence or emotional development nor does it necessarily predict future development. The DDST is not designed to measure intelligence or emotional development nor does it necessarily predict future development. The DDST is not designed to measure intelligence or emotional development nor does it necessarily predict future development.

Question 22. Which of the following would lead the nurse to suspect that a neonate with an infection is developing septic shock?

1. Axillary temperature is 99.8 c
2. Blood pressure is 45/25 mm Hg
3. Heart rate during sleep is 205 bpm
4. Respiratory rate while awake is 32 breaths/minute

Looking for answers(s):3
Explanation: RATIONALE: A sleeping heart rate of 205 bpm is above the normal 200 bpm for this age. Increased heart rate is an early indication of ensuing septic shock. Although the temperature is slightly elevated, it is not an indication of shock. A low axillary temperature may indicate the peripheral blood supply shutdown that occurs early in shock. A blood pressure of 45/25 mm Hg is normal for a neonate. The neonate's respiratory rate is within normal limits for age.

Question 23. The mother says that the infant's physician recommends certain foods, but the infant refuses to eat them after breast-feeding. The nurse should suggest that the mother alter the feeding plan by doing which of the following?

1. Offering dessert followed by some vegetables and meat
2. Offering breast milk as long as the infant refuses to eat solid foods
3. Mixing pureed food with some breast milk in a bottle with a large-holed nipple
4. Allowing the infant to nurse for a few minutes then offering solid foods

Looking for answers(s):4
Explanation: RATIONALE: It is typical for an infant just starting on solid foods to spit them out because the infant does not know how to swallow them. Also, the infant is hungry and is accustomed to having milk to satisfy that hunger. It is generally recommended that an infant be given some milk first then offered solid foods. Offering dessert followed by vegetables and meat is inappropriate because the infant will learn to prefer the sweets first, possibly refusing intake of the vegetables and meats. Offering breast milk as long as the infant refuses solid foods is inappropriate because an infant who takes all the milk first will have no interest in the solids. Mixing pureed foods with cow's or breast milk is inappropriate because solid food should be given by a spoon. Also, using a large-holed nipple may cause the infant to choke from getting too much fluid at one time.

Question 24. The parents express concern about the condition of their premature neonate. To meet the short-term goals of decreasing the parents' fears and fostering bonding, which of the following would the nurse include in the plan of care?

1. Allowing the parents to see and touch their neonate
2. Arranging for a visit with another couple who have an ill preterm neonate
3. Encouraging the parents to participate in the neonate's care
4. Telling the parents not to worry because the neonate is doing well

Looking for answers(s):1
Explanation: RATIONALE: Permitting the parents to see and touch the neonate allows for visual searching and information gathering, one of the first steps in the bonding process. Fingertip touching also helps promote the bonding process. Seeing and touching the neonate can often help the parents feel less concerned and more comfortable. The nurse should be present to help the parents understand therapeutic measures being used for the neonate. Although support from others is important, arranging for a visit and meeting with parents of another ill neonate may only increase the parents' concerns. Although parents are generally encouraged to care for their ill children, a high-risk neonate's care involves special skills that the parents may lack. A long-term nursing goal would be to instruct the parents in such care. Telling the parents not to worry ignores their feelings and tends to cut off communication.

Question 25. After resuming feedings in an infant who has undergone a pyloroplasty, which of the following would be most appropriate?

1. Keeping the head of the bed flat with the infant lying supine
2. Offering several ounces of an oral electrolyte solution initially
3. Placing the infant in a prone position after each feeding
4. Starting feedings with 5 to 10 mL, slowly increasing amounts as tolerated

Looking for answers(s):4
Explanation: RATIONALE: The child who has undergone pyloroplasty often vomits after the first feeding because peristalsis that has been in the right-to-left direction before repair has not reverted to the normal left-to-right direction. Peristalsis reverses as a result of the tightening of the pyloric sphincter, thus not allowing stomach contents to enter the small intestine. Therefore, small feedings of 5 to 10 mL are given and slowly increased as tolerated. Because there is a chance of vomiting, it is not advisable to place an infant supine with the head of the bed flat. If the infant does vomit, aspiration of stomach contents may occur, and pneumonia may result. Small feedings of 5 to 10 mL are given initially and then slowly increased as tolerated. The use of oral electrolyte solutions is unnecessary. The child will have an abdominal incision, so a prone position would be uncomfortable.

Question 26. After teaching the parents of a 15-month-old child who has undergone cleft palate repair how to use elbow restraints, which of the following statements by the parents indicates effective teaching?

1. "We'll keep the restraints in place continuously until the doctor says it's okay to remove them."
2. "We can take off the restraints while our child is playing but we'll make sure to put them back on at night."
3. "The restraints should be taped directly to our child's arms so that they will stay in one place."
4. "We'll remove the restraints temporarily at least three times a day to check his skin then put them right back on."

Looking for answers(s):4
Explanation: RATIONALE: Elbow restraints help to keep the child from placing fingers or any other object in the mouth that would cause injury to the operative site. The restraints are worn at all times except when they are removed to check the skin. Because of the risk for skin breakdown, the restraints are removed periodically during the day to assess the child's underlying skin. It is advisable to remove only one restraint at a time while keeping hold of the child's hand on the unrestrained side. Toddlers are quick and usually want to explore the area in the mouth that the surgery has made feel different. The restraints should be in place at all times during sleep and play to prevent inadvertent injury to the operative site. Toddlers are quick and usually want to explore the area in the mouth that the surgery has made feel different. Taping the restraints directly to the skin is not advised because skin breakdown can occur when tape is reapplied to the same area over several weeks. The restraints can be fastened to clothing to keep them from slipping.

Question 27. Which of the following methods for checking placement of a gavage feeding catheter would be most appropriate after introducing the catheter into the neonate's stomach?

1. Aspirating stomach contents through the catheter with a syringe
2. Auscultating clear breath sounds after instilling a small amount of air into the catheter
3. Aspirating water back into a syringe after introducing it into the catheter
4. Flushing the catheter with a small amount of water

Looking for answers(s):1
Explanation: RATIONALE: The method most often recommended to determine whether or not the gavage catheter is in the stomach is to aspirate stomach contents with a syringe. The presence of stomach contents indicates that the catheter is in the stomach. Any stomach contents obtained should be reintroduced into the stomach to prevent loss of electrolytes. Water introduced into the catheter before placement is confirmed may end up in the lungs. Air introduced into the catheter can be auscultated as a "whoosh" in the stomach area, not as clear breath sounds. No water should be used to confirm placement because water introduced into the catheter before placement is confirmed may end up in the lungs. No water should be used to confirm placement because water introduced into the catheter before placement is confirmed may end up in the lungs.

Question 28. On observing a parent propping a bottle for a 2-month-old child in the waiting room, the nurse explains the dangers of this to the parent. Which of the following statements indicates that the parent has understood the nurse's teaching?

1. "I didn't know it would cause my baby to gain too much weight."
2. "I can see how it might cause choking, but how does it cause dental caries?"
3. "So, because I prop the bottle, I might have trouble weaning the child?"
4. "I will stop propping the bottle so my child will sleep through the night."

Looking for answers(s):2
Explanation: RATIONALE: Many mothers prop a bottle of formula or fruit juice for their infants at bedtime. The infant then awakens periodically to take more formula or juice, constantly bathing the teeth with high-carbohydrate liquid that predisposes the infant to dental caries. Choking is also a risk because of the fluids dripping from the hole in the nipple if the child falls asleep while the nipple is still in the mouth. Propping a bottle does not necessarily lead to obesity, abnormally prolonged use of a bottle, or nighttime feedings. Propping a bottle does not necessarily lead to obesity, abnormally prolonged use of a bottle, or nighttime feedings. Propping a bottle does not necessarily lead to obesity, abnormally prolonged use of a bottle, or nighttime feedings.

Question 29. A preschool client immobilized in a spica cast complains of having trouble breathing after meals. Which of the following actions would be best?

1. Encourage the client to drink more between meals
2. Teach the child pursed-lip breathing
3. Give the client a laxative after meals
4. Offer the client small feedings several times a day

Looking for answers(s):4
Explanation: RATIONALE: A hip spica cast extends up over the abdomen. Because the abdomen is in a fixed space, abdominal distention secondary to eating pushes the abdominal contents against the diaphragm resulting in decreased chest expansion and subsequent possible respiratory distress. Because the client's complaints are associated with meals, offering small frequent meals provides nutritional support while minimizing distention. Encouraging increased drinking would increase the abdominal distention thus increasing the child's respiratory distress. With a hip spica cast, the child's complaints are due to decreased chest expansion from the abdomen pushing up against the diaphragm. Pursed lip breathing would be effective in preventing air trapping not decreased chest expansion. With a hip spica cast, the child's complaints are due to decreased chest expansion from the abdomen pushing up against the diaphragm. Administering a laxative with meals would be ineffective in relieving the decreased chest expansion.

Question 30. When determining the effectiveness of teaching a child's mother about sickle cell disease, which of the following statements by the mother indicates the need for additional teaching?

1. "I've started to give him some extra fluids with and between meals."
2. "I'm concerned about how the hospital staff will manage his pain."
3. "He's going to be playing on a soccer team when he's feeling better."
4. "I've told the child's father that both he and I are carriers of the disease."

Looking for answers(s):3
Explanation: RATIONALE: Physical and emotional stress can precipitate a sickle cell crisis. Physical exercise such as running involved in soccer would increase the child's risk for a crisis. Thus, the mother needs additional instructions about this area. Providing extra fluids with and in between meals is appropriate because it is important for the child with sickle cell disease to keep well-hydrated. In addition, these children often have nephrosis related to sickle cell disease and have difficulty conserving fluids. Therefore, they need up to 150% of normal fluid intake. Pain control is an issue in sickle cell crisis. The mother is showing concern for her child by asking how pain will be managed. Sickle cell disease is an autosomal recessive disease. For the child to have the disease, both parents must carry the recessive gene.

Question 31. After the nurse has taught the parents of a 5-year-old boy who has leukemia how to talk with their child about death and dying, which of the following would indicate that the parents have age-appropriate expectations about their child's reaction to his impending death?

1. "He is too young to understand what is happening to him."
2. "He might think he can cause his death because he has misbehaved."
3. "He will accept his death as caused by his disease."
4. "He will understand how much his siblings will miss him."

Looking for answers(s):2
Explanation: RATIONALE: A 5-year-old child is in the preoperational stage of cognitive development and thinks of death as temporary. Also, for a child this age, thinking about behavior often is believed to be magical; thus, the child may think that his behavior can cause death. Generally, children under 3 years of age are unable to differentiate death from temporary separation and are unable to understand what is happening. Logical thinking, evidenced by accepting death due to his disease, would occur during Piaget's stage of concrete operations between ages 6 and 12 years. Although a 5-year-old child will be able to understand that he will be missed, he lacks the cognitive development to understand the extent of how much his siblings will miss him.

Question 32. When preparing to conduct prenatal and parenting classes for a group of parents, the clinic's nursing staff will be providing childcare for the parents' children who range in age from 13 months to 6 years. The clinic has a playroom. Which of the following activities would be most appropriate to include?

1. Free play with adult supervision
2. A group sing-along
3. Drawing and painting projects
4. Viewing cartoon videos

Looking for answers(s):1
Explanation: RATIONALE: Planning any single activity that will appeal to children from ages 13 months to 6 years is next to impossible because of the developmental differences found in such a wide age group. It would be best to allow these children to participate in free play with adult supervision. A group sing-along would be appropriate for preschoolers and school-aged children. However, toddlers have short attention spans and would most likely find it difficult to participate in a group activity, such as a sing-along, for long. Although drawing and painting projects would be appropriate for preschoolers and school-aged children, toddlers have a tendency to put objects into their mouths. Therefore, drawing and painting projects would be inappropriate for this age group. Viewing cartoon videos would be inappropriate for young toddlers, who typically have short attention spans. Additionally, young toddlers may not understand the videos.

Question 33. When completing an assessment of a healthy adolescent client, which of the following would be most appropriate?

1. Obtain a detailed account of the adolescent's prenatal and early developmental history
2. Discuss sexual preferences and behaviors with the parents present for legal reasons
3. Discuss the client's smoking with parents present in the room
4. Assess the adolescent in private; gather additional information from the parents

Looking for answers(s):4
Explanation: RATIONALE: When assessing an adolescent, it is appropriate to first obtain information from the adolescent in private then interview the parents for additional information. Doing so helps to promote independence and responsibility for self-care. Obtaining prenatal and early developmental history information is usually not important for a healthy adolescent. In addition, this information typically would have already been obtained at an earlier age. No legal reason would prohibit the nurse from discussing sexuality with the adolescent without the parents present. Discussing smoking with the parents present in the room is inappropriate. If the adolescent smokes, the parents may be unaware and the adolescent would lose trust in the nurse. When assessing an adolescent, it is appropriate to first obtain information from the adolescent in private then interview the parents for additional information. Doing so helps to promote independence and responsibility for self care.

Question 34. When discussing a 7-month-old infant's motor skill development with the mother, the nurse should explain that by age 7 months, an infant most likely will be able to do which of the following?

1. Walk with one hand held
2. Eat successfully with a spoon
3. Stand while holding onto furniture
4. Sit alone using the hands for support

Looking for answers(s):4
Explanation: RATIONALE: By age 6 months, an infant can sit alone, leaning forward on the hands for support. The ability to sit follows progressive head control and straightening of the back. By 12 months, an infant can walk with one hand held. At about 18 months, an infant can eat successfully with a spoon. At 11 months, an infant can stand and walk while holding onto furniture.

Question 35. When planning a screening clinic for scoliosis, the nurse would anticipate targeting which of the following groups?

1. Preadolescents at the beginning of a growth spurt
2. Toddlers who have diets low in calcium and vitamin D
3. Preschoolers who are entering kindergarten
4. Infants whose mothers have had no prenatal care

Looking for answers(s):1
Explanation: RATIONALE: Preadolescents are at greatest risk for scoliosis because of the growth associated with this age group. Incidence is higher in girls than boys and increases during periods of rapid growth.

A toddler with a diet low in vitamin D and calcium is prone to develop rickets.

The risk for scoliosis is greatest during adolescence, not for preschoolers. However, prior to entering school, preschoolers are required to have their immunizations up-to-date.

No relationship exists between poor prenatal care and scoliosis.

Question 36. When assessing a 6-month-old child with a large ventricular septal defect, the nurse notices that the child has gained 5 pounds in 1 month. The mother reports that the child has not been wetting many diapers in the last week, although the child is taking the prescribed amounts of formula. "I think it is because he seems to sweat so much." Auscultation of the lung fields reveals fine crackles in the bases. The child's digoxin level is 1 mg/mL. Which of the following nursing diagnoses would be most appropriate?

1. Imbalanced Nutrition: More Than Body Requirements
2. Excess Fluid Volume
3. Risk for Injury
4. Urinary Retention

Looking for answers(s):2
Explanation: RATIONALE: The child is exhibiting characteristics of fluid volume excess related to heart failure. These include decreased output, diaphoresis, weight gain, and crackles. The heart failure is related to left to right shunting that occurs when the child has a large ventral septal defect. No evidence is presented to indicate that altered nutrition is the problem. In fact the mother reports that the child is taking the prescribed amounts of formula. The weight gain is due to the fluid overload. The child's digoxin level is within normal limits. Additionally, there is no evidence to suggest any risk for injury. Although the child's output is decreased, the weight gain is related to fluid overload systemically, not urinary retention.

Question 37. Assessment of a child with rheumatic fever reveals chorea. Which of the following would the nurse consider to be most important?

1. Explain to the child and family that the chorea will disappear over time
2. Institute measures to keep the child in a warm environment
3. Perform neurologic checks every 4 hours until the chorea subsides
4. Promote ambulation by giving aspirin every 4 hours

Looking for answers(s):1
Explanation: RATIONALE: Because the clumsiness and uncontrolled actions can be upsetting to both the child and family, they need to understand that chorea associated with rheumatic fever is not permanent. Measures to keep the child in a warm environment are unnecessary because the child's cardiac workload will increase as the child attempts to remain cool. Neurologic assessments every 4 hours are not necessary because chorea is self-limiting and nonprogressive. Because the child has cardiac involvement, ambulation is contraindicated to minimize the increased oxygen demands on the heart. Aspirin is used primarily as an anti-inflammatory drug and secondarily for pain relief.

Question 38. The mother of a 15-month-old child who is coughing and having trouble breathing telephones the clinic to ask advice because she suspects that her child has croup. Which of the following instructions would be most appropriate?

1. Administer acetaminophen (Tylenol) every 4 hours
2. Take the child into the bathroom and run the hot water
3. Give over-the-counter cough syrup every 6 hours
4. Get the child to take as much fluid as possible

Looking for answers(s):2
Explanation: RATIONALE: For the child with croup who is coughing and having difficulty breathing, the child should be taken into the shower where hot water is running to make the bathroom steamy. Steam helps to loosen secretion and relieve some of the respiratory distress. Giving acetaminophen is helpful but will not ease difficult breathing. Giving over-the-counter cough syrup is inappropriate because the underlying problem is airway inflammation and subsequent mucus accumulation and bronchoconstriction. Getting the child to take as much fluid as possible is important but it will not be effective in easing difficult breathing.

Question 39. The mother of an infant with a congenital heart defect involving decreased pulmonary blood flow tells the nurse that her child has not been gaining weight even with an increased-calorie formula. The mother states that the infant starts out with a good suck but tires and quits after 2 ounces. The infant is receiving oxygen through a nasal cannula as necessary and is on digoxin therapy. Which of the following should the nurse suggest to the mother?

1. Cut a large hole in the nipple
2. Feed the infant every 2 hours
3. Have the infant tested for digoxin toxicity
4. Increase the oxygen for feedings

Looking for answers(s):4
Explanation: RATIONALE: All children use energy to ingest and digest nutrients. The body needs oxygen to use the calories taken in to provide energy. Usually the caloric intake outweighs the energy needed to obtain the nutrients. A child with a congenital heart defect involving decreased pulmonary blood flow that circulates unoxygenated blood to the tissues may need extra oxygen support during times of high energy consumption such as feeding. Without this extra support, the child may become tired. If the child's suck is good, then enlarging the hole in the nipple will give the child too much volume with each suck and may cause the child to choke. Feeding the infant every 2 hours will tire the infant, possibly leading to the ingestion of fewer calories with the next feeding. Tiring during feedings is not a symptom of digoxin toxicity, although lack of appetite may be.
Question 40. The mother of an 8-year-old child with a fluid restriction of 1000 mL/day is staying with the child in the room. Which of the following would be most appropriate for the nurse to include in the child's plan of care?

1. Discussing the fluid restriction with the mother and child, allowing them to decide how to allocate the fluids over the 24 hours
2. Explaining to the mother that hospital personnel will assume the responsibility for providing fluids to the child.
3. Letting the child drink fluid until the limit is reached and then allowing the child to drink no more fluids
4. Telling the mother exactly how much fluid the child can have each hour, showing her examples of the amount

Looking for answers(s):1
Explanation: RATIONALE: Planning the child's fluid restriction with the mother and child is most appropriate because the mother and child would best know the child's usual pattern of fluid intake. Doing so also provides the mother with a feeling of some control over her child's situation and helps to promote compliance. Anyone, not just hospital personnel, can provide the child with fluids. However, a strict record of the child's intake must be kept to ensure adherence to the restriction. It is not advisable to allow a client on fluid restriction to drink all the allotted fluid at once. This may result in many thirsty hours for the client. The nurse also should remind the mother to count fluids used when the child takes any medications. Telling the mother exactly how much fluid the child can have each hour restricts the extent of the mother's and child's participation in care. Additionally, doing so ignores the child's usual needs, such as the usual pattern of fluid intake, possibly interfering with adherence to the fluid restriction.

Question 41. A mother asks the nurse when she should wean her 4-month-old infant from breast-feeding and begin using a cup. Which of the following would the nurse explain as the best indication of the infant's readiness to be weaned?

1. Taking solid foods well
2. Sleeping through the night
3. Shortening the nursing time
4. Eating on a regular schedule

Looking for answers(s):3
Explanation: RATIONALE: Readiness for weaning is an individual matter but is usually indicated when an infant begins to decrease the time spent nursing. The infant is then showing independence and will soon be ready to take a cup and learn a new skill. The infant ready for weaning may also demonstrate an ability to take solid foods well, sleep through the night, and eat on a regular schedule. These behaviors though are not necessarily the best evidence of readiness for weaning. The infant ready for weaning may also demonstrate an ability to take solid foods well, sleep through the night, and eat on a regular schedule. These behaviors though are not necessarily the best evidence of readiness for weaning. The infant ready for weaning may also demonstrate an ability to take solid foods well, sleep through the night, and eat on a regular schedule. These behaviors though are not necessarily the best evidence of readiness for weaning.

Question 42. A 10-day-old neonate brought to the clinic by the parents is lethargic and tachypneic with a heart rate of 200 bpm. Which of the following would be the nurse's primary focus initially?

1. Temperature pattern over the last few days
2. Number of wet diapers in the past 24 hours
3. Pupillary response now and 30 minutes later
4. Sleep patterns over the past week

Looking for answers(s):2
Explanation: RATIONALE: The neonate is exhibiting signs and symptoms of a possible infection that place her or him at risk for sepsis due to an immature immunologic response. In addition, a neonate's kidneys are immature so they cannot conserve water as necessary, making dehydration a rapid process in an ill neonate. Thus, the nurse's primary focus is to determine the neonate's hydration status by assessing the number of wet diapers in the past 24 hours. Sepsis can result in shock. Other important assessment data would include skin turgor, mucous membrane status, and status of the fontanel. (A sunken fontanel indicates dehydration.) A neonate with sepsis would exhibit a normal or lower than normal temperature. A neonate has an immature immune system and does not manifest signs and symptoms of illness as an older infant would. Pupillary response would be assessed if meningitis or another neurologic infection were suspected. When a neonate develops sepsis, sleep patterns change. Typically, the neonate sleeps more than usual and is commonly irritable when awake.

Question 43. The physician orders eye patching for a child with strabismus. Which of the following statements by the child's mother would indicate the need for additional teaching about this treatment?

1. "You see, his problem eye is patched."
2. "I keep the patch on even when he fusses."
3. "I have to watch him when he walks because he is clumsy."
4. "I take the patch off at night when he goes to bed."

Looking for answers(s):1
Explanation: RATIONALE: When an eye patch is used to correct strabismus, the normal eye is patched. That forces the child to use the abnormal, or "lazy," eye, thereby increasing that eye's muscle strength. Keeping the patch on during the child's waking hours, even when he's irritable or fussy, is appropriate to ensure effective treatment. Patching one eye interferes with depth perception and can cause the child to be clumsy at first. The patch can be removed at night while the child sleeps.

Question 44. A mother of an ill child is concerned because the child "isn't eating well." Which of the following strategies devised by the mother to help increase the child's intake should the nurse advise against using?

1. Allowing the child to choose his meals from an acceptable list of foods
2. Letting the child substitute items on his tray for other nutritious foods
3. Asking the child to say why he is not eating
4. Telling the child he must eat or else he will not get better

Looking for answers(s):4
Explanation: RATIONALE: Although nutrition plays a large part in the healing process, it is not advisable to tell a child that he will not get better if he does or does not do a particular activity. Not only is this dishonest, it also makes the child believe that his own actions are causing the illness. Allowing children choices often helps them feel in control. They also will be more likely to eat foods they have chosen. Letting the child substitute items on his tray for other nutritious foods is another way to allow the child to make choices, thus helping him to feel in control. It is important to find out the reason the child is not eating. Clients refuse to eat for multiple reasons, and interventions should be devised taking into consideration the reason for the child's refusal.

Question 45. Initial nursing interventions for a child admitted to the hospital with a diagnosis of meningitis due to H. influenzae should include which of the following?

1. Keeping the child well hydrated
2. Maintaining a quiet, cool environment
3. Keeping the child positioned flat in the bed
4. Placing the child on airborne precautions

Looking for answers(s):2
Explanation: RATIONALE: The child with meningitis should be kept in a quiet, cool environment to minimize stimulation, thus helping to decrease intracranial pressure. The child's hydration status requires a careful balance. Any fluid deficit should be corrected. Then the child should be kept on low fluid maintenance to prevent cerebral edema. To decrease intracranial pressure and facilitate venous return, the child should be positioned with the head of the bed elevated and the head midline. A child with meningitis does not need to be placed on airborne precautions. Rather, the treatment is droplet precautions because meningitis caused by H. influenzae is transmitted via contact with the conjunctivae or mucous membranes of the nose or mouth of a susceptible person via sneezing, coughing, or talking.

Question 46. A 23-month-old child pulled a pan of hot water off the stove and spilled it onto her chest and arms. Her mother was right there when it happened. Which of the following should the mother have done immediately?

1. Apply ice directly to the burned areas
2. Place the child in the bathtub of cool water
3. Apply antibiotic ointment to the burned areas
4. Call the neighbor to come over and help her

Looking for answers(s):2
Explanation: RATIONALE: The emergency treatment of both minor and major burns includes stopping the burning process by immersing the burned area in cool, but not cold, water. Thus, the mother should place the child in a bathtub of cool water. Applying ice directly to the burned area is inappropriate at this time because more tissue damage can result. Antibiotic ointment should not be applied to the burned area at this time because the burning process must be stopped first. Calling a neighbor for help is appropriate after she has placed then removed her child from the bathtub.

Question 47. Parents ask for advice about handling their 2-year-old's negativism. Which of the following would be the best recommendation?

1. Ignore this behavior because it is a stage the child is going through
2. Set realistic limits for the child, then be sure to stick to them
3. Encourage the grandmother to visit frequently to relieve them
4. Punish the child for misbehaving or violating set, strict limits

Looking for answers(s):2
Explanation: RATIONALE: A characteristic of 2-year-olds is negativism, a response to their developing autonomy. Setting realistic limits is important so that the toddler learns what behavior is and is not acceptable. Ignoring the behavior may lead the child to believe that there are no limits. As a result, the child does not learn appropriate behavior. Having the grandmother visit will give the parents a break, but setting limits is more important to the child's development. Limits need to be realistic to ensure that the child learns appropriate behavior. Limits that are too strict are inappropriate, interfering with learning appropriate behavior.

Question 48. When preparing to give a neonate the first feeding by nipple, for which of the following reasons would the nurse anticipate using a 5 mL feeding of sterile water first?

1. Ascertain the patency of the neonate's esophagus
2. Determine if the neonate can retain the feeding
3. Ensure that the neonate has the energy to take oral feedings
4. Ensure that the mother will be able to feed the neonate

Looking for answers(s):1
Explanation: RATIONALE: Small amounts of sterile water are given to a neonate first to ascertain if the esophagus is patent and to prevent the aspiration of formula if it is not. Assessment of the neonate's ability to retain feedings requires additional time and collection of additional information. Determining if the neonate has the energy to take oral feedings requires additional assessment time and data. More information about the mother is needed. For example, the nurse should watch the mother actually feeding the neonate to determine her ability.

Question 49. Which of the following would the nurse include in the plan of care for a child with a fracture in skeletal traction to prevent osteomyelitis?

1. Encouraging the child to eat nutritious foods
2. Administering prophylactic antibiotics as ordered
3. Maintaining the child in reverse isolation
4. Protecting the child from visitors with colds

Looking for answers(s):1
Explanation: RATIONALE: The best prevention strategy for osteomyelitis, a bacterial infection of the bone, is to maintain skin integrity and promote good nutrition. Encouraging the intake of nutritional foods is essential to ensure bone repair and healing, thereby minimizing the risk of infection. Unless the child already has a bacterial infection, antibiotics are not administered prophylactically when skeletal traction is used. Maintaining reverse isolation is not necessary for this child and could lead to social isolation. Protecting the child from visitors with colds is inappropriate because colds are caused by viruses while osteomyelitis is caused by bacteria invading bone tissue. Additionally, restricting visitors could lead to social isolation.

Question 50. A nurse working in a neonatal intensive care unit is developing infection control policies. Which of the following policies would the nurse expect to include as the single most effective means of preventing the spread of infection?

1. Having everyone coming in contact with neonates perform frequent hand and arm washing.
2. Keeping each neonate in an isolation incubator that is opened as infrequently as possible
3. Maintaining a ventilation system in the unit that provides for continuous clean-air exchange
4. Requiring everyone who comes in contact with neonates to wear gowns and masks

Looking for answers(s):1
Explanation: RATIONALE: Authorities agree that the single most effective way to control the spread of infection is to have personnel perform frequent arm and hand washings. Although using isolation incubators may be beneficial, it is not the most effective means of infection control. Although ventilation systems with clean-air exchanges may be beneficial, they are not the most effective means of infection control. Wearing gowns and masks is helpful but not the most effective means of infection control

Pediatric Drill 8 answers

Question 1. A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child?

1. All lesions crusted
2. Elevated temperature
3. Rhinorrhea and coryza
4. Presence of vesicles

Looking for answers(s):1
Explanation: The correct answer is All lesions crusted The rash begins as a macule, with fever, and progresses to a vesicle that breaks open and then crusts over. When all lesions are crusted, the child is no longer in a communicable stage.

Question 2. A nurse is doing preconceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?

1. "I understand that a glass of wine with dinner is healthy."
2. "Beer is not really hard alcohol, so I guess I can drink some."
3. "If I drink, my baby may be harmed before I know I am pregnant."
4. "Drinking with meals reduces the effects of alcohol."

Looking for answers(s):3
Explanation: The correct answer is "If I drink, my baby may be harmed before I know I am pregnant." Alcohol has the greatest teratogenic effect during organogenesis, in the first weeks of pregnancy. Therefore women considering a pregnancy should not drink.

Question 3. The school nurse suspects that a third grade child might have Attention Deficit Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse should

1. Observe the child's behavior on at least 2 occasions
2. Consult with the teacher about how to control impulsivity
3. Compile a history of behavior patterns and developmental accomplishments
4. Compare the child's behavior with classic signs and symptoms
Looking for answers(s):3

Explanation: The correct answer is Compile a history of behavior patterns and developmental accomplishments A complete behavioral, and developmental history plays an important role in determining the diagnosis.


Question 4. In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant?

1. Increased 10% in height
2. 2 deciduous teeth
3. Tripled the birth weight
4. Head > chest circumference

Looking for answers(s):3
Explanation: The correct answer is Tripled the birth weight The infant usually triples his birth weight by the end of the first year of life. Height usually increases by 50% from birth length. A 12 month- old child should have approximately 6 teeth. ( estimate number of teeth by subtracting 6 from age in months, ie 12 – 6 = 6). By 12 months of age, head and chest circumferences are approximately equal.

Question 5. A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age?

1. Jumping rope
2. Tying shoelaces
3. Riding a tricycle
4. Playing hopscotch

Looking for answers(s):3
Explanation: The correct answer is Riding a tricycle Coordination is gained through large muscle use. A child of 3 has the ability to ride a tricycle.

Question 6. A nurse arranges for a interpreter to facilitate communication between the health care team and a non-English speaking client. To promote therapeutic communication, the appropriate action for the nurse to remember when working with an interpreter is to

1. Promote verbal and nonverbal communication with both the client and the interpreter
2. Speak only a few sentences at a time and then pause for a few moments
3. Plan that the encounter will take more time than if the client spoke English
4. Ask the client to speak slowly and to look at the person spoken to

Looking for answers(s):1
Explanation: The correct answer is Promote verbal and nonverbal communication with both the client and the interpreter The nurse should communicate with the client and the family, not with the interpreter. Culturally appropriate eye contact, gestures, and body language toward the client and family are important factors to enhance rapport and understanding. Maintain eye contact with both the client and interpreter to elicit feedback and read nonverbal cues

Question 7. The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition?


1. Skin irritation
2. Drug tolerance
3. Severe headaches
4. Postural hypotension

Looking for answers(s):2
Explanation: The correct answer is Drug tolerance Removing a nitroglycerine patch for a period of 10-12 hours daily prevents tolerance to the drug, which can occur with continuous patch use.

Question 8. Which of these parents’ comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?

1. I noticed a little lump a little above the belly button.
2. The baby seems hungry all the time.
3. Mild vomiting that progressed to vomiting shooting across the room.
4. Irritation and spitting up immediately after feedings.

Looking for answers(s):3
Explanation: The correct answer is Mild emesis progressing to projectile vomiting Mild regurgitation or emesis that progresses to projectile vomiting is a pattern of vomiting associated with pyloric stenosis as an initial finding. The other findings are present, though not initial findings.

Question 9. A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should be what focus?

1. Discuss with the mother sharing parenting responsibilities
2. Set time aside to get the mother to express her feelings and concerns
3. Arrange for the parents to attend infant care classes
4. Talk with the father and help him accept the wife's decision

Looking for answers(s):2
Explanation: The correct answer is Set time aside to get the mother to express her feelings and concerns. Non-judgmental support for expressed feelings may lead to resolution of competitive feelings in a new family. Cultural influences may also be revealed.

Question 10. A client who has been drinking for five years states that he drinks when he gets upset about "things" such as being unemployed or feeling like life is not leading anywhere. The nurse understands that the client is using alcohol as a way to deal with

1. Recreational and social needs
2. Feelings of anger
3. Life’s stressors
4. Issues of guilt and disappointment

Looking for answers(s):3
Explanation: The correct answer is Life’s stressors Alcohol is used by some people to manage anxiety and stress. The overall intent is to decrease negative feelings and increase positive feelings.

Question 11. A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?

1. "Touching the abdomen could cause cancer cells to spread."
2. "Examining the area would cause difficulty to the child."
3. "Pushing on the stomach might lead to the spread of infection."
4. "Placing any pressure on the abdomen may cause an abnormal experience."

Looking for answers(s):1
Explanation: The correct answer is "Touching the abdomen could cause cancer cells to spread." Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully. The other options are similar but not the most specific.

Question 12. The nurse is teaching diet restrictions for a client with Addison's disease. The client would indicate an understanding of the diet by stating

1. "I will increase sodium and fluids and restrict potassium."
2. "I will increase potassium and sodium and restrict fluids."
3. "I will increase sodium, potassium and fluids."
4. "I will increase fluids and restrict sodium and potassium."

Looking for answers(s):1
Explanation: The correct answer is "I will increase sodium and fluids and restrict potassium." The manifestation of Addison''s disease due to mineralocorticoid deficiency resulting from renal sodium wasting and potassium retention include dehydration, hypotension, hyponatremia, hyperkalemia and acidosis.

Question 13. The father of an 8 month-old infant asks the nurse if his infant's vocalizations are normal for his age. Which of the following would the nurse expect at this age?
1. Cooing
2. Imitation of sounds
3. Throaty sounds
4. Laughter

Looking for answers(s):2
Explanation: The correct answer is Imitation of Sounds Imitation of sounds such as "da-da" is expected at this time.

Question 14. A diabetic client asks the nurse why the health care provider ordered a glycolsylated hemoglobin (HbA) measurement, since a blood glucose reading was just performed. You will explain to the client that the HbA test:

1. Provides a more precise blood glucose value than self-monitoring
2. Is performed to detect complications of diabetes
3. Measures circulating levels of insulin
4. Reflects an average blood sugar for several months

Looking for answers(s):4
Explanation: The correct answer is Reflects an average blood sugar for several months Glycosolated hemoglobin values reflect the average blood glucose (hemoglobin-bound) for the previous 3-4 months and is used to monitor client adherence to the therapeutic regimen.

Question 15. The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the nurse?

1. "Do you want to take this pretty red medicine?"
2. "You will feel better if you take your medicine."
3. "This is your medicine, and you must take it all right now."
4. "Would you like to take your medicine from a spoon or a cup?"

Looking for answers(s):4
Explanation: The correct answer is "Would you like to take your medicine from a spoon or a cup?" At 3 years of age, a child often feels a loss of control when hospitalized. Giving a choice about how to take the medicine will allow the child to express an opinion and have some control.

Question 16. The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention?

1. Temperature of 102 degrees Fahrenheit
2. Pulse rate of 98 beats per minute
3. Respiratory rate of 32
4. Blood pressure of 90/50

Looking for answers(s):3
Explanation: The correct answer is Respiratory rate of 32 Clients with deep vein thrombosis are at risk for the development of pulmonary embolism. The most common symptoms are tachypnea, dyspnea, and chest pain.

Question 17. What is the major developmental task that the mother must accomplish during the first trimester of pregnancy?

1. Acceptance of the pregnancy
2. Acceptance of the termination of the pregnancy
3. Acceptance of the fetus as a separate and unique being
4. Satisfactory resolution of fears related to giving birth

Looking for answers(s):1
Explanation: The correct answer is Acceptance of the pregnancy During the first trimester the maternal focus is directed toward acceptance of the pregnancy and adjustment to the minor discomforts.

Question 18. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet

1. High in carbohydrates and proteins
2. Low in carbohydrates and proteins
3. High in carbohydrates, low in proteins
4. Low in carbohydrates, high in proteins

Looking for answers(s):1
Explanation: The correct answer is High in carbohydrates and proteins Provide a high-energy diet by increasing carbohydrates, protein and fat (possibly as high as 40%). A favorable response to the supplemental pancreatic enzymes is based on tolerance of fatty foods, decreased stool frequency, absence of steatorrhea, improved appetite and lack of abdominal pain.

Question 19. The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!". What would be the most appropriate next action?

1. Leave the room and return five minutes later and give the medicine
2. Explain to the child that the medicine must be taken now
3. Give the medication to the father and ask him to give it
4. Mix the medication with ice cream or applesauce

Looking for answers(s):1
Explanation: The correct answer is Leave the room and return five minutes later and give the medicine Since the nurse gave the child a choice about taking the medication, the nurse must comply with the child''s response in order to build or maintain trust. Since toddlers do not have an accurate sense of time, leaving the room and coming back later is another episode to the toddler.

Question 20. An eighteen month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional findings of

1. Septicemia
2. Dehydration
3. Hypokalemia
4. Hypercalcemia

Looking for answers(s):2
Explanation: The correct answer is Dehydration Clinical findings dehydration include lethargy, irritability, dry skin, and increased pulse.

Question 21. The nurse is planning care for a 2 year-old hospitalized child. Which of the following will produces the most stress at this age?

1. Separation anxiety
2. Fear of pain
3. Loss of control
4. Bodily injury

Looking for answers(s):1
Explanation: The correct answer is Separation anxiety While a toddler will experience all of the stresses, separation from parents is the major stressor.

Question 22. A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special family gatherings?" Which initial response by the nurse would be best?

1. "A recovering person has to be very careful not to lose control, therefore, confine your drinking just at family gatherings."
2. "At your next AA meeting discuss the possibility of limited drinking with your sponsor."
3. "A recovering person needs to get in touch with their feelings. Do you want a drink?"
4. "A recovering person cannot return to drinking without starting the addiction process over."

Looking for answers(s):4
Explanation: The correct answer is "The recovering person cannot return to drinking without starting the addiction process over." Recovery is total abstinence from all drugs.

Question 23. The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?

1. Take the client's vital signs
2. Place the client in a sitting position with legs dangling
3. Contact the health care provider
4. Administer the PRN antianxiety agent

Looking for answers(s):2
Explanation: The correct answer is Place the client in a sitting position with legs dangling Place the client in a sitting position with legs dangling to pool the blood in the legs. This helps to diminish venous return to the heart and minimize the pulmonary edema. The result will enhance the client’s ability to breathe. The next actions would be to contact the heath care provider, then take the vital signs and then the administration of the antianxiety agent.

Question 24. After successful alcohol detoxification, a client remarked to a friend, "I’ve tried to stop drinking but I just can’t, I can’t even work without having a drink." The client’s belief that he needs alcohol indicates his dependence is primarily

1. Psychological
2. Physical
3. Biological
4. Social-cultural

Looking for answers(s):1
Explanation: The correct answer is Psychological With psychological dependence, it is the client ‘s thoughts and attitude toward alcohol that produces craving and compulsive use.

Question 25. The nurse is caring for a depressed client with a new prescription for an SSRI antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about the safety of this medication?

1. History of obesity
2. Prescribed use of an MAO inhibitor
3. Diagnosis of vascular disease
4. Takes antacids frequently

Looking for answers(s):2
Explanation: The correct answer is Prescribed use of an MAO inhibitor SSRIs should not be taken concurrently with MAO inhibitors because serious, life-threatening reactions may occur with this combination of drugs.

Question 26. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to
1. Dress the child warmly to avoid chilling
2. Keep the child away from other children for the duration of the rash
3. Clean the affected areas with tepid water and detergent
4. Wrap the child's hand in mittens or socks to prevent scratching

Looking for answers(s):4
Explanation: The correct answer is Wrap the child''s hand in mittens or socks to prevent scratching A toddler with atopic dermatitis need to have fingernails cut short and covered so the child will not be able to scratch the skin lesions, thereby causing new lesions and possible a secondary infection.

Question 27. The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the appropriate nursing action?

1. Pack the nose and ears with sterile gauze
2. Apply pressure to the injury site
3. Apply bulky, loose dressing to nose and ears
4. Apply an ice pack to the back of the neck

Looking for answers(s):3
Explanation: The correct answer is Apply bulky, loose dressing to nose and ears. Applying a bulky, loose dressing to the nose and ears permits the fluid to drain and provides a visual reference for the amount of drainage.

Question 28. A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client

1. Eat foods high in sodium increases sputum liquefaction
2. Use oxygen during meals improves gas exchange
3. Perform exercise after respiratory therapy enhances appetite
4. Cleanse the mouth of dried secretions reduces risk of infection

Looking for answers(s):2
Explanation: The correct answer is Use oxygen during meals improves gas exchange Clients with emphysema breathe easier when using oxygen while eating.

Question 29. The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction?

1. "I should position my baby completely facing me with my baby's mouth in front of my nipple."
2. "The baby should latch onto the nipple and areola areas."
3. "There may be times that I will need to manually express milk."
4. "I can switch to a bottle if I need to take a break from breast feeding."

Looking for answers(s):4
Explanation: The correct answer is I can switch to a bottle if I need to take a break from breast feeding. Babies adapt more quickly to the breast when they aren''t confused about what is put into their mouths and its purpose. Artificial nipples do not lengthen and compress the way the human nipples (areola) do. The use of an artificial nipple weakens the baby''s suck as the baby decreases the sucking pressure to slow fluid flow. Babies should not be given a bottle during the learning stage of breast feeding.

Question 30. Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner’s injuries by

1. Seeking medical help for the victim's injuries
2. Minimizing the episode and underestimating the victim’s injuries
3. Contacting a close friend and asking for help
4. Being very remorseful and assisting the victim with medical care

Looking for answers(s):2
Explanation: The correct answer is Minimizing the episode and underestimating the victim’s injuries Many abusers lack an understanding of the effect of their behavior on the victim and use excessive minimization and denial.

Question 31. A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparations. What is the initial action the nurse should take?

1. Report the behavior to the charge nurse
2. Talk with the client to find out about the preferred herbal preparation
3. Contact the client's health care provider
4. Explain the importance of the medication to the client

Looking for answers(s):2
Explanation: The correct answer is Talk with the client to find out about the preferred herbal preparation Respect for differences is demonstrated by incorporating traditional cultural practices for staying healthy into professional prescriptions and interventions. The challenge for the health-care provider is to understand the client''s perspective. "Culture care preservation or maintenance refers to those assistive, supporting, facilitative or enabling professional actions and decisions that help people of a particular culture to retain and/or preserve relevant care values to that they can maintain their well-being, recover from illness or face handicaps and/or death".

Question 32. The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate finding?

1. Retractions in the intercostal tissues of the thorax
2. Chest pain aggravated by respiratory movement
3. Cyanosis and mottling of the skin
4. Rapid, shallow respirations

Looking for answers(s):1
Explanation: The correct answer is Retractions in the soft tissues of the thorax Slight intercostal retractions are normal. However in disease states, especially in severe airway obstruction, retractions become extreme.

Question 33. The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown?

1. Massage legs frequently
2. Frequent turning
3. Moisten skin with lotions
4. Apply moist heat to reddened areas

Looking for answers(s):2
Explanation: The correct answer is Frequent turning Frequent turning will prevent skin breakdown.

Question 34. The nurse will administer liquid medicine to a 9 month-old child. Which of the following methods is appropriate?

1. Allow the infant to drink the liquid from a medicine cup
2. Administer the medication with a syringe next to the tongue
3. Mix the medication with the infant's formula in the bottle
4. Hold the child upright and administer the medicine by spoon

Looking for answers(s):2
Explanation: The correct answer is Administer the medication with a syringe next to the tongue Using a needle-less syringe to give liquid medicine to an infant is often the safest method. If the nurse directs the medicine toward the side or the back of the mouth, gagging will be reduced.

Question 35. Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care?

1. Measure head circumference
2. Place in airborne isolation
3. Provide passive range of motion
4. Provide an over-the-crib protective top

Looking for answers(s):1
Explanation: The correct answer is Measure head circumference In meningitis, assessment of neurological signs should be done frequently. Head circumference is measured because subdural effusions and obstructive hydrocephalus can develop as a complication of meningitis. The client will have already been on airborne precautions and crib top applied to bed on admission to the unit.

Question 36. The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct?

1. May drink as much milk as desired
2. Can have milk mixed with other foods
3. Will benefit from fat-free cow's milk
4. Should be limited to 3-4 cups of milk daily

Looking for answers(s):4
Explanation: The correct answer is Should be limited to three to four cups of milk daily More than 32 ounces of milk a day considerably limits the intake of solid foods, resulting in a deficiency of dietary iron, as well as other nutrients.

Question 37. The nurse is caring for a client with COPD who becomes dyspneic. The nurse should

1. Instruct the client to breathe into a paper bag
2. Place the client in a high Fowler's position
3. Assist the client with pursed lip breathing
4. Administer oxygen at 6L/minute via nasal cannula

Looking for answers(s):3
Explanation: The correct answer is Assist the client with pursed lip breathing Use pursed-lip breathing during periods of dyspnea to control rate and depth of respiration

Question 38. In preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider before administering which of the following drugs through the tube?

1. Cardizem SR tablet (diltiazem)
2. Lanoxin liquid
3. Os-cal tablet (calcium carbonate)
4. Tylenol liquid (acetaminophen)

Looking for answers(s):1
Explanation: The correct answer is Cardizem SR tablet (diltiazem) Cardizem SR is a "sustained-release" drug form. Sustained release (controlled-release; long-acting) drug formulations are designed to release the drug over an extended period of time. If crushed, as would be required for gastrostomy tube administration, sustained-release properties and blood levels of the drug will be altered. The health care provider must substitute another medication.

Question 39. A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse would expect the client to have

1. Scrotal discoloration
2. Sustained painful erection
3. Inability to achieve erection
4. Heaviness in the affected testicle

Looking for answers(s):4
Explanation: The correct answer is Heaviness in the affected testicle The feeling of heaviness in the scrotum is related to testicular cancer and not epididymitis. Sexual performance and related issues are not affected at this time.

Question 40. In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding?

1. Age 40 years
2. Lactose intolerance
3. Family history of breast cancer
4. Uses cocaine on weekends

Looking for answers(s):4
Explanation: The correct answer is Uses cocaine on weekends Binge use of cocaine can be just as harmful to the breast fed newborn as regular use.

Question 41. The most common reason for an Apgar score of 8 and 9 in a newborn is an abnormality of what parameter?

1. Heart rate
2. Muscle tone
3. Cry
4. Color

Looking for answers(s):4
Explanation: The correct answer is Color Acrocyanosis (blue hands and feet) is the most common Apgar score deduction, and is a normal adaptation in the newborn.

Question 42. Based on principles of teaching and learning, what is the best initial approach to pre-op teaching for a client scheduled for coronary artery bypass?

1. Touring the coronary intensive unit
2. Mailing a video tape to the home
3. Assessing the client's learning style
4. Administering a written pre-test

Looking for answers(s):3
Explanation: The correct answer is Assessing the client''s learning style As with any anticipatory teaching, assess the client''s level of knowledge and learning style first.

Question 43. A nurse is assigned to a client who is a new admission for the treatment of a frontal lobe brain tumor. Which history offered by the family members would be anticipated by the nurse as associated with the diagnosis and communicated?

1. "My partner's breathing rate is usually below 12."
2. "I find the mood swings and the change from a calm person to being angry all the time hard to deal with."
3. "It seems our sex life is nonexistant over the past 6 months."
4. "In the morning and evening I hear complaints that reading is next to impossible from blurred print."

Looking for answers(s):2
Explanation: The correct answer is "I find the mood swings and the change from a calm person to being angry all the time hard to deal with." The frontal lobe of the brain controls affect, judgment and emotions. Dysfunction in this area results in findings such as emotional lability, changes in personality, inattentiveness, flat affect and inappropriate behavior.

Question 44. A 9 year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be the child's greatest fear?
1. Change in body image
2. An unfamiliar environment
3. Perceived loss of control
4. Guilt over being hospitalized

Looking for answers(s):3
Explanation: The correct answer is Perceived loss of control For school age children, major fears are loss of control and separation from friends/peers.

Question 45. A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is

1. A transparent film dressing
2. Wet dressing with debridement granules
3. Wet to dry with hydrogen peroxide
4. Moist saline dressing

Looking for answers(s):4
Explanation: The correct answer is D: Moist saline dressing This wound is a stage III pressure ulcer. The wound is red (granulation tissue) and does not require debridement. The wound must be protected for granulation tissue to proliferate. A moist dressing allows epithelial tissues to migrate more rapidly.

Question 46. The nurse, assisting in applying a cast to a client with a broken arm, knows that

1. The cast material should be dipped several times into the warm water
2. The cast should be covered until it dries
3. The wet cast should be handled with the palms of hands
4. The casted extremity should be placed on a cloth-covered surface

Looking for answers(s):3
Explanation: The correct answer is The wet cast should be handled with the palms of hands Handle cast with palms of the hands and lift at 2 points of the extremity. This will prevent stress at the injury site and pressure areas on the cast.

Question 47. The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse’s best response about the purpose of the Denver?

1. It measures a child’s intelligence.
2. It assesses a child's development.
3. It evaluates psychological responses.
4. It helps to determine problems.

Looking for answers(s):2
Explanation: The correct answer is It assesses a child''s development. The Denver Developmental Test II is a screening test to assess children from birth through 6 years in personal/social, fine motor adaptive, language and gross motor development. A child experiences the fun of play during the test.

Question 48. A client admits to benzodiazepine dependence for several years. She is now in an outpatient detoxification program. The nurse must understand that a priority during withdrawal is

1. Avoid alcohol use during this time
2. Observe the client for hypotension
3. Abrupt discontinuation of the drug
4. Assess for mild physical symptoms

Looking for answers(s):1
Explanation: The correct answer is Avoid alcohol use during this time Central nervous system depressants interact with alcohol. The client will gradually reduce the dosage, under the health care provider''s direction. During this time, alcohol must be avoided

Question 49. The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions?

1. 14 minutes
2. 10 minutes
3. 15 minutes
4. 9 minutes

Looking for answers(s):3
Explanation: The correct answer is 15 minutes Frequency is the time from the beginning of one contraction to the beginning of the next contraction.

Question 50. A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond?

1. With acceptance and views the victim’s comment as an indication that their marriage is in trouble
2. With fear of rejection causing increased rage toward the victim
3. With a new commitment to seek counseling to assist with their marital problems
4. With relief, and welcomes the separation as a means to have some personal time

Looking for answers(s):2
Explanation: The correct answer is With fear of rejection causing increased rage toward the victim. The fear of rejection and loss only serve to increase the batterer’s rage at his partner.