NURSING 3463 ATI nursing questions (GRADED A) answers | All you need to ACE the exams | (Following, Black-and-white films, urinary tract infection) | Rasmussen College

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1. A nurse manager on a pediatric unit is preparing an education program on working with families for a group of newly hired nurses. Which of the following should the nurse include when discussing th... e developmental theory? A. Describes that stress is inevitable B. Emphasizes that change with one member affects the entire family C. Provides guidance to assist families adapting to stress D. Defines consistencies in how families change 2. A nurse is assisting a group of guardians of adolescents to develop skills that will improve communication within the family. The nurse hears one guardian state, “My son knows he better do what I say.” Which of the following parenting styles is the parent exhibiting? A. Authoritarian B. Permissive C. Authoritative D. Passive 3. A nurse is performing family assessment. Which of the following should the nurse include? (Select all that apply.) A. Medical history B. Parents’ education level C. Child’s physical growth D. Support systems E. Stressors 1. A nurse is preparing to assess a preschooler. Which of the following actions should the nurse take to prepare the child? A. Allow the child to role-play using miniature equipment. B. Use medical terminology to describe what will happen. C. Separate the child from the caregiver during the examination. D. Keep medical equipment visible to the child. 2. A nurse is checking the vital signs of a 3-year-old child during a well-child visit. Which of the following findings should the nurse report to the provider? A. Temperature 37.2° C (99.0° F) B. Heart rate 106/min C. Respirations 30/min D. Blood pressure 88/54 mm Hg 3. A nurse is assessing a child’s ears. Which of the following findings should the nurse expect? A. Light reflex is located at the 2 o’clock position. B. Tympanic membrane is red in color. C. Bony landmarks are not visible. D. Cerumen is present bilaterally. 4. A nurse is assessing a 6-month-old infant. Which of the following reflexes should the infant exhibit? A. Moro B. Plantar grasp C. Stepping D. Tonic neck 5. A nurse is performing a neurologic assessment on an adolescent. Which of the following responses should the nurse expect the adolescent to exhibit when assessing the trigeminal nerve? (Select all that apply.) A. Clenching teeth together tightly B. Recognizing sour tastes on the back of the tongue C. Identifying smells through each nostril D. Detecting facial touches with eyes closed E. Looking down and in with the eyes 1. A nurse is assessing a 12-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? A. Closed anterior fontanel B. Eruption of six teeth C. Birth weight doubled D. Birth length increased by 50% 2. A nurse is performing a developmental screening on a 10-month-old infant. Which of the following fine motor skills should the nurse expect the infant to perform? (Select all that apply.) A. Grasp a rattle by the handle B. Try building a two-block tower C. Use a crude pincer grasp D. Place objects into a container E. Walks with one hand held 3. A nurse is conducting a well-baby visit with a 4-month-old infant. Which of the following immunizations should the nurse plan to administer to the infant? (Select all that apply.) A. Measles, mumps, rubella (MMR) B. Polio (IPV) C. Pneumococcal vaccine (PCV) D. Varicella E. Rotavirus vaccine (RV) 4. A nurse is providing education about introducing new foods to the guardians of a 4-month-old infant. The nurse should recommend that the caregiver introduce which of the following foods first? A. Strained yellow vegetables B. Iron-fortified cereals C. Pureed fruits D. Whole milk 5. A nurse is providing teaching about dental care and teething to the caregiver of a 9-month-old infant. Which of the following statements by the caregiver indicates an understanding of the teaching? A. “I can give my baby a warm teething ring to relieve discomfort.” B. “I should clean my baby’s teeth with a cool, wet wash cloth.” C. “I can give Advil for up to 5 days while my baby is teething.” D. “I should place diluted juice in the bottle my baby drinks while falling asleep.” 1. A nurse is assessing a 2 ½-year-old toddler at a well-child visit. Which of the following findings should the nurse report to the provider? A. Height increased by 7.5 cm (3 in) in the past year. B. Head circumference exceeds chest circumference. C. Anterior and posterior fontanels are closed. D. Current weight equals four times the birth weight. 2. A nurse is performing a developmental screening on an 18 month old. Which of the following skills should the toddler be able to perform? (Select all that apply.) A. Build a tower with six blocks B. Throw a ball overhand C. Walk up and down stairs D. Stand on one foot for a few seconds E. Use a spoon without rotation 3. A nurse is providing teaching about age-appropriate activities to the guardian of a 2 year old. Which of the following statements by the guardian indicates an understanding of the teaching? A. “I will send my child’s favorite stuffed animal when napping away from home will occur.” B. ”My child should be able to stand on one foot for a second.” C. “The soccer team my child will be playing on starts practicing next week.” D. “I should expect my child to be able to draw circles.” 4. A nurse is providing anticipatory guidance to the caregivers of a toddler. Which of the following should the nurse include? (Select all that apply.) A. Develop food habits that will prevent dental caries. B. Meeting caloric needs results in an increased appetite. C. Expression of bedtime fears is common. D. Expect behaviors associated with negativism and ritualism. E. Annual screenings for phenylketonuria are important. 1. A nurse is providing teaching to the guardian of a preschool-age child about methods to promote sleep. Which of the following statements by the parent indicates an understanding of the teaching? A. “I will sleep in the bed with my child if she wakes up during the night.” B. “I will let my child stay up an additional 2 hours on weekend nights.” C. “I will let my child watch television for 30 minutes just before bedtime each night.” D. “I will keep a dim lamp on in my child’s room during the night.” 2. A nurse is conducting a well-child visit with a 5-year-old child. Which of the following immunizations should the nurse plan to administer to the child? (Select all that apply.) A. Diphtheria, tetanus, pertussis (DTaP) B. Inactivated poliovirus (IPV) C. Measles, mumps, rubella (MMR) D. Pneumococcal (PCV) E. Haemophilus influenzae type B (Hib) 3. A nurse is preparing an education program for a group of caregivers of preschool-age children about promoting optimum nutrition. Which of the following information should the nurse include in the teaching? A. Saturated fats should equal 20% of total daily caloric intake. B. Average calorie intake should be 1,800 calories per day. C. Daily intake of fruits and vegetables should total 2 servings. D. Healthy diets include a total of 8 g protein each day. 4. A nurse is performing a developmental screening on a 3-year-old child. Which of the following skills should the nurse expect the child to perform? A. Ride a tricycle B. Hop on one foot C. Jump rope D. Throw a ball overhead 5. A nurse is caring for a preschool-age child who expresses the need to leave because their doll is scared to be at home alone. Which of the following characteristics of preoperational thought is the child exhibiting? A. Egocentrism B. Centration C. Animism D. Magical thinking 1. A nurse is discussing prepubescence and preadolescence with a group of guardians of schoolage children. Which of the following information should the nurse include in the discussion? A. Initial physiologic changes appear during early childhood. B. Changes in height and weight occur slowly during this period. C. Growth differences between boys and girls become evident. D. Sexual maturation becomes highly visible in boys. 2. A nurse is conducting a well-child visit with a child who is scheduled to receive the recommended immunizations for 11- to 12-year-olds. Which of the following immunizations should the nurse administer? (Select all that apply.) A. Trivalent inactivated influenza (TIV) B. Pneumococcal (PCV) C. Meningococcal (MCV4) D. Tetanus and diphtheria toxoids and pertussis (Tdap) E. Rotavirus (RV) 3. A nurse is providing education about ageappropriate activities for the caregivers of a 6-year-old child. Which of the following activities should the nurse include in teaching? A. Jumping rope B. Playing card games C. Solving jigsaw puzzles D. Joining competitive sports 4. A nurse is teaching a course about safety during the school-age. Which of the following information should the nurse include in the course? (Select all that apply.) A. Gating stairs at the top and bottom B. Wearing helmets when riding bicycles or skateboarding C. Riding safely in bed of pickup trucks D. Implementing firearm safety E. Wearing seat belts 1. A nurse is providing teaching about expected changes during puberty to a group of guardians of early adolescent girls. Which of the following statements by one of the guardians indicates an understanding of the teaching? A. “Girls usually stop growing about 2 years after menarche.” B. “Girls are expected to gain about 65 pounds during puberty.” C. “Girls experience menstruation prior to breast development.” D. “Girls typically grow more than 10 inches during puberty.” 2. A nurse is providing anticipatory guidance to the caregiver of a 13-year-old adolescent. Which of the following screenings should the nurse recommend for the adolescent? (Select all that apply.) A. Body mass index B. Blood lead level C. 24-hr dietary recall D. Weight E. Scoliosis 3. A nurse is caring for an adolescent whose guardian expresses concerns about the child sleeping such long hours. Which of the following conditions should the nurse inform the guardian as requiring additional sleep during adolescence? A. Sleep terrors B. Rapid growth C. Elevated zinc levels D. Slowed metabolism 4. A nurse is teaching a class about puberty in boys. Which of the following should the nurse include as the first manifestation of sexual maturation? A. Pubic hair growth B. Vocal changes C. Testicular enlargement D. Facial hair growth 1. A nurse is planning to administer the influenza vaccine to a toddler. Which of the following actions should the nurse take? A. Administer subcutaneously in the abdomen. B. Use a 20-gauge needle. C. Divide the medication into two injections. D. Place the child in the supine position. 2. A nurse is preparing to administer an intramuscular (IM) injection to a child. Which of the following muscle groups is contraindicated? A. Deltoid B. Ventrogluteal C. Vastus lateralis D. Dorsogluteal 3. A nurse is teaching a guardian of an infant about administration of oral medications. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Use a universal dropper for medication administration. B. Ask the pharmacy to add flavoring to the medication. C. Add the medication to a formula bottle before feeding. D. Use the nipple of a bottle to administer the medication. E. Hold the infant in an semi-reclining position. 4. A nurse is preparing to administer medication to a toddler. Which of the following actions should the nurse take? (Select all that apply.) A. Identify the toddler by asking the caregiver. B. Tell the caregiver to administer the medication. C. Calculate the safe dosage. D. Ask the toddler to pick a toy to hold during administration. E. Offer juice after the medication. 5. A nurse is caring for an infant who needs otic medication. Which of the following is an appropriate action for the nurse to take? A. Hold the infant in an upright position. B. Pull the pinna downward and straight back. C. Hyperextend the infant’s neck. D. Ensure that the medication is cool. 1. A nurse is completing a pain assessment on an infant. Which of the following pain scales should the nurse use? A. FACES B. FLACC C. Oucher D. Non-communicating children’s pain checklist 2. A nurse is planning care for a child following a surgical procedure. Which of the following interventions should the nurse include in the plan of care? A. Administer NSAIDs for pain greater than 7 on a scale of 0 to 10. B. Administer intranasal analgesics PRN. C. Administer IM analgesics for pain. D. Administer IV analgesics on a schedule. 3. A nurse is assessing an infant. Which of the following are findings of pain in an infant? (Select all that apply.) A. Pursed lips B. Loud cry C. Lowered eyebrows D. Rigid body E. Pushes away stimulus 4. A nurse is planning care for an infant who is experiencing pain. Which of the following interventions should the nurse include the plan of care? (Select all that apply.) A. Offer a pacifier. B. Use guided imagery. C. Use swaddling. D. Initiate a behavioral contract. E. Encourage kangaroo care. 5. A nurse is preparing a toddler for an intravenous catheter insertion using atraumatic care. Which of the following actions should the nurse take? (Select all that apply.) A. Explain the procedure using the child’s favorite toy. B. Ask the parents to leave during the procedure. C. Perform the procedure with the child in his bed. D. Allow the child to make one choice regarding the procedure. E. Apply lidocaine and prilocaine cream to three potential insertion sites. 1. A nurse is caring for a preschooler. Which of the following is an expected behavior of a preschool-age_child? A. Describing manifestations of illness B. Relating fears to magical thinking C. Understanding cause of illness D. Awareness of body functioning 2. A nurse on a pediatric unit is caring for a toddler. Which of the following behaviors is an effect of hospitalization? (Select all that apply.) A. Believes the experience is a punishment B. Experiences separation anxiety C. Displays intense emotions D. Exhibits regressive behaviors E. Manifests disturbance in body image 3. A nurse is teaching a guardian about parallel play in children. Which of the following statements should the nurse include in the teaching? A. “Children sit and observe others playing.” B. “Children exhibit organized play when in a group.” C. “The child plays alone.” D. “The child plays independently when in a group.” 4. A nurse is teaching a group of caregivers about separation anxiety. Which of the following information should the nurse include in the teaching? A. It is often observed in the school-age child. B. Detachment is the stage exhibited in the hospital. C. It results in prolonged issues of adaptability. D. Kicking a stranger is an example. 1. A nurse is caring for a child who is dying. Which of the following are findings of impending death? (Select all that apply.) A. Heightened sense of hearing B. Tachycardia C. Difficulty swallowing D. Sensation of being cold E. Cheyne-Stokes respirations 2. A nurse is teaching a guardian about complicated grief. Which of the following statements should the nurse make? A. “Complicated grief occurs when little time is spent thinking about the loss.” B. “Personal activities are rarely affected when experiencing complicated grief.” C. “Guardians will experience complicated grief together.” D. “Counseling can be helpful in resolving complicated grief.” 3. A nurse is teaching a caregiver of a preschool child about factors that affect the child’s perception of death. Which of the following factors should the nurse include in the teaching? A. Preschool children have no concept of death. B. Preschool children perceive death as temporary. C. Preschool children often regress to an earlier stage of behavior. D. Preschool children experience fear related to the disease process. 4. A nurse often cares for children who are dying. Which of the following are actions for the nurse to take to maintain professional effectiveness? (Select all that apply.) A. Remain in contact with the family after their loss. B. Develop a professional support system. C. Take time off from work. D. Suggest that a hospital representative attend the funeral. E. Demonstrate feelings of sympathy toward the family. 5. A nurse is caring for a child who has a terminal illness and reviews palliative care with an assistive personnel (AP). Which of the following statements by the AP indicates understanding of this review? A. “I’m sure the family is hopeful that the new medication will stop the illness.” B. “I’ll miss working with this client now that only nurses will be caring for the child.” C. “I will get all the client’s personal objects out of the room.” D. “I will listen and respond as the family talks about their child’s life.” 1. A nurse is caring for a client who has suspected meningitis and a decreased level of consciousness. Which of the following actions should the nurse take? A. Place the client on NPO status. B. Prepare the client for a liver biopsy. C. Position the client dorsal recumbent. D. Put the client in a protective environment. 2. A nurse is reviewing cerebrospinal fluid analysis for a client who has suspected meningitis. Which of the following findings should the nurse identify as indicating viral meningitis? (Select all that apply.) A. Negative Gram stain B. Normal glucose content C. Cloudy color D. Decreased WBC count E. Normal protein content 3. A nurse is assessing a 4-month-old infant who has meningitis. Which of the following manifestations should the nurse expect? A. Depressed anterior fontanel B. Constipation C. Presence of the rooting reflex D. High-pitched cry 4. A nurse is reviewing the medical record of a client who has Reye syndrome. Which of the following findings should the nurse identify as a risk factor for Reye syndrome? A. Recent history of infectious cystitis caused by Candida B. Recent history of bacterial otitis media C. Recent episode of gastroenteritis D. Recent episode of Haemophilus influenzae meningitis 5. A nurse is developing an educational program about viral and bacterial meningitis. The nurse should include that the introduction of which of the following immunizations decreased the incidence of bacterial meningitis in children? (Select all that apply.) A. Inactivated polio vaccine (IPV) B. Pneumococcal conjugate vaccine (PCV) C. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) D. Haemophilus influenzae type B (Hib) vaccine E. Trivalent inactivated influenza vaccine (TIV) 1. A nurse is caring for a child who has absence seizures. Which of the following findings should the nurse expect? (Select all that apply.) A. Loss of consciousness B. Appearance of daydreaming C. Dropping held objects D. Falling to the floor E. Having a piercing cry 2. A nurse is caring for a child who just experienced a generalized seizure. Which of the following is the priority action for the nurse to take? A. Position the child in a side-lying position. B. Try to determine the seizure trigger. C. Reorient the child to the environment. D. Note the time of the postictal period. 3. A nurse is providing teaching to the guardians of a child who is to have an electroencephalogram (EEG). Which of the following statements, by a guardian indicates teaching was effective? A. “My child should remain quiet and still during this procedure.” B. “I cannot wash my child’s hair prior to the procedure.” C. “I should not give my child anything to eat prior to the procedure.” D. “This procedure will be very painful for my child.” 4. A nurse is teaching a group of caregivers about the risk factors for seizures. Which of the following factors should the nurse include in the teaching? (Select all that apply.) A. Febrile episodes B. Hypoglycemia C. Sodium imbalances D. Low blood lead levels E. Presence of diphtheria 5. A nurse is reviewing treatment options with the guardian of a child who has worsening seizures. Which of the following treatment options should the nurse include in the discussion? (Select all that apply.) A. Vagal nerve stimulator B. Additional antiepileptic medications C. Corpus callosotomy D. Focal resection E. Radiation therapy 1. A nurse is in the emergency department is assessing a child following a motor-vehicle crash. The child is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding. Which of the following actions should the nurse take first? A. Stabilize the child’s neck. B. Clean the child’s laceration with soap and water. C. Implement seizure precautions for the child. D. Initiate IV access for the child. 2. A nurse is caring for an adolescent who has a closed head injury. Which of the following findings are indications of increased intracranial pressure (ICP)? (Select all that apply.) A. Report of headache B. Alteration in pupillary response C. Increased motor response D. Increased sleeping E. Increased sensory response 3. A nurse is caring for a child who has ICP. Which of the following actions should the nurse take? (Select all that apply.) A. Suction the endotracheal tube every 2 hr. B. Maintain a quiet environment. C. Use two pillows to elevate the head. D. Administer a stool softener. E. Maintain body alignment. 4. A nurse is assessing a child who has a concussion. Which of the following findings should the nurse expect? (Select all that apply.) A. Amnesia B. Systemic hypertension C. Bradycardia D. Respiratory depression E. Confusion 5. A nurse is caring for a child who is taking mannitol for cerebral edema. Which of the findings should the nurse monitor for as an adverse effect of mannitol? A. Bradycardia B. Weight loss C. Confusion D. Constipation 1. A nurse is planning to perform a peripheral vision test on a child. Which of the following actions should the nurse take? A. Place the child 10 feet away from a Snellen chart. B. Show a set of cards to the child one at a time. C. Cover the child’s eye while performing the test on the other eye. D. Have the child focus on an object while performing the test. 2. A nurse is teaching a group of parents about possible manifestations of Down syndrome. Which of the following findings should the nurse include in the teaching? (Select all that apply.) A. A large head with bulging fontanels B. Larger ears that are set back C. Protruding abdomen D. Broad, short feet and hands E. Hypotonia 3. A nurse is assessing a child who has myopia. Which of the following findings should the nurse expect? (Select all that apply.) A. Headaches B. Photophobia C. Difficulty reading D. Difficulty focusing on close objects E. Poor school performance 4. A nurse is assessing a toddler for possible hearing loss. Which of the following findings are indications of a hearing impairment? (Select all that apply.) A. Uses monotone speech B. Speaks loudly C. Repeats sentences D. Appears shy E. Is overly attentive to the surroundings 5. A nurse is teaching the parent of an infant who has Down syndrome. Which of the following statements by the parent indicates an understanding of the teaching? A. “I should expect him to have frequent diarrhea.” B. “I should place a cool mist humidifier in his room.” C. “I should avoid the use of lotion on his skin.” D. “I should expect him to grow faster in length than other infants.” 1. A nurse is teaching an adolescent to self-administer a corticosteroid medication using a metered-dose inhaler (MDI). Which of the following instructions should the nurse include? (Select all that apply.) A. Shake the device prior to use. B. Rinse and expectorate after administration. C. Inhale slowly with medication administration. D. Exhale quickly after medication administration. E. Wait 30 seconds between puffs. 2. A nurse caring for a child who is receiving oxygen therapy and is on a continuous oxygen saturation monitor that is reading 89%. Which of the following actions should the nurse take first? A. Increase the oxygen flow rate. B. Encourage the child to take deep breaths. C. Ensure proper placement of the sensor probe. D. Place the child in the Fowler’s position. 3. A nurse in the emergency department is assessing a newly-admitted infant. Which of the following findings is an early indication of hypoxemia? A. Nonproductive cough B. Hypoventilation C. Tachypnea D. Nasal stuffiness 4. A nurse is caring for a child who is receiving oxygen. Which of the following findings indicates oxygen toxicity? A. Increased blood pressure B. Hyperventilation C. Decreased PaCO2 D. Unconsciousness 5. A nurse is caring for a child who is receiving a bronchodilator medication by nebulized aerosol therapy. Which of the following actions should the nurse take? (Select all that apply.) A. Instruct the child that the treatment will last 30 min. B. Obtain vital signs prior to the procedure. C. Tell the child to take slow deep breaths. D. Determine if the child should use a mask. E. Attach the device to an air source. 1. A nurse is caring for a child who has bronchiolitis. Which of the following actions should the nurse take? (Select all that apply.) A. Administer oral prednisone. B. Initiate chest percussion and postural drainage. C. Administer humidified oxygen. D. Suction the nasopharynx as needed. E. Administer oral penicillin. 2. A nurse is teaching a group of guardians about influenza. Which of the following information should the nurse include in the teaching? A. “Amantadine will prevent the illness.” B. “Rimantadine is administered intramuscularly.” C. “Zanamivir can be given to children 1 year and older.” D. “Oseltamivir should be given within 48_hours of onset of manifestations.” 3. A nurse is caring for a child who is in the postoperative period following a tonsillectomy. Which of the following is a clinical finding of postoperative bleeding? A. Hgb 11.6 and Hct 37% B. Inflamed and reddened throat C. Frequent swallowing and clearing of the throat D. Blood-tinged mucus 4. A nurse is caring for a child in the postoperative period following a tonsillectomy. Which of the actions should the nurse take? A. Encourage the child to blow her nose gently. B. Administer analgesics on a schedule. C. Offer orange juice. D. Position the child supine. 5. A nurse is assessing a child who has epiglottitis. Which of the following findings should the nurse expect? (Select all that apply.) A. Hoarseness and difficulty speaking B. Difficulty swallowing C. Low-grade fever D. Drooling E. Dry, barking cough F. Stridor 1. A nurse is assessing a child who has asthma. Which of the following are indications of deterioration in the child’s respiratory status? (Select all that apply.) A. Oxygen saturation 95% B. Wheezing C. Retraction of sternal muscles D. Warm extremities E. Nasal flaring 2. A nurse is teaching an adolescent about the appropriate use of his asthma medications. Which of the following medications should the nurse instruct the client to use as needed before exercise? A. Fluticasone/salmeterol B. Montelukast C. Prednisone D. Albuterol 3. A nurse is planning care for a child who has asthma. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Perform chest percussion. B. Place the child in an upright position. C. Monitor oxygen saturation. D. Administer bronchodilators. E. Administer dornase alfa daily. 4. A nurse is teaching a child who has asthma how to use a peak flow meter. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Zero the meter before each use. B. Record the average of the attempts. C. Perform three attempts. D. Deliver a long, slow breath into the meter. E. Sit in a chair with feet on the floor. 5. A nurse is discussing risk factors for asthma with a group of newly licensed nurses. Which of the following conditions should the nurse include in the teaching? (Select all that apply.) A. Family history of asthma B. Family history of allergies C. Exposure to smoke D. Low birth weight E. Being underweight 1. A nurse is reviewing the diagnostic findings for a preschool age child who is suspected of having cystic fibrosis. Which of the following findings should the nurse identify as an indication of cystic fibrosis? A. Sweat chloride content 85 mEq/L B. Increased blood levels of fat-soluble vitamins C. 72 hr stool analysis sample indicating hard, packed stools D. Chest x-ray negative for atelectasis 2. A nurse is admitting a child who has cystic fibrosis. Which of the following medications should the nurse expect to include in the plan of care? (Select all that apply.) A. Tobramycin B. Loperamide C. Fat-soluble vitamins D. Albuterol E. Dornase alfa 3. A nurse is performing an admission assessment for a child who has cystic fibrosis. Which of the following findings should the nurse expect? (Select all that apply.) A. Wheezing B. Clubbing of fingers and toes C. Barrel-shaped chest D. Thin, watery mucus E. Rapid growth spurts 4. A nurse is providing discharge teaching for a child who has cystic fibrosis. Which of the following instructions should the nurse include? A. Provide a low-calorie, low-protein diet. B. Administer pancreatic enzymes with meals and snacks. C. Implement a fluid restriction during times of infection. D. Restrict physical activity. 1. A nurse is assessing an infant who has coarctation of the aorta. Which of the following findings should the nurse expect? (Select all that apply.) A. Weak femoral pulses B. Cool skin of lower extremities C. Severe cyanosis D. Clubbing of the fingers E. Low blood pressure 2. A nurse is assessing an infant who has heart failure. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Cool extremities C. Peripheral edema D. Increased urinary output E. Nasal flaring 3. A nurse is providing teaching to the caregiver of an infant who has a prescription for digoxin. Which of the following instructions should the nurse include? A. “Do not offer your baby fluids after giving the medication.” B. “Digoxin increases your baby’s heart rate.” C. “Give the correct dose of medication at regularly scheduled times.” D. “If your baby vomits a dose, you should repeat the dose to ensure that the correct amount is received.” 4. A nurse is caring for a 2-year-old child who has a heart defect and is scheduled for cardiac catheterization. Which of the following actions should the nurse take? A. Place on NPO status for 12_hr prior to the procedure. B. Check for iodine or shellfish allergies prior to the procedure. C. Elevate the affected extremity following the procedure. D. Limit fluid intake following the procedure 5. A nurse is caring for a child who is suspected of having rheumatic fever. Which of the following findings should the nurse expect? (Select all that apply.) A. Erythema marginatum (rash) B. Continuous joint pain of the digits C. Tender, subcutaneous nodules D. Decreased erythrocyte sedimentation rate E. Elevated C-reactive protein 1. A nurse is providing teaching about the management of epistaxis to an adolescent. Which of the following positions should the nurse instruct the adolescent to take when experiencing a nosebleed? A. Sit up and lean forward. B. Sit up and tilt the head up. C. Lie in a supine position. D. Lie in a prone position. 2. A nurse is providing teaching about epistaxis to the parent of a school-age child. Which of the following should the nurse include as an action to take when managing an episode of epistaxis? (Select all that apply.) A. Press the nares together for at least 10 min. B. Breathe through the nose until bleeding stops. C. Pack cotton or tissue into the naris that is bleeding. D. Apply a warm cloth across the bridge of the nose. E. Insert petroleum into the naris after the bleeding stops. 3. A nurse is providing teaching to the parent of a child who has a new prescription for liquid oral iron supplements. Which of the following statements by the parent indicates an understanding of the teaching? A. “I should take my child to the emergency department if his stools become dark.” B. “My child should avoid eating citrus fruits while taking the supplements.” C. “I should give the iron with milk to help prevent an upset stomach.” D. “My child should take the supplement through a straw.” 4. A nurse is preparing to administer iron dextran IM to a school-age child who has iron deficiency anemia. Which of the following actions by the nurse is appropriate? A. Administer the dose in the deltoid muscle. B. Use the Z-track method when administering the dose. C. Avoid injecting more than 2 mL with each dose. D. Massage the injection site for 1 min after administering the dose. 5. A nurse is caring for an infant whose screening test reveals a potential diagnosis of sickle cell disease. Which of the following tests should be performed to distinguish if the infant has the trait or the disease? A. Sickle solubility test B. Hemoglobin electrophoresis C. Complete blood count D. Transcranial Doppler 1. A nurse is caring for a child who has had watery diarrhea for the past 3 days. Which of the following is an action for the nurse to take? A. Offer chicken broth. B. Initiate oral rehydration therapy. C. Start hypertonic IV solution. D. Keep NPO until the diarrhea subsides. 2. A nurse is caring for a child who is suspected to have Enterobius vermicularis. Which of the following actions should the nurse take? A. Perform a tape test. B. Collect stool specimen for culture. C. Test the stool for occult blood. D. Initiate IV fluids. 3. A nurse is assessing a child who has a rotavirus infection. Which of the following are expected findings? (Select all that apply.) A. Fever B. Vomiting C. Watery stools D. Bloody stools E. Confusion 4. A nurse is teaching a group of parents about Salmonella. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Incubation period is nonspecific. B. It is a bacterial infection. C. Bloody diarrhea is common. D. Transmission can be from house pets. E. Antibiotics are used for treatment. 5. A nurse is teaching a group of caregivers about E. coli. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Severe abdominal cramping occurs. B. Watery diarrhea is present for more than 5 days. C. It can lead to hemolytic uremic syndrome. D. It is a foodborne pathogen. E. Antibiotics are given for treatment. 1. A nurse is assessing an infant who has hypertrophic pyloric stenosis. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Projectile vomiting B. Dry mucus membranes C. Currant jelly stools D. Sausage-shaped abdominal mass E. Constant hunger 2. A nurse is caring for a child who has Hirschsprung’s disease. Which of the following actions should the nurse take? A. Encourage a high-fiber, low-protein, low-calorie diet. B. Prepare the family for surgery. C. Place an NG tube for decompression. D. Initiate bed rest. 3. A nurse is caring for an infant who has just returned from PACU following cleft lip and palate repair. Which of the following actions should the nurse take? A. Remove the packing in the mouth. B. Place the infant in an upright position. C. Offer a pacifier with sucrose. D. Assess the mouth with a tongue blade. 4. A nurse is caring for a child who has Meckel’s diverticulum. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Abdominal pain B. Fever C. Mucus and blood in stools D. Vomiting E. Rapid, shallow breathing 5. A nurse is teaching a parent of an infant about gastrointestinal reflux disease. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Offer frequent feedings. B. Thicken formula with rice cereal. C. Use a bottle with a one-way valve. D. Position baby upright after feedings. E. Use a wide-based nipple for feedings. 1. A nurse is teaching a parent of a child who has a urinary tract infection. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Wear nylon underpants. B. Avoid bubble baths. C. Empty bladder completely with each void. D. Watch for manifestations of infection. E. Wipe perineal area back to front. 2. A nurse is planning care of a child who has a urinary tract infection. Which of the following interventions should the nurse include? A. Administer an antidiuretic. B. Restrict fluids. C. Evaluate the child’s self-esteem. D. Encourage frequent voiding. 3. A nurse is caring for a child who has enuresis. Which of the following is a complication of enuresis? A. Urinary tract infections B. Emotional problems C. Urosepsis D. Progressive kidney disease 4. A nurse is assessing an infant who has a suspected urinary tract infection. Which of the following are expected findings? (Select all that apply.) A. Increase in hunger B. Irritability C. Decrease in urination D. Vomiting E. Fever 5. A nurse is assessing a child who has a urinary tract infection. Which of the following are manifestations of a urinary tract infection? (Select all that apply.) A. Night sweats B. Swelling of the face C. Pallor D. Pale-colored urine E. Fatigue 1. A nurse is caring for an infant who has a hydrocele. Which of the following actions should the nurse take? A. Prepare the child for surgery. B. Explain to the parents that the issue will self-resolve. C. Retract the foreskin and cleanse several times daily. D. Refer the family for genetic counseling. 2. A nurse is caring for a male infant who has an epispadias. Which of the following findings should the nurse expect? (Select all that apply.) A. Bladder exstrophy B. Inability to retract foreskin C. Widened pubic symphysis D. Urethral opening on the dorsal side of the penis. E. Pain 3. A nurse is caring for an infant who has ambiguous genitalia. Which of the following actions should the nurse take? (Select all that apply.) A. Prepare the child for surgery. B. Test the child’s infant’s function. C. Cover the genitals with a sterile dressing. D. Refer the family for genetic counseling. E. Explain the need for a chromosomal analysis. 4. A nurse is caring for an infant who has obstructive uropathy. Which of the following findings should the nurse expect? (Select all that apply.) A. Decreased urine flow B. Urinary tract infection C. Intrauterine polyhydramnios D. Concentrated urine E. Hydronephrosis 1. A nurse is assessing a child who has nephrotic syndrome. Which of the following findings should the nurse expect? (Select all that apply.) A. Urine dipstick +2 protein B. Edema in the ankles C. Hyperlipidemia D. Polyuria E. Anorexia 2. A nurse is caring for a school-age child who has acute glomerulonephritis. Which of the following findings should the nurse report to the provider? A. BUN 8 mg/dL B. Blood creatinine 1.3 mg/dL C. Blood pressure 100/74 mm Hg D. Urine output 550 mL in 24 hr 3. A nurse is caring for a preschooler who has nephrotic syndrome. Which of the following findings should the nurse report to the provider? A. Blood protein 5.0 g/dL B. Hgb 14.5 g/dL C. Hct 40% D. Platelet 200,000 mm3 4. A nurse is assessing a child who has chronic renal failure. Which of the following findings should the nurse expect? A. Flushed face B. Hyperactivity C. Weight gain D. Delayed growth 5. A nurse is caring for a child who has acute post-streptococcal glomerulonephritis (APSGN). Which of the following manifestations should the nurse expect? (Select all that apply.) A. Pale urine B. Periorbital edema C. Ill appearance D. Decreased creatinine E. Hypertension 1. A nurse is caring for a child who is in a plaster spica cast. Which of the following actions should the nurse take? A. Use a heat lamp to facilitate drying. B. Avoid turning the child until the cast is dry. C. Assist the client with crutch walking after the cast is dry. D. Apply moleskin to the edges of the cast. 2. A nurse is teaching a group of caregivers about fractures. Which of the following information should the nurse include in the teaching? A. “Children need a longer time to heal from a fracture than an adult.” B. “Epiphyseal plate injuries can result in altered bone growth.” C. “A greenstick fracture is a complete break in the bone.” D. “Bones are unable to bend, so they break.” 3. A nurse is caring for a child who sustained a fracture. Which of the following actions should the nurse take? (Select all that apply.) A. Place a heat pack on the site of injury. B. Elevate the affected limb. C. Assess neurovascular status frequently. D. Encourage ROM of the affected limb. E. Stabilize the injury. 4. A nurse is caring for a child who has a fracture. Which of the following are manifestations of a fracture? (Select all that apply.) A. Crepitus B. Edema C. Pain D. Fever E. Ecchymosis 5. A nurse is caring for a child who is in skeletal traction. Which of the following actions should the nurse take? (Select all that apply.) A. Remove the weights to reposition the client. B. Assess the child’s position frequently. C. Assess pin sites every 4 hr. D. Ensure the weights are hanging freely. E. Ensure the rope’s knot is in contact with the pulley. 1. A nurse is caring for a toddler who has hip dysplasia and has been placed in a hip spica cast. The child’s guardian asks the nurse why a Pavlik harness is not being used. Which of the following responses should the nurse make? A. “The Pavlik harness is used for children with scoliosis, not hip dysplasia.” B. “The Pavlik harness is used for school-age children.” C. “The Pavlik harness cannot be used for your child because her condition is too severe.” D. “The Pavlik harness is used for infants less than 6 months of age.” 2. A nurse is completing preoperative teaching with an adolescent client who is scheduled to receive spinal instrumentation for scoliosis. Which of the following information should the nurse include in the_teaching? A. “You will go home the same day of surgery.” B. “You will have minimal pain.” C. “You will need to receive blood.” D. “You will not be able to eat until the day after surgery.” 3. A nurse is caring for a child who is suspected of having Legg-Calve-Perthes disease. The nurse should prepare the child for which of the following diagnostic procedures? A. Bone biopsy B. Genetic testing C. CT scan D. Radiographs 4. A nurse is assessing a child who has Legg-Calve-Perthes disease. Which of the following findings should the nurse expect? (Select all that apply.) A. Longer affected leg B. Hip stiffness C. Back pain D. Limited ROM E. Limp with walking 5. A nurse is caring for an infant and notices an audible click in their left hip. Which of the following diagnostic test should the nurse expect the provider to perform? (Select all that apply.) A. Barlow test B. Babinski sign C. Manipulation of foot and ankle D. Ortolani test E. Ponseti method 1. A nurse is caring for a child who has cerebral palsy. Which of the following medications should the nurse expect to administer to treat painful muscle spasms? (Select all that apply.) A. Baclofen B. Diazepam C. Oxybutynin D. Methotrexate E. Prednisone 2. A nurse is developing a plan of care for a toddler who has cerebral palsy. Which of the following actions should the nurse include? A. Structure interventions according to the toddler’s chronological age. B. Evaluate the toddler’s need for an evaluation of hearing ability. C. Monitor the toddler’s pain level routinely using a numeric rating scale. D. Provide total care for daily hygiene activities. 3. A nurse is caring for a school-age child who has juvenile idiopathic arthritis. Which of the following home care instructions should the nurse include in the teaching? (Select all that apply.) A. Provide extra time for completion of ADLs. B. Use cold compresses for joint pain. C. Take ibuprofen on an empty stomach. D. Remain home during periods of exacerbation E. Perform range-of-motion exercises. 4. A nurse is caring for a child who has muscular dystrophy. For which of the following findings should the nurse assess? (Select all that apply.) A. Purposeless, involuntary, abnormal movements B. Spinal defect and saclike protrusion C. Muscular weakness in lower extremities D. Unsteady, wide-based or waddling gait E. Upward slant to the eyes 5. A nurse is caring for an infant who has a myelomeningocele. Which of the following actions should the nurse include in the preoperative plan of care? A. Assist the caregiver with cuddling the infant. B. Assess the infant’s temperature rectally. C. Place the infant in a supine position. D. Apply a sterile, moist dressing on the sac. 1. A nurse is assessing an infant who has scabies. Which of the following findings should the nurse expect? (Select all that apply.) A. Presence of nits on the hair shaft B. Pencil-like marks on hands C. Blisters on the soles of the feet D. Small, red bumps on the scalp E. Pimples on the trunk 2. A nurse is teaching a group of parents about preventing insect bites. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Wear perfumes when outside. B. Avoid areas of tall grass. C. Wear bright-colored clothing. D. Wear insect repellent. E. Check house pets frequently. 3. A nurse is teaching a parent of a child who has pediculosis capitis. Which of the following instructions should the nurse include in the teaching? A. Apply mayonnaise to the affected area at night. B. Treat all household pets. C. Use an over-the-counter medication containing 1% permethrin. D. Discard the child’s stuffed animals. 4. A nurse is caring for a child who has cellulitis on the hand. Which of the following actions should the nurse take? A. Administer oral antibiotics. B. Cleanse area using Burrow solution. C. Prepare for cryotherapy. D. Apply a topical antifungal medication. 5. A nurse is planning care for a child who has tinea capitis. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Treat infected house pets. B. Use selenium sulfide shampoo. C. Cleanse area with Burrow solution. D. Administer antiviral medication. E. Use moist, warm compresses. 1. A nurse is teaching the guardian of an infant who has seborrheic dermatitis of the scalp. Which of the following instructions should the nurse include in the teaching? A. “You can use petrolatum to help soften and remove patches from your infant’s scalp.” B. “When patches are present, you should keep your infant away from others.” C. “You should avoid washing your infant’s hair while patches are present on the scalp.” D. “When patches are present, it indicates that your infant has a systemic infection.” 2. A nurse is caring for a child who has contact dermatitis due to poison ivy. Which of the following actions should the nurse take? (Select all that apply.) A. Remove the clothing over the rash. B. Initiate contact isolation precautions while the rash is present. C. Expose the rash to a heat lamp for 15 min. D. Cleanse the affected skin with hydrogen peroxide solution. E. Apply calamine lotion to the skin. 3. A nurse is caring for an adolescent who has acne and a prescription for isotretinoin from the dermatologist. Which of the following laboratory findings should the nurse plan to monitor? A. Cholesterol and triglycerides B. BUN and creatinine C. Blood potassium D. Blood sodium 4. A nurse is planning care for an infant who has diaper dermatitis. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Apply talcum powder with every diaper change. B. Allow the buttocks to air dry. C. Use commercial baby wipes to cleanse the area. D. Use cloth diapers until the rash is gone. E. Apply zinc oxide ointment to the affected area. 5. A nurse is assessing an infant who has eczema. Which of the following findings should the nurse expect? (Select all that apply.) A. Generalized distribution of lesions B. Papules C. Ecchymosis in flexural areas D. Crusting lesions E. Keratosis pilaris 1. A nurse is caring for a client who has a superficial partial-thickness burn. Which of the following actions should the nurse take? A. Administer IV infusion of 0.9% sodium chloride. B. Apply cool, wet compresses to the affected area. C. Clean the affected area using a soft-bristle brush. D. Administer morphine sulfate. 2. A nurse is caring for a client who has major burns and suspected septic shock. Which of the following findings are consistent with septic shock? (Select all that apply.) A. Increased body temperature B. Altered sensorium C. Decreased capillary refill time D. Decreased urine output E. Increased bowel sounds 3. A nurse is caring for a client who has a major burn and is experiencing severe pain. Which of the following actions should the nurse implement to manage this client’s pain? A. Administer morphine sulfate IV via continuous infusion. B. Administer meperidine IM as needed. C. Administer acetaminophen PO every 4 hr. D. Administer hydrocodone PO every 6 hr. 4. A nurse is caring for a client who has a skin graft. Which of the following manifestations indicate infection? (Select all that apply.) A. Pink color to subcutaneous fat B. Unstable body temperature C. Generation of granulation tissue D. Subeschar hemorrhage E. Change in skin color around the affected area 5. A nurse is caring for a client who has a moderate burn. Which of the following actions should the nurse take? A. Maintain immobilization of the affected area. B. Expose affected area to the air. C. Initiate a high-protein, high-calorie diet. D. Implement contact isolation. 1. A nurse is reviewing sick-day management with a parent of a child who has type 1 diabetes mellitus. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Monitor blood glucose levels every 3 hr. B. Discontinue taking insulin until feeling better. C. Drink 8 oz of fruit juice every hour. D. Test urine for ketones. E. Call the provider if blood glucose is greater than 240 mg/dL. 2. A nurse is teaching a child who has type 1 diabetes mellitus about self-care. Which of the following statements by the child indicates understanding of the teaching? A. “I should skip breakfast when I am not hungry.” B. “I should increase my insulin with exercise.” C. “I should drink a glass of milk when I am feeling irritable.” D. “I should draw up the NPH insulin into the syringe before the regular insulin.” 3. A nurse is caring for a child who has type 1 diabetes mellitus. Which of the following are manifestations of diabetic ketoacidosis? (Select all that apply.) A. Blood glucose 58 mg/dL B. Weight gain C. Dehydration D. Mental confusion E. Fruity breath 4. A nurse is teaching a school-age child who has diabetes mellitus about insulin administration. Which of the following should the nurse include in the teaching? A. “You should inject the needle at a 30-degree angle.” B. “You should combine your glargine and regular insulin in the same syringe.” C. ”You should aspirate for blood before injecting the insulin.” D. ”You should give four to six injections in one area before switching sites.” 5. A nurse is teaching an adolescent who has diabetes mellitus about manifestations of hypoglycemia. Which of the following findings should the nurse include in the teaching? (Select all that apply.) A. Increased urination B. Hunger C. Poor skin turgor D. Irritability E. Sweating and pallor F. Kussmaul respirations 1. A nurse is caring for a child who has short stature. Which of the following diagnostic tests should be completed to confirm growth hormone (GH) deficiency? (Select all that apply.) A. CT scan of the head B. Skeletal x-rays C. GH stimulation test D. Blood IGF-1 E. DNA testing 2. A nurse is teaching the parent of a child who has a growth hormone deficiency. Which of the following are complications of untreated growth hormone deficiency? (Select all that apply.) A. Delayed sexual development B. Premature aging C. Advanced bone age D. Short stature E. Increased epiphyseal closure 3. A parent of a school-age child who has GH deficiency asks the nurse how long the child will need to take injections for growth delay. Which of the following responses should the nurse make? A. “Injections are usually continued until age 10 for girls and age 12 for boys.” B. “Injections continue until your child reaches the fifth percentile on the growth chart.” C. “Injections might be stopped once your child grows less than 1 inch/year.” D. “The injections will need to be administered throughout your child’s entire life.” 4. A nurse is assessing a child who has short stature. Which of the following findings would indicate a growth hormone deficiency? A. Proportional height to weight B. Height proportionally greater than weight C. Oversized jaw D. Early-onset puberty 1. A nurse is preparing to administer immunizations to a 4-month-old infant. Which of the following actions should the nurse take to provide atraumatic care? A. Administer 81 mg of aspirin. B. Use the Z-track method when injecting. C. Ask the parents to leave the room during the injection. D. Provide sucrose solution on the pacifier. 2. A nurse is planning to administer recommended immunizations to a 2-month-old infant. Which of the following vaccines should the nurse plan to give? (Select all that apply.) A. Rotavirus (RV) B. Diphtheria, tetanus, and acellular pertussis (DTaP) C. Haemophilus influenzae type b (Hib) D. Hepatitis A (HepA) E. Pneumococcal conjugate (PCV13) F. Inactivated poliovirus (IPV) 3. A nurse is planning to administer recommended immunizations to a 4-year-old child. Which of the following vaccines should the nurse plan to give? (Select all that apply.) A. Inactivated poliovirus (IPV) B. Haemophilus influenzae type b (Hib) C. Measles, mumps, rubella (MMR) D. Varicella (VAR) E. Hepatitis B (HepB) F. Diphtheria, tetanus, and acellular pertussis (DTaP) 4. A nurse is preparing to administer the varicella vaccine to an adolescent. Which of the following questions should the nurse ask to determine whether there is a contraindication to administering the vaccine? A. “Do you have an allergy to eggs?” B. “Have you ever had encephalopathy following immunizations?” C. “Are you currently taking corticosteroid medication?” D. “Have you ever had an anaphylactic reaction to yeast?” 5. A nurse is caring for a 15-month-old child in a clinic. Which of the following actions should the nurse take? (See the chart for additional client information.) IMMUNIZATION RECORD HepB: 1 month, 2-months, 12 months Rotavirus: 2 months, 4-months, 6 months DTaP: 2 months, 4-months, 6 months Hib: 2 months, 4-months, 12 months IPV: 2 months, 4-months, 6 months MMR: 12 months Varicella: 12 months HepA: 12 months NURSES NOTES Temperature: 37.8° C (100.1° F) Sore throat Family history of seizures A. Administer DTaP vaccine. B. Administer rotavirus vaccine. C. Hold immunizations until fever subsides. D. Administer hepatitis A vaccine. 1. A nurse is teaching a group of family members about complications of communicable diseases. Which of the following communicable diseases can lead to pneumonia? (Select all that apply.) A. Rubella (German measles) B. Rubeola (measles) C. Pertussis (whooping cough) D. Varicella (chickenpox) E. Mumps 2. A nurse is caring for a client who has rubeola. The nurse should monitor for which of the following complications? (Select all that apply.) A. Otitis media B. Constipation C. Laryngitis D. Arthralgia E. Syncope 3. A nurse is assessing a client who has pertussis. Which of the following findings should the nurse expect? (Select all that apply.) A. Runny nose B. Mild fever C. Cough with whooping sound D. Swollen salivary glands E. Red rash 4. A nurse is teaching a group of family members about communicable diseases. The nurse should include that which of the following is the best method to prevent a communicable disease? A. Hand washing B. Avoiding persons who have active disease C. Covering your cough D. Obtaining immunizations 1. A nurse is caring for a toddler who has acute otitis media. Which of the following is the priority action for the nurse to take? A. Provide emotional support to the family. B. Educate the family on care of the child. C. Provide a diversional activity. D. Administer analgesics. 2. A nurse is caring for an infant who has manifestations of acute otitis media (AOM). Which of the following factors places the infant at risk for otitis media? (Select all that apply.) A. Breastfeeds without formula supplementation. B. Attends day care 4 days per week. C. Immunizations are up to date. D. History of a cleft palate repair. E. Parents smoke cigarettes outside. 3. A nurse is caring for a toddler who has had rhinitis, cough, and diarrhea for 2 days. Upon assessment, it is noted that the tympanic membrane has an orange discoloration and decreased movement. Which of the following statements should the nurse to make? A. “Your child has an ear infection that requires antibiotics.” B. “Your child could experience transient hearing loss.” C. “Your child will need to be on a decongestant until this clears.” D. “Your child will need to have a myringotomy.” 4. A nurse is caring for a toddler who has had three ear infections in the past 5 months. Which of the following long-term complications is the child at risk for developing? A. Balance difficulties B. Rash C. Speech delays D. Mastoiditis 5. A nurse is assessing an infant. Which of the following findings are clinical manifestations of acute otitis media? (Select all that apply.) A. Decreased pain in the supine position B. Rolling head side to side C. Loss of appetite D. Increased sensitivity to sound E. Crying 1. A nurse is teaching a parent of a child who has HIV. Which of the following information should the nurse include? (Select all that apply.) A. Obtain yearly influenza vaccination. B. Monitor a fever for 24 hr before seeking medical care. C. Avoid individuals who have colds. D. Provide nutritional supplements. E. Administer aspirin for pain. 2. A nurse is caring for a child who has AIDS. Which of the following isolation precautions should the nurse implement? A. Contact B. Airborne C. Droplet D. Standard 3. A nurse is admitting a child who has HIV. The nurse should identify which of the following findings as an indication that the child is in the mildly symptomatic category of HIV? (Select all that apply.) A. Herpes zoster B. Anemia C. Oral candidiasis D. Hepatomegaly E. Lymphadenopathy 4. A nurse is teaching a group of adolescents about HIV/AIDS. Which of the following statements should the nurse include in the teaching? A. “You can contract HIV through casual kissing.” B. “HIV is transmitted through IV substance use.” C. “HIV is now curable if caught in the early stages.” D. “Medications inhibit transmission of the HIV virus.” 5. A nurse is admitting a child who has severely symptomatic HIV. Which of the following findings should the nurse expect? (Select all that apply.) A. Kaposi’s sarcoma B. Hepatitis C. Wasting syndrome D. Pulmonary candidiasis E. Cardiomyopathy 1. A nurse is providing teaching to the parent of a child who has a neuroblastoma. Which of the following statements should the nurse include in the teaching? (Select all that apply.) A. “Chemotherapy and radiotherapy may be necessary for treatment.” B. “Your child will need a bone marrow biopsy.” C. “Your child will be paralyzed because of this tumor.” D. “Most children are diagnosed around age 12.” E. “Your child will need surgery for resection of the tumor.” 2. A nurse is caring for a toddler who has a Wilms’ tumor. Which of the following actions should the nurse take? A. Palpate the child’s abdomen to identify the size of the tumor. B. Prepare the child for surgery. C. Teach the parents about dialysis. D. Obtain a 24-hr urine specimen from the child. 3. A nurse is teaching the parent of a child who has a Wilms’ tumor. Which of the following statements should the nurse include in the teaching? (Select all that apply.) A. “Your child will need to have chemotherapy for 12 months.” B. “Wilms’ tumors are typically genetic in nature.” C. “Surgery is done usually within 48 hours of diagnosis.” D. “Palpating the tumor could cause spread of the cancer.” E. “Further treatments will start immediately after surgery.” 4. A nurse is caring for a child who is postoperative following surgical removal of a Wilms’ tumor. Which of the following assessments is an indication to continue NPO status? A. Abdominal girth 1 cm larger than yesterday B. Report of pain at the operative site C. Absent bowel sounds D. Passing of flatus every 30 min 5. A nurse is assessing a child who has neuroblastoma of the adrenal gland. Which of the following are manifestations of metastasis from the primary site? (Select all that apply.) A. Weight gain B. Bone pain C. Periorbital ecchymoses D. Proptosis E. Weight loss 1. A nurse is assessing a child who has leukemia. Which of the following are early manifestations of leukemia? (Select all that apply.) A. Hematuria B. Anorexia C. Petechiae D. Ulcerations in the mouth E. Unsteady gait 2. A nurse is caring for a child who has thrombocytopenia. Which of the following actions should the nurse take? (Select all that apply.) A. Monitor for manifestations of bleeding. B. Administer routine immunizations. C. Obtain rectal temperatures. D. Avoid peripheral venipunctures. E. Limit visitors. 3. A nurse is caring for a child who is experiencing neuropathy due to chemotherapy. Which of the following are manifestations of neuropathy? (Select all that apply.) A. Constipation B. Skin breakdown C. Foot drop D. Jaw pain E. Hemorrhage cystitis 4. A nurse is caring for a child who has oral mucositis. Which of the following actions should the nurse take? (Select all that apply.) A. Swab the mucosa with lemon glycerin swabs. B. Apply viscous lidocaine. C. Offer soft foods. D. Use a soft, disposable toothbrush for oral care. E. Encourage gargling with a warm saline mouthwash. 5. A nurse is planning care for an infant who is scheduled to have a lumbar puncture. Which of the following actions should the nurse include in the plan of care? A. Cleanse the thoracic area of the infant’s back with an antiseptic solution. B. Apply a eutectic mixture of local anesthetic cream just before the procedure begins. C. Restrain the infant during the procedure to prevent movement. D. Position the infant with his head extended and chin raised. 1. A nurse is caring for a child following an above-the-knee amputation. Which of the following actions should the nurse take? A. Avoid discussing the amputation. B. Administer aspirin for phantom pain. C. Prepare the child for a prosthesis fitting. D. Maintain the affected limb in the dependent position. 2. A nurse is caring for an adolescent who has a new diagnosis of osteosarcoma. Which of the following actions should the nurse take first? A. Ensure that the adolescent has a referral for a psychiatrist visit. B. Prepare a teaching plan to educate the adolescent in detail about the diagnosis and treatment. C. Spend time with the adolescent to answer any questions. D. Perform a mental status examination to assess the adolescent’s thought patterns. 3. A nurse is providing home care instructions to a parent of a child who is receiving chemotherapy. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. Manifestations of infection B. Bleeding precautions C. Hand hygiene D. Homeschooling E. Airborne precautions 4. A nurse is assessing a child who has rhabdomyosarcoma of the nasopharynx. Which of the following are manifestations of rhabdomyosarcoma? (Select all that apply.) A. Enlarged neck lymph nodes B. Pain C. Vomiting D. Epistaxis E. Diplopia 5. A nurse is assessing a child who has rhabdomyosarcoma of the upper arm. Which of the following findings should the nurse expect? (Select all that apply.) A. Pain B. Discoloration of the skin C. Lymph node enlargement D. Easy bruising E. Palpable mass 1. A nurse is reviewing the medical record of a newborn who has necrotizing enterocolitis (NEC). Which of the following findings is a risk factor for NEC? A. Macrosomia B. Transient tachypnea of the newborn (TTN) C. Maternal gestational hypertension D. Gestational age 36 weeks 2. A nurse is assessing a newborn who has congenital hypothyroidism. Which of the following findings should the nurse expect? (Select all that apply.) A. Hypertonicity B. Cool extremities C. Short neck D. Tachycardia E. Hyperreflexia 3. A nurse is teaching the parent of a newborn how to treat the newborn’s plagiocephaly. Which of the following statements by the parent indicates an understanding of the teaching? A. “I should put my baby to sleep on the belly during her afternoon nap.” B. “I should ensure my baby’s head is in the same position whenever sleeping.” C. “I should have my baby wear the prescribed helmet 23 hours a day.” D. “I should allow my baby to sleep in an infant swing.” 4. A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and is to undergo phototherapy. Which of the following actions should the nurse include in the plan of care? A. Reposition the newborn every 4 hr. B. Lotion the newborn’s skin twice per day. C. Check the newborn’s temperature every 8 hr. D. Remove the newborn’s eye mask during feedings. 5. A nurse is providing preconception teaching with a client who has phenylketonuria (PKU). Which of the following information should the nurse include in the teaching? A. Follow a low-phenylalanine diet once pregnancy is confirmed. B. The client will undergo testing of phenylalanine levels one to two times per week throughout pregnancy. C. Increase intake of dietary proteins prior to conception. D. The client will require a cesarean section birth due to the likelihood of having a fetus with macrosomia. 1. A nurse is caring for a child who is experiencing respiratory distress. Which of the following findings are early manifestations of respiratory distress? (Select all that apply.) A. Bradypnea B. Peripheral cyanosis C. Tachycardia D. Diaphoresis E. Restlessness 2. A nurse in the emergency department is caring for a child whose parent reports that the child has swallowed paint thinner. The child is lethargic, gagging, and cyanotic. Which of the following actions should the nurse take? A. Induce vomiting with syrup of ipecac. B. Insert a nasogastric tube, and administer activated charcoal. C. Prepare for intubation with a cuffed endotracheal tube. D. Administer chelation therapy using deferoxamine mesylate. 3. A nurse in the emergency department is admitting an infant who experienced a life-threatening event. Which of the following prescriptions by the provider should the nurse anticipate? (Select all that apply.) A. Electroencephalogram B. Electrocardiogram C. Urine culture D. Arterial blood gases E. Blood culture 4. A nurse is providing teaching to a caregiver about acetaminophen poisoning. Which of the following information should the nurse include in the teaching? A. Nausea begins 24 hr after ingestion. B. Pallor can appear as early as 2 hr after ingestion. C. Jaundice will appear in 12_hr if the child is toxic. D. Children can have 4 g/day of acetaminophen. 5. A nurse in a community center is providing an in-service to a group of parents on management of airway obstructions in toddlers. Which of the following responses by one of the caregivers indicates understanding? (Select all that apply.) A. “I will push on my child’s abdomen.” B. “I will hyperextend my child’s head to open the airway.” C. “I will listen over my child’s mouth for sounds of breathing.” D. “I will use my finger to check my child’s mouth for objects.” E. “I will place my child in my car and take them to the closest emergency facility.” 1. A nurse is teaching a group of parents about characteristics of infants who have failure to thrive. Which of the following characteristics should the nurse include in the teaching? A. Intense fear of strangers B. Increased risk for childhood obesity C. Inability to form close relationships with siblings D. Developmental delays 2. A nurse is providing instruction to the teacher of a child who has attention-deficit/hyperactivity disorder (ADHD). Which of the following classroom strategies should the nurse include in the teaching? (Select all that apply.) A. Eliminate testing. B. Allow for regular breaks. C. Combine verbal instruction with visual cues. D. Establish consistent classroom rules. E. Increase stimuli in the environment. 3. A nurse is teaching a parent about posttraumatic stress disorder (PTSD). Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Children who have PTSD can benefit from psychotherapy. B. A manifestation of PTSD is phobias. C. Personality disorders are a complication of PTSD. D. PTSD develops following a traumatic event. E. There are six stages of PTSD. 4. A nurse is teaching the parent of a child about risk factors for attention-deficit/hyperactivity disorder (ADHD). Which of the following should the nurse include in the teaching? A. Formula-feeding as an infant B. History of head trauma C. History of postterm birth D. Child of a single parent 5. A nurse is caring for a child who has depression. Which of the following findings should the nurse expect? (Select all that apply.) A. Preferring being with peers B. Weight loss or gain C. Report of low self-esteem D. Sleeping more than usual E. Hyperactivity [Show More]

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