Advanced Pediatric Assessment 3rd Edition By Ellen M. Chiocca – Test Bank

 

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Sample Questions

 

 

Advanced Pediatric Assessment Third Edition Test Bank

 

Chapter 1. Child Health Assessment: An Overview

 

MULTIPLE CHOICE

 

1.   A nurse is reviewing changes in healthcare delivery and funding for pediatric populations.

Which current trend in the pediatric setting should the nurse expect to find?

1.   Increased hospitalization of children

2.   Decreased number of uninsured children

3.   An increase in ambulatory care

4.   Decreased use of managed care

 

2.   A nurse is referring a low-income family with three children under the age of 5 years to a

program that assists with supplemental food supplies. Which program should the nurse refer this

family to?

1.   Medicaid

2.   Medicare

3.   Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program

4.   Women, Infants, and Children (WIC) program

 

3.   In most states, adolescents who are not emancipated minors must have parental permission

before:

1.   treatment for drug abuse.

2.   treatment for sexually transmitted diseases (STDs).

3.   obtaining birth control.

4.   surgery.

 

4.   A nurse is completing a clinical pathway for a child admitted to the hospital with pneumonia.

Which characteristic of a clinical pathway is correct?

1.   Developed and implemented by nurses

2.   Used primarily in the pediatric setting

3.   Specific time lines for sequencing interventions

4.   One of the steps in the nursing process

 

5.   When planning a parenting class, the nurse should explain that the leading cause of death in

children 1 to 4 years of age in the United States is:

1.   premature birth.

2.   congenital anomalies.

3.   accidental death.

4.   respiratory tract illness.

 

6.   Which statement is true regarding the quality assurance or incident report?

7.   The report assures the legal department that there is no problem.

8.   Reports are a permanent part of the clients chart.

9.   The nurses notes should contain the following: Incident report filed and copy

placed in chart.

1.   This report is a form of documentation of an event that may result in legal action.

 

7.   Which client situation fails to meet the first requirement of informed consent?

8.   The parent does not understand the physicians explanations.

9.   The physician gives the parent only a partial list of possible side effects and

complications.

1.   No parent is available and the physician asks the adolescent to sign the consent

form.

1.   The infants teenage mother signs a consent form because her parent tells her to.

 

8.   A nurse assigned to a child does not know how to perform a treatment that has been prescribed

for the child. What should the nurses first action be?

1.   Delay the treatment until another nurse can do it.

2.   Make the childs parents aware of the situation.

3.   Inform the nursing supervisor of the problem.

4.   Arrange to have the child transferred to another unit.

 

9.   A nurse is completing a care plan for a child and is finishing the assessment phase. Which

activity is not part of a nursing assessment?

1.   Writing nursing diagnoses

2.   Reviewing diagnostic reports

3.   Collecting data

4.   Setting priorities

 

10.                Which patient outcome is stated correctly?

11.                The child will administer his insulin injection before breakfast on 10/31.

12.                The child will accept the diagnosis of type 1 diabetes mellitus before discharge.

13.                The parents will understand how to determine the childs daily insulin dosage.

14.                The nurse will monitor blood glucose levels before meals and at bedtime.

 

1.   A nurse is reviewing the nursing care plan for a hospitalized child. Which statements are

collaborative problems? Select all that apply.

1.   Risk for injury

2.   Potential complication of seizure disorder

3.   Altered nutrition: Less than body requirements

4.   Fluid volume deficit

5.   Potential complication of respiratory acidosis

 

2.   Which nursing activities do not meet the standard of care? Select all that apply.

3.   Failure to notify a physician about a childs worsening condition

4.   Calling the supervisor about staffing concerns

5.   Delegating assessment of a new admit to the Unlicensed Assistive Personnel

(UAP)

1.   Asking the Unlicensed Assistive Personnel (UAP) to take vital signs

2.   Documenting that a physician was unavailable and the nursing supervisor was

notified

 

Chapter 2. Assessment of Child Development and Behavior

 

MULTIPLE CHOICE

1.   The nurse is performing an abdominal assessment on a child. When percussing over the

stomach, the nurse should hear which sound?

1.   Tympany

2.   Resonance

3.   Flatness

4.   Dullness

 

2.   A nurse is preparing to begin an assessment on a newly admitted child. The nurse should be

aware that the single most important component of a pediatric physical examination is:

1.   assessment of heart and lungs.

2.   measurement of height and weight.

3.   documentation of parental concerns.

4.   obtaining an accurate history.

 

3.   In which section of the health history should the nurse record that the parent brought the infant

to the clinic today because of frequent diarrhea?

1.   Review of systems

2.   Chief complaint

3.   Lifestyle and life patterns

4.   Health history

 

4.   A nurse is reviewing pediatric physical assessment techniques. Which statement about

performing a pediatric physical assessment is correct?

1.   Physical examinations proceed systematically from head to toe unless

developmental considerations dictate otherwise.

1.   The physical examination should be done with parents in the examining room for

children of any age.

1.   Measurement of head circumference is done until the child is 5 years old.

2.   The physical examination is done only when the child is cooperative.

 

5.   A nurse is conducting an assessment on a child during a well-child visit. Which of the

following includes the components of a complete pediatric history?

1.   Statistical information, client profile, health history, family history, review of

systems, and lifestyle and life patterns

1.   Vital signs, chief complaint, and a list of previous problems

2.   Chief complaint, including body location, quality, quantity, time frame, and

alleviating and aggravating factors

1.   Pertinent developmental and family information

 

6.   At what age can the nurse expect a childs head and chest circumference to be almost equal?

7.   Birth

8.   6 months

9.   1 year

10.                3 years

 

7.   A nurse is teaching unlicensed assistive personnel (UAP) how to take accurate blood pressure

on children. The nurse knows the UAPs have understood the teaching if they state that to obtain

an accurate measurement of a childs blood pressure, the cuff should cover which portion of the

childs upper arm?

1.   Two-thirds

2.   Three-fourths

3.   One-half

4.   One-third

 

8.   Which chart should the nurse use to assess the visual acuity of an 8-year-old child?

9.   Lea chart

10.                Snellen chart

11.                HOTV chart

12.                Tumbling E chart

 

9.   Which action is appropriate when the nurse is assessing breath sounds of an 18-month-old

crying child?

1.   Ask the parent to quiet the child so the nurse can listen.

2.   Auscultate breath sounds and chart that the child was crying.

3.   Encourage the child to play with the stethoscope to distract and to calm down the

child before auscultating.

1.   Document that data are not available because of noncompliance.

 

10.                Which is the most appropriate site for the nurse to use to measure a pulse rate on a 1-year-old

child?

1.   Apical

2.   Radial

3.   Carotid

4.   Femoral

 

11.                What is the most appropriate action for the nurse to take when a crying toddler has a blood

pressure measurement of 120/70 mm Hg?

1.   Notify the physician of the measurement.

2.   Document the blood pressure reading and check it again in 4 hours.

3.   Quiet the child and retake the blood pressure.

4.   Ask the parent if the child has a history of hypertension.

 

12.                What term should be used in the nurses documentation to describe auscultation of breath

sounds that are short, popping, and discontinuous on inspiration?

1.   Pleural friction rub

2.   Bronchovesicular sounds

3.   Crackles

4.   Wheeze

 

13.                Which strategy should be the best approach when initiating the physical examination of a 9-

month-old infant?

1.   Undress the infant and do a head-to-toe examination.

2.   Have the parent hold the child on his or her lap.

3.   Put the infant on the examination table and begin assessments at the head.

4.   Ask the parent to leave because the infant will be upset.

 

14.                Which strategy is not always appropriate for a pediatric physical examination?

15.                Take the history in a quiet, private place.

16.                Examine the child from head to toe.

17.                Exhibit sensitivity to cultural needs and differences.

18.                Perform frightening procedures last.

 

15.                Which assessment should the nurse perform last when examining a 5-year-old child?

16.                Heart

17.                Lungs

18.                Abdomen

19.                Throat

 

16.                When would be the most appropriate time to inspect the genital area during a well-child

examination of a 14-year-old female?

1.   It is not necessary to inspect the genital area.

2.   Examine the genital area first.

3.   After the abdominal assessment.

4.   Do the genital inspection last.

 

17.                Which measurement is not indicated for a 4-year-old well-child examination?

18.                Blood pressure

19.                Weight

20.                Height

21.                Head circumference

 

18.                The nurse inspecting the skin of a dark-skinned child notices an area that is a dusky red or

violet color. This skin coloration is associated with which?

1.   Cyanosis

2.   Erythema

3.   Vitiligo

4.   Nevi

 

19.                The nurse palpated the anterior fontanel of a 14-month-old infant and found that it was

closed. What would this finding indicate?

1.   This is a normal finding.

2.   This finding indicates premature closure of cranial sutures.

3.   This is an abnormal finding and the child should have a developmental

evaluation.

1.   This is an abnormal finding and the child should have a neurological evaluation.

 

20.                A nurse is conducting vision screening on preschool children. Which of the following

corresponds with the normal range for visual acuity of a 4-year-old child?

1.   20/50 to 20/80

2.   20/40 to 20/70

3.   20/30 to 20/40

4.   20/20 to 20/30

 

21.                A child begins to squirm and giggle when the nurse begins to palpate the abdomen. What is

the best approach for the nurse to use with a child who is ticklish?

1.   Skip the abdominal palpation.

2.   Touch the abdomen firmly as the child takes short, quick breaths.

3.   Press the abdomen with the child bearing down and holding the breath.

4.   Palpate with the childs hand under the examiners hand.

 

22.                Which cranial nerve is assessed when the child is asked to imitate the examiners wrinkled

frown, wrinkled forehead, smile, and raised eyebrow?

1.   Accessory

2.   Hypoglossal

3.   Trigeminal

4.   Facial

 

23.                Which assessment finding is considered a neurological soft sign in a 7-year-old child?

24.                Plantar reflex

25.                Poor muscle coordination

26.                Stereognostic function

27.                Graphesthesia

 

MULTIPLE RESPONSE

 

1.   A nurse is performing an assessment on a newborn. Which vital signs indicate a normal

finding for this age group? Select all that apply.

1.   Pulse of 80 to 125 a minute

2.   B/P of systolic 65 to 95 and diastolic 30 to 60

3.   Temperature of 36.5 to 37.3 Celsius (axillary)

4.   Temperature of 36.4 to 37 Celsius (axillary)

5.   Respirations of 30 to 60 a minute

 

2.   A school nurse is screening children for scoliosis. Which assessment findings should the nurse

expect to observe for scoliosis? Select all that apply.

1.   Pain with deep palpation of the spinal column

2.   Unequal shoulder heights

3.   The trouser pant leg length appears shorter on one side

4.   Inability to bend at the waist

5.   Unequal waist angles

 

Chapter 3. Communicating with Children and Families

 

MULTIPLE CHOICE

1.   Which information should the nurse include when preparing a 5-year-old child for a cardiac

catheterization?

1.   A detailed explanation of the procedure

2.   A description of what the child will feel and see during the procedure

3.   An explanation about the dye that will go directly into his vein

4.   An assurance to the child that he and the nurse can talk about the procedure when

it is over

2.   Who are the experts in planning for the care of a 9-year-old child with a profound sensory

impairment who is hospitalized for surgery?

1.   The childs parents

2.   The childs teacher

3.   The case manager

4.   The primary nurse

5.   Which is an effective technique for communicating with toddlers?

6.   Have the toddler make up a story from a picture.

7.   Involve the toddler in dramatic play with dress-up clothing.

8.   Repeatedly read familiar stories to the child.

9.   Ask the toddler to draw pictures of his fears.

10.                What is the most important consideration for effectively communicating with a child?

11.                The childs chronological age

12.                The parentchild interaction

13.                The childs receptiveness

14.                The childs developmental level

15.                Which behavior is most likely to encourage open communication?

16.                Avoiding eye contact

17.                Folding arms across the chest

18.                Standing with head bowed

19.                Soft stance with arms loose at the side

20.                Which strategy is most likely to encourage a child to express feelings about the hospital

experience?

1.   Asking close-ended questions

2.   Asking direct questions

3.   Sharing personal experiences

4.   Actively listening

5.   Which is the most appropriate question to ask to encourage conversation when interviewing an

adolescent?

1.   Are you in school?

2.   Are you doing well in school?

3.   How is school going for you?

4.   How do your parents feel about your grades?

5.   What is the most appropriate response for the nurse to make to the parent of a 3-year-old child

found in a bed with the side rails down?

1.   You must never leave the child in the room alone with the side rails down.

2.   I am very concerned about your childs safety when you leave the side rails down.

The hospital has guidelines stating that side rails need to be up if the child is in

the bed.

1.   It is hospital policy that side rails need to be up if the child is in bed.

2.   When parents leave side rails down, they might be considered as uncaring.

3.   Which is an appropriate preoperative teaching plan for a school-age child?

4.   Begin preoperative teaching the morning of surgery.

5.   Schedule a tour of the hospital a few weeks before surgery.

6.   Show the child books and pictures 4 days before surgery.

7.   Limit teaching to 5 minutes and use simple terminology.

8.   A primary nurse bought a hospitalized child a new toy to replace a broken one. What is the

best interpretation of the nurses behavior?

1.   The nurse is displaying signs of overinvolvement.

2.   The nurse is a kind and generous person.

3.   The nurse feels a special closeness to the child.

4.   The nurse wants to make the child happy.

5.   When meeting a toddler for the first time, the nurse initiates contact by:

6.   calling the toddler by name and picking the toddler up.

7.   asking the toddler for her first name.

8.   kneeling in front of the toddler and speaking softly to the child.

9.   telling the toddler that you are her nurse.

 

MULTIPLE RESPONSE

 

1.   A nurse is admitting a school-age child with a visual impairment to the hospital. To effectively

communicate the nurse should plan which interventions? Select all that apply.

1.   Orient the child to his or her surroundings.

2.   Enter quietly and touch the child before speaking.

3.   Put the nurse call bell close to the parent.

4.   Allow the child to handle equipment.

5.   Explain sounds the child may hear frequently.

6.   A preschool age child is being admitted for some diagnostic tests and possible surgery. The

nurse planning care should use which statements when explaining procedures to the child? Select

all that apply.

1.   Fluids will be given through tubing connected to a small tiny tube inserted into

your arm.

1.   After surgery, we will be doing dressing changes.

2.   You will get a shot before surgery.

3.   The doctor will give you medicine that will help you go into a deep sleep.

4.   We will take you to surgery on a bed on wheels.

 

Chapter 4. Assessment of the Family

 

MULTIPLE CHOICE

1.   A nurse is teaching parents how to apply time-out as a disciplinary method for their 4 year old.

Parents have understood the teaching if they state which formula correctly guides the use of

time-out?

1.   Use the guideline of 1 minute per each year of the childs age.

2.   Relate the length of the time-out to the severity of the behavior.

3.   Never use time-out for a child younger than age 4 years.

4.   Follow the time-out with a treat.

5.   What is the nurses best approach when an 8-year-old boy frequently causes a disruption in the

playroom by taking toys from other children?

1.   Exclude the child from the playroom.

2.   Explain to the children in the playroom that he is very ill and should be allowed

to have the toys.

1.   Approach the child in his room and ask, Would you like it if the other children

took your toys from you?

1.   Approach the child in his room and state, I am concerned that you are taking the

other childrens toys. It upsets them and me.

3.   Families that deal most effectively with stress have which behavior patterns?

4.   Focus on family problems.

5.   Feel weakened by stress.

6.   Expect that some stress is normal.

7.   Feel guilty when stress exists.

8.   Which family will most likely have the greatest difficulty in coping with an ill child?

9.   A single-parent mother who has the support of her parents and siblings

10.                Parents who have just moved to the area and are living in an apartment while they

look for a house

1.   The family of a child who has had multiple hospitalizations related to asthma and

has adequate relationships with the nursing staff

1.   A family in which there is a young child and four older married children who live

in the area

5.   Which is the priority nursing intervention for the family of a child who has been admitted to

the hospital?

1.   Begin discharge teaching.

2.   Identify and mobilize internal and external strengths.

3.   Identify ways in which the family could have prevented their childs

hospitalization.

1.   Instruct the parents on normal growth and development.

2.   A nurse is planning culturally competent care for a child of Hispanic descent. Which

characteristic found in a Hispanic family should the nurse include in the plan of care?

1.   Stoicism

2.   Close extended family

3.   Docile children are considered weak

4.   Very interested in health-promoting lifestyles

5.   While reviewing nursing documentation on dietary intake for a 7-year-old child of Asian

descent, the nurse notes that he consistently refuses to eat the food on his tray. Which assumption

is most likely accurate?

1.   He is a picky eater.

2.   He needs less food because he is on bed rest.

3.   He may have culturally related food preferences.

4.   He is probably eating between meals and spoiling his appetite.

5.   To resolve family conflict, it is necessary to have open communication, accurate perception of

the problem, and a(n):

1.   intact family structure.

2.   arbitrator.

3.   willingness to consider the view of others.

4.   balance in personality types.

5.   A nurse is planning a parenting class for expectant parents. Which statement is true about the

characteristics of a healthy family?

1.   The parents and children have rigid assignments for all the family tasks.

2.   Young families assume total responsibility for the parenting tasks, refusing any

assistance.

1.   The family is overwhelmed by the significant changes that occur as a result of

childbirth.

1.   Adults agree on the majority of basic parenting principles.

2.   A nurse determines that a child consistently displays predictable behavior and is regular in

performing daily habits. Which temperament is the child displaying?

1.   Easy

2.   Slow-to-warm-up

3.   Difficult

4.   Shy

 

11.                The parent of a child who has had numerous hospitalizations asks the nurse for advice

because her child has been having behavior problems at home and in school. In discussing

effective discipline, which is an essential component?

1.   All children display some degree of acting out and this behavior is normal.

2.   The child is manipulative and should have firmer limits set on her behavior.

3.   Use positive reinforcement and encouragement to promote cooperation and the

desired behaviors.

1.   Underlying reasons for rules should be given and the child should be allowed to

decide on which rules should be followed.

12.                A nurse assesses that parents discuss rules with their children when the children do not agree

with the rules. Which style of parenting is being displayed?

1.   Authoritarian

2.   Authoritative

3.   Permissive

4.   Disciplinarian

5.   Which should the nurse expect to be problematic for a family whose religious affiliation is

Jehovahs Witness?

1.   Immunizations

2.   Autopsy

3.   Organ donation

4.   Blood transfusion

 

MULTIPLE RESPONSE

 

1.   The nurse is caring for a child from a Middle Eastern family. Which interventions should the

nurse include in planning care? Select all that apply.

1.   Include the father in the decision making.

2.   Ask for a dietary consult to maintain religious dietary practices.

3.   Plan for a male nurse to care for a female patient.

4.   Ask the housekeeping staff to interpret if needed.

5.   A nurse is caring for a child with the religion of Christian Science. What interventions should

the nurse include in the care plan for this child? Select all that apply.

1.   Offer iced tea to the child who is experiencing fluid volume deficit.

2.   Inform the Christian Science practitioner that the child has been admitted to the

hospital.

1.   Allow parents to sign a form opting out of routine immunizations.

2.   Ask parents if the child has been baptized and if parents want a pastor to visit.

 

Chapter 5. Cultural Assessment of Children and Families

 

Multiple Choice

 

1.   Elsa is working with an 11-year-old patient in the outpatient pediatric clinic. As Elsa reviews

the chart, she reads that the patient follows the Muslim tradition. When Elsa enters the room, she

notes that the child is wearing a hijab on her head. Elsa has never worked with this tradition

before. Elsa should:

1.   Realize that her verbal and non-verbal communication will impact the care she gives the child.

2.   Not ask the parent for input on the care of the child because this would disrespect the family

and child.

3.   Have another nurse, who has experience with this culture, take care of the patient.

4.   Realize that the patient is uncomfortable and seek a fellow nurse to help her.

 

2.The lack of communication with the parent and child is not therapeutic

for the child.

3.Another nurse may be beneficial, but since Elsa has already started

caring for the child, this may create problems.

4.There is no indication of the patient feeling uncomfortable.

2.   A pediatric nursing class has been assigned to use the Giger and Davidhizar Transcultural

Assessment Model. The students are assigned to families they do not have a prior relationship

with. When performing the assessment, one of the students is given a seat in close proximity to a

grandmother on the couch. The student should know that according to this model:

1.   Visiting a family is considered a privilege.

2.   It is important to identify the family lifestyle.

3.   Sitting close to the grandmother can affect the communication.

4.   Only the interpersonal relationships of the individuals are emphasized.

 

3.   A staff educational day has been planned for the pediatric unit of a major hospital. The goal is

to make the staff culturally competent. This is important because:

1.   This competency meets JCAHO requirements.

2.   This competency meets cultural care requirements for the hospital system.

3.   This allows nurses to tailor their care to the patient and provide holistic care.

4.   This education is needed to reach Magnet status.

5.   Hussains parents have a language barrier with the nursing staff on the pediatric floor. When

working with communication barriers, it is important to:

1.   Use pictures when an interpreter is not available.

2.   Use hand gestures to attempt to communicate.

3.   Ask the interpreter to speak to the family over the phone.

4.   Require the family to provide a family member to interpret.

5.   Social skills between different cultures are important for a pediatric nurse to understand. All of

the following are part of social skills except:

1.   Personal space.

2.   Eye contact.

3.   Diet.

4.   Exercise.

5.   The community pediatric nurse is conducting a home visit with a new family. The nurse

knows when she is in the home, it will be important to get a thorough assessment. The

assessment should consist of:

1.   The number of family members living in the home.

2.   The employment of the adults in the home.

3.   How personal space is perceived.

4.   All of the above should be considered in the assessment.

5.   Culturally competent care includes:

6.   1. Treating others exactly how you would like to be treated.

7.   2. Seeing individuals as unique.

8.   3. Treating individuals within the same cultural group the same.

9.   4. Providing care without concern of your own values.

10.                A nurse is caring for a 12-year-old patient who has recently been hospitalized. Which

statement by the patient proves that the nurse did not perform a complete cultural assessment?

1.   Im glad that my prayer times work around my care.

2.   I feel better when my mom stays with me.

3.   Im not allowed to eat pork, and it is on my lunch tray.

4.   My mom does not like it when my room is messy.

5.   Pediatric visitations should:

6.   1. Be 24 hours a day for parents and grandparents.

7.   2. Be semi-structured for other visitors.

8.   3. Provide time for socialization and playing.

9.   4. All of the above.

.

10.                A nurse promotes family-centered care when:

11.                1. Caregivers can room in and provide care to their child.

12.                2. The nurse provides the care as the physician orders.

13.                3. Care is provided after the family steps out of the room.

14.                4. Visitation guidelines are strictly followed.

15.                When utilizing an interpreter, which item does not need to be documented?

16.                1. Name of the individual interpreting

17.                2. Primary language of the patient and caregiver

18.                3. Pictures used to communicate an idea

19.                4. Understanding of the patient and the care provider

20.                A nursing student understands pediatric cultural and dietary needs when she tells the parent

of her patient:

1.   1. You can bring in food from home.

2.   2. The hospital food should be adequate.

3.   3. I dont know how the food is prepared.

4.   4. Food from home will only make your child miss home.

.

13.                Staff education should include:

14.                1. Education on cultures common to their practice.

15.                2. Annual updates and reviews.

16.                3. Self-reflection on the care providers own values and beliefs.

17.                4. All of the above.

18.                Spiritual assessments should be performed:

19.                1. During every contact with health-care providers.

20.                2. During hospitalizations.

21.                3. Annually.

22.                4. As needed.

23.                Effective communication can be confirmed when:

24.                1. The patient or caregiver asks questions.

25.                2. When the patient and caregiver do not verbalize questions.

26.                3. The receiver of the messages understands the information as the provider intended the

message to be received.

4.   4. The receiver of the message speaks the same language as the person giving the

message.

16.                When performing an initial assessment, the FICA Spiritual Assessment tool will:

17.                1. Help the care provider to include spiritual needs in the care plan.

18.                2. Will complete the questionnaire in the chart.

19.                3. Be answered by the parent or care provider.

20.                4. Only be answered by the patient.

21.                An example of a nurse-patient relationship would be:

22.                1. Attending a birthday party outside of the hospital.

23.                2. Providing special toys for favorite patients.

24.                3. Reporting suspected child abuse.

25.                4. Keeping a secret about suspected child abuse to keep confidentiality with the patient.

26.                The medical clinics staff ensures quality multidisciplinary care by:

27.                1. Following hospital policies.

28.                2. Documenting and sharing all information.

29.                3. Not questioning other disciplines.

30.                4. Utilizing the correct form when obtaining data.

31.                Which finding most likely demonstrates lack of full disclosure?

32.                1. Health questionnaire completed in the waiting room

33.                2. Inability to explain how long symptoms have occurred

34.                3. Poor eye contact during exam

35.                4. Providing family history

36.                A parent with a low-income job can get more groceries with less money when:

37.                1. Purchasing processed food.

38.                2. Purchasing fresh fruits and vegetables.

39.                3. Purchasing meat products.

40.                4. Purchasing snack foods.

41.                The nurse tells the caregivers of a 5-year-old patient that the patient will be discharged at

lunch time. At 12:00 noon, the family is not present, but does come in at 2:00 dmm. The

caregivers are wondering why the nurse thinks that they are late. This could be attributed to:

1.   1. Lack of discharge paper processing.

2.   2. Cultural differences in lunch time.

3.   3. The caregivers believing that the child is being watched adequately.

4.   4. The nurse being busy and losing track of time.

5.   The female caregiver of a patient wears a scarf that covers her head and face when males

enter the room. The nurse noted that male nurses were entering the room without notice to the

caregiver. The nurses best action would be to:

1.   1. No intervention is needed by the nurse.

2.   2. Place a sign on the door stating that all males must first knock and ask permission prior

to entering the room.

3.   3. Only allow female caregivers.

4.   4. Only allow male caregivers.

5.   Due to genetics, African American patients are at higher risk for:

6.   1. Liver cancer.

7.   2. Injury.

8.   3. Infectious diseases.

9.   4. Diabetes.

10.                European Americans may wear a horn charm to ward off evil spirits. They believe that

diseases may be caused from a curse called:

1.   1. The evil spirit of the ancestors.

2.   2. The disease.

3.   3. The evil spell.

4.   4. The maloic.

5.   Asian Americans may use this to cure diseases.

6.   1. Balance of hot and cold fluids

7.   2. Increased vegetable intake

8.   3. Increase in exercise to sweat out impurities

9.   4. Well-balanced diet

10.                Spirituality can be defined as:

11.                1. Defining God.

12.                2. Feeling a greater being has control over world events.

13.                3. The concept of where and how the human race began.

14.                4. All of the above.

.

27.                This religious affiliation may not accept blood products, so frequent blood draws and

procedures that may involve blood loss should be limited.

1.   1. Atheism

2.   2. Buddhism

3.   3. Jehovahs Witness

4.   4. Judaism

5.   These two religious affiliations do not eat pork products.

6.   1. Muslim and Mormonism

7.   2. New Age and Atheism

8.   3. Judaism and Muslim

9.   4. Judaism and Buddhism

10.                This religious group may need assistance with ablution, which is a process of washing prior

to praying.

1.   1. Buddhist

2.   2. Christian

3.   3. Muslim

4.   4. Mormon

5.   Christians believe:

6.   1. Salvation comes from the belief that Jesus Christ died on the cross for all sins and

transgressions.

2.   2. The day of rest is called Sabbath and occurs from sundown Friday to sundown on

Saturday.

3.   3. Praying to ancestors will promote good karma.

4.   4. Life is comprised of suffering.

5.   Family is best defined by:

6.   1. The patient.

7.   2. The family bloodline.

8.   3. The nurse.

9.   4. The care provider.

10.                Inadequate sidewalks in a community represent:

11.                1. A poor community.

12.                2. A community with few children.

13.                3. A community danger.

14.                4. An industrial community.

15.                A childs home environment will influence culture by:

16.                1. Promoting shelter from the elements of the weather.

17.                2. The child observing how to behave and respond to the environment.

18.                3. Providing a safe place to live.

19.                4. Providing a place to play and pretend.

20.                A family from a different ethnic group comes into a clinic. A nurse thinks that they are not

interacting well with her because they are not making direct eye contact. The nurse that thinks

the family is not interacting well is demonstrating:

1.   1. Cultural competency.

2.   2. Cultural bias.

3.   3. Cultural diversity.

4.   4. Transcultural nursing.

5.   A nurse is caring for a child considered to be in spiritual distress. Spiritual distress can be

described by the child as:

1.   1. I feel better after I pray.

2.   2. I will trust in my God.

3.   3. I dont agree with Gods decisions.

4.   4. I feel like God is punishing me.

5.   A fellow nursing student feels offended because the mother of her patient is invading her

personal space. Your peer states that the mom is a close talker and is right in my face. You

inform her that:

1.   1. The mom is wrong in invading her space.

2.   2. This might be a spacial norm for this moms culture.

3.   3. She should just ignore it until clinical is over.

4.   4. She should tell the mom not to stand so close when talking.

5.   The mother of a critically ill baby just found out that her child is likely to die. She asks you

to quickly contact a priest. The mom would like a prayer and baptism performed because the

baby has yet to be baptized. Your best response would be:

1.   1. Our chaplain usually comes in during the afternoon.

2.   2. I will have the secretary call for a priest.

3.   3. I will call for one as soon as I catch up with your childs charting.

4.   4. Feel free to call your spiritual leader.

5.   The father of your patient wants the patient to ingest an herbal tea to help the child feel

better. The nurse should:

1.   1. Allow the dad to give the patient the herbal tea.

2.   2. Evaluate if the herb will interact with any of the current medications or procedures that

will be done.

3.   3. Ask the doctor.

4.   4. Not allow the child to ingest the herbal tea.

5.   Transcultural nursing entails which of the following?

6.   1. Communication, space, beliefs, and time

7.   2. Communication, number of siblings, and skin color

8.   3. Space, number of siblings, and bedrooms

 

4.   4. Space, environment, and dialect

5.   Leiningers Cultural Care Theory includes the elements of:

6.   1. Values, beliefs, health, siblings, and culture.

7.   2. Values, beliefs, food, and culture.

8.   3. Values, beliefs, religion, lifestyles, and perceptions of health.

9.   4. Values, beliefs, and clothing.

10.                The care provider can individualize spiritual and cultural care by:

11.                1. Asking if there is a religious preference.

12.                2. Assessing the country of origin.

13.                3. Assessing needs that are verbalized by the patient.

14.                4. Assessing spiritual and cultural aspects of care and including the patient and caregivers

in care planning.

42.                A home health nurse is obtaining a cultural assessment on a family of five. The nurse should

include which of the following in her assessment?

1.   Food preferences

2.   Religious beliefs

3.   Perceptions of the cause for disease

4.   All of the above are correct

5.   Spirituality plays a role in the care of a patient. A nurse should be aware that spirituality

consists of:

1.   Individualized definitions of God.

2.   Individualized concepts of how the human race began.

3.   Individualized concepts of what others should believe.

4.   Individualized concepts of a greater being who affects daily life.

5.   Individualized concepts of eternity.

 

Chapter 6. Obtaining the Pediatric Health History

 

MULTIPLE CHOICE

1.   The nurse is preparing to conduct a health history. Which of these statements best describes

the purpose of a health history?

1.   To provide an opportunity for interaction between the patient and the nurse

2.   To provide a form for obtaining the patients biographic information

3.   To document the normal and abnormal findings of a physical assessment

4.   To provide a database of subjective information about the patients past and

current health

2.   When the nurse is evaluating the reliability of a patients responses, which of these statements

would be correct? The patient:

1.   Has a history of drug abuse and therefore is not reliable.

 

1.   Provided consistent information and therefore is reliable.

2.   Smiled throughout interview and therefore is assumed reliable.

3.   Would not answer questions concerning stress and therefore is not reliable.

4.   A 18-year-old patient tells the nurse that he has ulcerative colitis. He has been having black

stools for the last 24 hours. How would the nurse best document his reason for seeking care?

1.   J.M. is a 18-year-old man seeking treatment for ulcerative colitis.

2.   J.M. came into the clinic complaining of having black stools for the past 24

hours.

1.   J.M. is a 18-year-old man who states that he has ulcerative colitis and wants it

checked.

1.   J.M. is a 18-year-old man who states that he has been having black stools for the

past 24 hours.

4.   A patient tells the nurse that she has had abdominal pain for the past week. What would be the

nurses best response?

1.   Can you point to where it hurts?

2.   Well talk more about that later in the interview.

3.   What have you had to eat in the last 24 hours?

4.   Have you ever had any surgeries on your abdomen?

5.   A 17-year-old woman tells the nurse that she has excruciating pain in her back. Which would

be the nurses appropriate response to the womans statement?

1.   How does your family react to your pain?

2.   The pain must be terrible. You probably pinched a nerve.

3.   Ive had back pain myself, and it can be excruciating.

4.   How would you say the pain affects your ability to do your daily activities?

5.   In recording the childhood illnesses of a patient who denies having had any, which note by the

nurse would be most accurate?

1.   Patient denies usual childhood illnesses.

2.   Patient states he was a very healthy child.

3.   Patient states his sister had measles, but he didnt.

4.   Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.

5.   A female patient tells the nurse that she has had six pregnancies, with four live births at term

and two spontaneous abortions. Her four children are still living. How would the nurse record

this information?

1.   P-6, B-4, (S)Ab-2

2.   Grav 6, Term 4, (S)Ab-2, Living 4

3.   Patient has had four living babies.

4.   Patient has been pregnant six times.

5.   A patient tells the nurse that he is allergic to penicillin. What would be the nurses best

response to this information?

1.   Are you allergic to any other drugs?

2.   How often have you received penicillin?

3.   Ill write your allergy on your chart so you wont receive any penicillin.

4.   Describe what happens to you when you take penicillin.

5.   The nurse is taking a family history. Important diseases or problems about which the patient

should be specifically asked include:

1.   Emphysema.

2.   Head trauma.

3.   Mental illness.

4.   Fractured bones.

5.   The review of systems provides the nurse with:

6.   Physical findings related to each system.

7.   Information regarding health promotion practices.

8.   An opportunity to teach the patient medical terms.

9.   Information necessary for the nurse to diagnose the patients medical problem.

10.                Which of these statements represents subjective data the nurse obtained from the patient

regarding the patients skin?

1.   Skin appears dry.

2.   No lesions are obvious.

3.   Patient denies any color change.

4.   Lesion is noted on the lateral aspect of the right arm.

5.   The nurse is obtaining a history from a 18-year-old male patient and is concerned about

health promotion activities. Which of these questions would be appropriate to use to assess

health promotion activities for this patient?

1.   Do you perform testicular self-examinations?

2.   Have you ever noticed any pain in your testicles?

3.   Have you had any problems with passing urine?

4.   Do you have any history of sexually transmitted diseases?

5.   Which of these responses might the nurse expect during a functional assessment of a patient

whose leg is in a cast?

1.   I broke my right leg in a car accident 2 weeks ago.

2.   The pain is decreasing, but I still need to take acetaminophen.

3.   I check the color of my toes every evening just like I was taught.

4.   Im able to transfer myself from the wheelchair to the bed without help.

5.   In response to a question about stress, a 18-year-old woman tells the nurse that her husband

and mother both died in the past year. Which response by the nurse is most appropriate?

1.   This has been a difficult year for you.

2.   I dont know how anyone could handle that much stress in 1 year!

3.   What did you do to cope with the loss of both your husband and mother?

4.   That is a lot of stress; now lets go on to the next section of your history.

5.   In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse

needs to know. What is the reason for needing this information?

1.   This information is necessary to determine the patients reliability.

2.   Alcohol can interact with all medications and can make some diseases worse.

3.   The nurse needs to be able to teach the patient about the dangers of alcohol use.

4.   This information is not necessary unless a drinking problem is obvious.

5.   The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What

would be an appropriate response?

1.   Maybe she is just teething.

2.   I will check her ear for an ear infection.

3.   Are you sure she is really having pain?

4.   Describe what she is doing to indicate she is having pain.

5.   During an assessment of a patients family history, the nurse constructs a genogram. Which

statement best describes a genogram?

1.   List of diseases present in a persons near relatives

2.   Graphic family tree that uses symbols to depict the gender, relationship, and age

of immediate family members

1.   Drawing that depicts the patients family members up to five generations back

2.   Description of the health of a persons children and grandchildren

3.   A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which

information should the nurse collect before this procedure?

1.   Childs birth weight

2.   Age at which he crawled

3.   Whether the child has had the measles

4.   Childs reactions to previous hospitalizations

5.   As part of the health history of a 6-year-old boy at a clinic for a sports physical examination,

the nurse reviews his immunization record and notes that his last measles-mumps-rubella

(MMR) vaccination was at 15 months of age. What recommendation should the nurse make?

1.   No further MMR immunizations are needed.

2.   MMR vaccination needs to be repeated at 4 to 6 years of age.

3.   MMR immunization needs to be repeated every 4 years until age 21 years.

4.   A recommendation cannot be made until the physician is consulted.

5.   In obtaining a review of systems on a healthy 7-year-old girl, the health care provider knows

that it would be important to include the:

1.   Last glaucoma examination.

2.   Frequency of breast self-examinations.

3.   Date of her last electrocardiogram.

4.   Limitations related to her involvement in sports activities.

5.   When the nurse asks for a description of who lives with a child, the method of discipline, and

the support system of the child, what part of the assessment is being performed?

1.   Family history

2.   Review of systems

3.   Functional assessment

4.   Reason for seeking care

5.   The nurse is obtaining a health history on an 17-year-old woman. Which of the following

areas of questioning would be most useful at this time?

1.   Obstetric history

2.   Childhood illnesses

3.   General health for the past 20 years

4.   Current health promotion activities

5.   The nurse is performing a review of systems on a 16-year-old patient. Which of these

statements is correct for this situation?

1.   The questions asked are identical for all ages.

2.   The interviewer will start incorporating different questions for patients 16 years

of age and older.

1.   Questions that are reflective of the normal effects of aging are added.

2.   At this age, a review of systems is not necessarythe focus should be on current

problems.

24.                A 18-year-old patient tells the nurse that he cannot remember the names of the medications

he is taking or for what reason he is taking them. An appropriate response from the nurse would

be:

1.   Can you tell me what they look like?

2.   Dont worry about it. You are only taking two medications.

3.   How long have you been taking each of the pills?

4.   Would you have a family member bring in your medications?

5.   The nurse is performing a functional assessment on an 17-year-old patient who recently had a

stroke. Which of these questions would be most important to ask?

1.   Do you wear glasses?

2.   Are you able to dress yourself?

3.   Do you have any thyroid problems?

4.   How many times a day do you have a bowel movement?

5.   The nurse is preparing to do a functional assessment. Which statement best describes the

purpose of a functional assessment?

1.   The functional assessment assesses how the individual is coping with life at

home.

1.   It determines how children are meeting developmental milestones.

2.   The functional assessment can identify any problems with memory the individual

may be experiencing.

1.   It helps determine how a person is managing day-to-day activities.

2.   The nurse is asking a patient for his reason for seeking care and asks about the signs and

symptoms he is experiencing. Which of these is an example of a symptom?

1.   Chest pain

2.   Clammy skin

3.   Serum potassium level at 4.2 mEq/L

4.   Body temperature of 100 F

5.   A patient is describing his symptoms to the nurse. Which of these statements reflects a

description of the setting of his symptoms?

1.   It is a sharp, burning pain in my stomach.

2.   I also have the sweats and nausea when I feel this pain.

3.   I think this pain is telling me that something bad is wrong with me.

4.   This pain happens every time I sit down to use the computer.

5.   During an assessment, the nurse uses the CAGE test. The patient answers yes to two of the

questions. What could this be indicating?

1.   The patient is an alcoholic.

2.   The patient is annoyed at the questions.

3.   The patient should be thoroughly examined for possible alcohol withdrawal

symptoms.

1.   The nurse should suspect alcohol abuse and continue with a more thorough

substance abuse assessment.

30.                The nurse is incorporating a persons spiritual values into the health history. Which of these

questions illustrates the community portion of the FICA (faith and belief, importance and

influence, community, and addressing or applying in care) questions?

1.   Do you believe in God?

2.   Are you a part of any religious or spiritual congregation?

3.   Do you consider yourself to be a religious or spiritual person?

4.   How does your religious faith influence the way you think about your health?

5.   The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents

have brought her to the clinic. Which instruction would be appropriate for the parents before the

interview begins?

1.   Please stay during the interview; you can answer for her if she does not know the

answer.

1.   It would help to interview the three of you together.

2.   While I interview your daughter, will you please stay in the room and complete

these family health history questionnaires?

1.   While I interview your daughter, will you step out to the waiting room and

complete these family health history questionnaires?

32.                The nurse is assessing a new patient who has recently immigrated to the United States.

Which question is appropriate to add to the health history?

1.   Why did you come to the United States?

2.   When did you come to the United States and from what country?

3.   What made you leave your native country?

4.   Are you planning to return to your home?

 

MULTIPLE RESPONSE

 

1.   The nurse is assessing a patients headache pain. Which questions reflect one or more of the

critical characteristics of symptoms that should be assessed? Select all that apply.

1.   Where is the headache pain?

2.   Did you have these headaches as a child?

3.   On a scale of 1 to 10, how bad is the pain?

4.   How often do the headaches occur?

5.   What makes the headaches feel better?

6.   Do you have any family history of headaches?

7.   The nurse is conducting a developmental history on a 5-year-old child. Which questions are

appropriate to ask the parents for this part of the assessment? Select all that apply.

1.   How much junk food does your child eat?

2.   How many teeth has he lost, and when did he lose them?

3.   Is he able to tie his shoelaces?

4.   Does he take a childrens vitamin?

5.   Can he tell time?

6.   Does he have any food allergies?

 

Chapter 7. Assessing Safety and Injury Risk in Children

 

MULTIPLE CHOICE

1.   The pediatric nurse clarifies the history of a child who is brought to the emergency room with

abdominal pain. The nurse uses the mnemonic OLD CAT to ask the appropriate questions,

including which of the following?

1.   Activity

2.   Diet

3.   Output

4.   Timing

5.   The pediatric nurse takes a comprehensive health history of a 10-year-old patient and asks the

parents about their use of herbal products or home remedies. What information does the nurse

know regarding herbal products?

1.   Aloe vera can affect clotting time by decreasing platelets.

2.   Bilberry can cause hypersensitivity in patients with allergies to plants.

3.   Echinacea is contraindicated for patients with autoimmune disorders.

4.   Fennel is contraindicated in patients with diabetes, hypertension, or liver disease.

5.   The pediatric nurse performs a health assessment on a 9-year-old girl who weighs 23 kg and is

132 cm tall. How does the nurse document the patients BMI?

13.                13.20

14.                13.82

15.                14.25

16.                14.68

17.                On physical assessment of the skin of a patient, the nurse documents cyanosis. What other

related assessment should the nurse perform?

1.   Ask the parent about yellow and orange vegetable intake.

2.   Draw blood for hemoglobin, hematocrit, and liver function studies.

3.   Palpate all the childs lymph nodes, assessing for enlargement.

4.   Take the childs vital signs, including blood pressure and pulse.

5.   A nursing manager is concerned about frequent errors on the pediatric unit and wants to

decrease them. What action by the manager is best?

1.   Have two nurses verify all new orders when they are written.

2.   Institute a standardized handoff format at shift change.

3.   Provide remedial education to nurses who make errors.

4.   Require charge nurses to verify care plans with staff nurses.

5.   The pediatric nurse assessing a patient for breath sounds documents a loud, high-pitched

sound heard only over the trachea. The nurse should document this finding as which of the

following?

1.   Adventitious breath sound

2.   Bronchial breath sound

3.   Bronchovesicular breath sound

4.   Vesicular breath sound

5.   The pediatric nurse is assessing a 5-year-old for developmental milestones. Which assessment

tool should the nurse use?

1.   CHEOPS scale

2.   Denver II screening tool

3.   FLACC scale

4.   OLD CAT questions

5.   A nurse is explaining to a nursing student that a patient experienced a sentinel event during a

previous hospitalization. What does the student understand about this event?

1.   Experienced an unusual event that is rare in the literature

2.   Had an unexpected response to treatment or nursing care

3.   Meeting a major milestone in treatment for an illness

4.   Unexpected event resulting in serious injury (or death)

5.   The pediatric nurse working in a hospital setting uses both standard precautions and

transmission-based precautions for patients. Which patient requires only standard precautions?

1.   Infectious diarrhea

2.   Staphylococcal infection

3.   Tonsillitis

4.   Tuberculosis

5.   A pediatric nurse needs to administer acetaminophen (Childrens Tylenol) to patients in the

intensive care unit (ICU). Which dose, based on age, is correct?

1.   0 to 3 months, 40 mg

2.   4 to 11 months, 220 mg

3.   2 to 3 years, 120 mg

4.   4 to 5 years, 100 mg

5.   A parent of a teething child asks for guidance on nonpharmacological treatments for gum

pain. What herbal preparation can the nurse suggest?

1.   Aloe vera

2.   Chamomile

3.   Echinacea

4.   Tea tree oil

5.   A nurse is attempting to assess a toddler, who is being uncooperative. What action by the

nurse would be best to accomplish this task?

1.   Get on the floor while assessing the child.

2.   Give the child toys to play with.

3.   Have the parent restrain the toddler.

4.   Visit with the parent for a short while.

5.   A middle-aged woman has brought a fussy baby to the pediatric clinic. After placing the

woman and child in an exam room, which of the following questions should the nurse ask first?

1.   Have you taken the babys temperature?

2.   How are you related to the baby?

3.   How long has the baby been so fussy?

4.   What brings you to the office today?

5.   A teenager is in the family practice clinic for a school physical. When the parent leaves the

room, the teen admits to cutting myself after a relative touched me in my private area. What

action by the nurse is most appropriate?

1.   Document the statements and alert the provider.

2.   Explain that this information must be shared.

3.   Have the secretary call the police department.

4.   Reassure the teen of confidentiality rules.

5.   A nurse is assessing a school-age child who complains of stomach aches after eating. Which

question is appropriate for the D component of the OLD CAT mnemonic?

1.   Can you describe how your tummy pain feels?

2.   Have you tried any over-the-counter drugs?

 

1.   How long does the pain last after you eat?

2.   What day did you first notice the pain?

3.   A nurse is assessing a school-age child in the clinic with an earache and fever. Using the

SODA mnemonic, what question by the nurse best relates to S?

1.   Does it keep you from sleeping?

2.   Has this affected your schoolwork?

3.   How long have you been sick?

4.   How sore is your ear today?

5.   A 1-week-old infant is in the pediatric clinic. The birth weight was 8 lb, 1 oz (3.65 kg).

Today the infant weighs 7 lb (3.17 kg). The mother breastfeeds exclusively. What action by the

nurse is best?

1.   Assess the mothers breastfeeding technique.

2.   Document the finding and alert the provider.

3.   Reassure the woman that weight loss is normal.

4.   Refer the mother to a lactation consultant.

5.   A nurse is providing nutritional information to a parent group. Which information is most

appropriate?

1.   At least 35% of calories should come from protein.

2.   Limit carbohydrates to 1015% of daily calories.

3.   Saturated fats are the healthiest fat choice.

4.   Use whole milk until your child is 2 years old.

5.   A nurse is weighing a 2-month-old infant in the clinic. To ensure safety, which action is most

appropriate?

1.   Have the parent hold the child while standing on an adult scale.

2.   Place the baby in the scale and place one hand on top of the baby.

3.   Place the baby in the scale and hold one hand just over the baby.

4.   Prop the infant sitting up in the scale, then weigh the prop separately.

5.   A nurse is assessing a 10-month-old babys anterior fontanel and finds it slightly depressed;

the fontanel measures 2 inches (5.08 cm). What conclusion and action are most appropriate?

1.   Delayed closing; alert health-care provider.

2.   Fontanel is closing; document findings.

3.   Large for age; assess for Downs syndrome.

4.   Sign of dehydration; assess fluid status.

5.   A child has had eye testing. The nurse reads in the childs chart that the Hirschberg test

demonstrated displacement of light reflection in one eye. What does this indicate to the nurse?

1.   Color blindness

2.   Normal ocular alignment

3.   Presence of cataracts

4.   Presence of strabismus

5.   A child needs hearing assessments. To assess air and bone conduction of sound, which

assessment technique is most appropriate?

1.   Have the child place a block into a box each time he or she hears a sound.

 

1.   Place a probe into the ear canal and measure the amount of sound reflected.

2.   Strike a tuning fork and place the handle against the back of the childs head.

3.   Strike a tuning fork, place it on the mastoid process, then move it to within1 inch of the ear

canal.

23.                A nurse reads in a childs chart that the child has pectus carinatum. What does the nurse

understand this term to mean?

1.   Barrel chest from chronic illness

2.   Depression of the lower chest

3.   Protrusion of the chest

4.   Underdeveloped breast bone

5.   A 5-year-old child is having an acute asthma attack. How does the nurse position the child

while waiting for a respiratory treatment?

1.   Prone across the parents lap

2.   Semi-Fowlers position in bed

3.   Upright in a hard-backed chair

4.   Upright in the tripod position

5.   A school-age child with asthma came to the emergency department with a respiratory rate of

44 breaths/minute and wheezes heard throughout. After two breathing treatments, the nurse

assesses a respiratory rate of 8 breaths/minute and hears no wheezing. The child is lying quietly

on the bed. What action by the nurse is best?

1.   Allow the child to rest undisturbed.

2.   Call for another respiratory treatment.

3.   Obtain oxygen saturation; notify provider.

4.   Reassess the child in 30 minutes.

5.   A toddler is brought to the clinic with a low-grade fever and the mother describes a grunting

sound made by the child on expiration. The respiratory rate is 24 breaths/minute. What action by

the nurse is most appropriate?

1.   Assess nose and throat for foreign bodies.

2.   Facilitate a stat chest x-ray.

3.   Obtain an oxygen saturation; notify provider.

4.   Weigh and measure child then calculate BMI.

5.   A nurse is listening to a school-age childs heart sounds and hears an abnormal noise after S2

that is heard best when the child is lying in the left lateral position. What action by the nurse is

most appropriate?

1.   Arrange a cardiology consult.

2.   Document the findings in the chart.

3.   Notify the provider immediately.

4.   Perform assessments for fluid balance.

5.   A visiting nurse is making a home visit on a male 2-month-old child who was born

prematurely. The nurse notes that the child has not been circumcised. What action by the nurse is

most important?

1.   Assess the number of the babys wet diapers per day.

2.   Give parents a referral to have the child circumcised.

3.   Instruct parents not to retract the foreskin until after age 1.

4.   Teach parents to retract the foreskin for cleaning.

5.   A nurse has been asked to perform a Romberg test on a school-age child. What action does

the nurse take to perform this assessment?

1.   Ask the child to smile, frown, and make other faces.

2.   Have the child touch a finger to the nose several times.

3.   Instruct the child to walk across the room and back.

4.   Tell the child to stand, close his or her eyes, and hold the arms out in front.

5.   A nurse is caring for a 5-year-old who broke his arm and is complaining of pain. What

statement by the nurse to the child would be most helpful?

1.   I bet your arm will stop hurting really soon.

2.   You dont have to stand pain; I can give you medicine.

3.   You didnt do anything wrong that caused the hurt.

4.   Wait until you see the cool cast you are going to get.

5.   A 66-lb child complains of mild pain after a procedure. What action by the nurse is best?

6.   Administer 0.3 mg of naloxone (Narcan) every 4 hours orally if needed.

7.   Administer 300 mg of acetaminophen (Tylenol) orally and provide a movie to watch.

8.   Administer 450 mg of acetaminophen (Tylenol) orally every 3 hours as requested.

9.   Administer morphine sulfate (Astromorph) 9 mg orally every 4 hours if needed.

10.                A new nurse caring for a toddler in pain after a procedure is reluctant to medicate the child

for fear of causing a respiratory arrest. What action by the nurses preceptor is best?

1.   Agree about withholding medication and teach some distraction techniques.

2.   Explain that pain has detrimental health effects and needs treatment.

3.   Have the new nurse get naloxone (Narcan) and place it at the childs bedside.

4.   Tell the new nurse to give the child analgesics and not worry about respiratory arrest.

5.   A student nurse on the pediatric floor finds a patient in pain and gives the child some toys to

play with. The registered nurse asks why the student did not medicate the child. The student

states that because the child was easily distracted, it did not appear that the child needed pain

medication. What action by the registered nurse is most appropriate?

1.   Give the child some pain medication.

2.   Have the student reassess the childs pain.

3.   Instruct the student to take the childs vital signs.

4.   Thank the student for distracting the child.

5.   A mother brings her severely disabled child to the pediatric clinic with complaints that the

child has his fourth upper respiratory infection in 3 months. The mother appears disheveled and

fatigued. What action by the nurse is best?

1.   Ask the mother when the last time she ate or bathed was.

2.   Inquire as to the whereabouts of the childs father.

3.   Make a referral to the visiting nurses for a home evaluation.

4.   Offer the mother information on local respite care options.

5.   A father is at the bedside of his hospitalized disabled child. He begins crying, saying he has

lost his job and no longer has insurance, so he is unsure of how to pay for the childs medical

bills. What action by the nurse would be most helpful?

1.   Consult with a social worker who can discuss state and federal insurance programs.

2.   Give the father written information on state health insurance options for children.

3.   Listen to the fathers concerns and tell him you understand how he must feel.

4.   Tell the father not to worry; the health of his child is more important than money.

5.   A nurse is providing anticipatory guidance to the parents of a 4-year-old disabled child. What

nutritional information should the nurse provide?

1.   Feed the child as any other 4-year-old child.

2.   Give child more than 7090 kcal/kg/day.

3.   Offer extra protein and vitamins daily.

4.   Provide extra carbohydrates and fat intake.

5.   A child is in the emergency department following an overdose of acetaminophen (Tylenol).

What medication does the nurse anticipate administering?

1.   Activated charcoal

2.   N-acetylcysteine (NAC)

3.   Naloxone (Narcan)

4.   Syrup of ipecac

5.   A child is in the clinic to follow up on a blood lead level of 7 g/dL. What action by the nurse

is best?

1.   Call social work or Child Protective Services to evaluate home safety.

2.   Instruct parents to have the child re-tested at the beginning of the school year.

3.   Reassure parents that this is below the threshold for lead poisoning.

4.   Teach parents to wet-mop surfaces instead of vacuuming the house.

5.   A child will be hospitalized in the following week. In order to decrease the childs and parents

stress related to the hospitalization, which action by the clinic nurse would be most helpful?

1.   Arrange for the family to visit the hospital and have a tour.

2.   Give the family written information on visiting hours.

3.   Introduce the family to another family whose child is hospitalized.

4.   Suggest the family take a break and not stay with the child.

5.   A nursing manager wants to decrease the amount of stress children have during

hospitalization. What environmental change can the manager implement to best meet this goal?

1.   Create a treatment room for procedures.

2.   Have dim lighting installed in patient rooms.

3.   Keep the play area unlocked and open at all hours.

4.   Provide guest trays for parents staying in the room.

5.   A nurse needs to administer medication to a toddler. What action by the nurse is most likely

to gain cooperation from the child?

1.   Allow the child to negotiate a reward.

2.   Allow the parent to give the medication.

3.   Explain that medicine is not a punishment.

4.   Let the toddler self-administer the medicine.

5.   A preschool-age child is going to have a potentially painful procedure. What action by the

nurse is best to prepare the child for this event?

1.   Allow the child to decide if the parents stay or not.

2.   Let the child touch and explore the equipment first.

3.   Talk about it briefly for several days beforehand.

4.   Use play to demonstrate the procedure to the child.

5.   A child who weighs 35 lb needs chloral hydrate (Aquachloral) for sedation prior to a medical

procedure. What dose should this child receive?

1.   150 mg

2.   450 mg

3.   1,000 mg

4.   1,500 mg

5.   A pediatric nurse reads in a chart that a female patient is in Tanner stage 3. Which of the

following best describes this patient?

1.   Breast buds and thick, curly pubic hair

2.   Entire breast enlarged; pubic hair in inverted triangle

3.   Has breast buds and sparse, straight pubic hair

4.   Nipples protruded; pubic hair extending to medial thighs

 

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