A nurse is conducting an admission interview with the mother of a 2 year old child. What history question is most important at this time?
a. How many children are in the family?
b. What is your child's normal routine
...
A nurse is conducting an admission interview with the mother of a 2 year old child. What history question is most important at this time?
a. How many children are in the family?
b. What is your child's normal routine?
c. Does your child attend daycare?
d. What toys are most important to your child? - ANSWER b. What is your child's normal routine?
A 9 month old is sitting on his father's lap at the bedside. The nurse needs to do a shift assessment. How should the nurse proceed?
a. Ask the father to put the child in bed, and proceed with the exam.
b. Talk with the father for a few minutes, before examining child.
c. Listen to the heart and lungs of the child.
d. Take the child from the father, and proceed with the exam. - ANSWER b. Talk with the father for a few minutes, before examining child.
Which nursing intervention best supports the concept of atraumatic care for a hospitalized child?
a. Allowing parents to visit once every shift.
b. Encouraging six year old to be brave during an IV start.
c. Allowing adolescent to keep the hospital door shut.
d. Asking parents of baby to wait outside treatment room door during spinal tap. - ANSWER c. Allowing adolescent to keep the hospital door shut.
A six year old is in the recovery room following an appendectomy. He is not yet fully awake, though he opens his eyes when his name is called. Which pain assessment tool would be most effective for the nurse to use at this time?
a. OUCHER assessment tool.
b. Wong's FACES assessment tool.
c. FLAACC pain assessment tool.
d. 1-10 verbal assessment scale. - ANSWER c. FLAACC pain assessment tool.
A nurse enters the room of an 8-year-old child newly admitted and diagnosed with type I diabetes. His mother is sitting in a chair at his bedside. What should the nurse do first?
a. Go the bedside and meet the child.
b. Stand by the door, and say "I am the assigned nurse today."
c. Go over to the mother and ask what brought the child into the hospital today.
d. Explain the use of the call light to child. - ANSWER a. Go the bedside and meet the child.
Which hospitalized child would the nurse be most worried about as needing support or follow-up?
a. The 9-month-old that cries when the nurse walks in the room.
b. The 2-year-old that holds still during an IV start.
c. An adolescent that asks her father to leave the room during an assessment.
d. A school-age child that angrily throws his food tray on the floor. - ANSWER b. The 2-year-old that holds still during an IV start.
What nursing intervention would be most appropriate for a 10-year-old child with type I diabetes in order to meet their needs (as described by Erikson).
a. Explain carefully to the mother the need to rigidly adhere to dietary modifications.
b. Allow the child to eat whatever he or she wants and administer insulin to maintain optimum glucose levels.
c. Allow the child to perform his or her own Accuchecks and administration of insulin.
d. Perform Accuchecks four times a day and at bedtime. - ANSWER c. Allow the child to perform his or her own Accuchecks and administration of insulin.
A 16 year old female comes for a sport's physical in the clinic. During the nursing history, the teenage states she is bothered that she "towers over her companions and everyone is staring at her at school." What would be the most therapeutic response by the nurse?
a. "Just ignore the other kids at school."
b. "You are so lucky to be tall. You can play basketball or whatever you want."
c. "This will resolve itself in time."
d. "Tell me more about how this embarasses you." - ANSWER d. "Tell me more about how this embarasses you."
The maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the mother to take which measure?
A. Allow the newborn infant to signal a need.
B. Anticipate all the needs of the newborn infant.
C. Attend to the newborn infant immediately when crying.
D. Avoid the newborn infant during the first 10 minutes of crying. - ANSWER A. Allow the newborn infant to signal a need.
Rationale:
According to Erikson, the caregiver should not try to anticipate the newborn infant's needs at all times but must allow the newborn infant to signal needs. If a newborn infant is not allowed to signal a need, the newborn will not learn how to control the environment. Erikson believed that a delayed or prolonged response to a newborn infant's signal would inhibit the development of trust and lead to mistrust of others.
The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse should make which response?
A. "You need to be concerned."
B. "You need to monitor the child's behavior closely."
C. "At this age, the child is developing his own personality."
D. "You need to provide more praise to the child to stop this behavior." - ANSWER C. "At this age, the child is developing his own personality."
Rationale:
According to Erikson, during school-age years (6 to 12 years of age), the child begins to move toward peers and friends and away from the parents for support. The child also begins to develop special interests that reflect his or her own developing personality instead of the parents. Therefore options 1, 2, and 4 are incorrect responses.
A parent of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. Using Erikson's psychosocial development theory, which instructions should the nurse provide to the parent? SELECT ALL THAT APPLY
A. Set limits on the child's behavior.
B. Ignore the child when this behavior occurs.
C. Allow the behavior, because this is normal at this age period.
D. Provide a simple explanation of why the behavior is unacceptable.
E. Punish the child every time the child says "no" to change the behavior. - ANSWER A. Set limits on the child's behavior.
D. Provide a simple explanation of why the behavior is unacceptable.
Rationale:
According to Erikson, the child focuses on gaining some basic control over self and the environment and independence between ages 1 and 3 years. Gaining independence often means that the child has to rebel against the parents' wishes. Saying things like "no" or "mine" and having temper tantrums are common during this period of development. Being consistent and setting limits on the child's behavior are necessary elements. Providing a simple explanation of why certain behaviors are unacceptable is an appropriate action. Options 2 and 3 do not address the child's behavior. Option 5 is likely to produce a negative response during this normal developmental pattern.
A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears?
A. Encourage the child's parents to stay with the child.
B. Encourage play with other children of the same age.
C. Advise the family to visit only during the scheduled visiting hours.
D. Provide a private room, allowing the child to bring favorite toys from home. - ANSWER A. Encourage the child's parents to stay with the child.
A 16-year-old is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively?
A. Encourage the child to rest and read.
B. Encourage the parents to room in with the child.
C. Allow the family to bring in the child's favorite computer games.
D. Allow the child to interact with others in his or her same age group. - ANSWER D. Allow the child to interact with others in his or her same age group.
Rationale:
Adolescents often are not sure whether they want their parents with them when they are hospitalized. Because of the importance of their peer group, separation from friends is a source of anxiety. Ideally, the members of the peer group will support their ill friend. Options 1, 2, and 3 isolate the child from the peer group.
Which car safety device should be used for a child who is 8 years old and is 4 feet tall?
A. Seat belt
B. Booster seat
C. Rear-facing convertible seat
D. Front-facing convertible seat - ANSWER B. Booster Seat
Rationale:
All children whose weight or height is above the forward-facing limit for their car safety seat should use a belt-positioning booster seat until the vehicle seat belt fits properly, typically when they have reached 4 feet 9 inches in height and are between 8 and 12 years of age. Infants should ride in a car in a semireclined, rear-facing position in an infant-only seat or a convertible seat until they weigh at least 20 pounds and are at least 1 year of age. The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat but is generally at a body weight of 9 kg (20 pounds) and 1 year of age.
The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. On the basis of this finding, which action is most appropriate?
A. Administer oxygen.
B. Document the findings.
C. Notify the health care provider.
D. Reassess the respiratory rate in 15 minutes. - ANSWER B. Document the findings
Rationale:
The normal respiratory rate in a 12-month-old infant is 20 to 40 breaths/minute. The normal apical heart rate is 90 to 130 beats/minute, and the average blood pressure is 90/56 mm Hg. The nurse would document the findings.
The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate?
A. Increase oral fluids.
B. Document the finding.
C. Notify the health care provider (HCP).
D. Elevate the head of the bed to 90 degrees. - ANSWER B. Document the finding.
Rationale:
The anterior fontanel is diamond-shaped and located on the top of the head. The fontanel should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. The nurse would document the finding because it is normal. There is no useful reason to increase oral fluids, notify the HCP, or elevate the head of the bed to 90 degrees.
The nurse is evaluating the developmental level of a 2-year-old. Which does the nurse expect to observe in this child?
A. Uses a fork to eat
B. Uses a cup to drink
C. Pours own milk into a cup
D. Uses a knife for cutting food - ANSWER B. Uses a cup to drink
Rationale:
By age 2 years, the child can use a cup and spoon correctly but with some spilling. By age 3 to 4, the child begins to use a fork. By the end of the preschool period, the child should be able to pour milk into a cup and begin to use a knife for cutting.
The 2-year-old child is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home?
A. "We will be sure not to leave hot liquids unattended."
B. "I guess my children need to understand what the word hot means."
C. "We will be sure that the children stay in their rooms when we work in the kitchen."
D. "We will install a safety gate as soon as we get home so the children cannot get into the kitchen." - ANSWER A. "We will be sure not to leave hot liquids unattended."
Rationale:
Toddlers, with their increased mobility and development of motor skills, can reach hot water or hot objects placed on counters and stoves and can reach open fires or stove burners above their eye level. The nurse should encourage parents to remain in the kitchen when preparing a meal, use the back burners on the stove, and turn pot handles inward and toward the middle of the stove. Hot liquids should never be left unattended or within the child's reach, and the toddler should always be supervised. The statements in options 2, 3, and 4 do not indicate an understanding of the principles of safety.
A mother arrives at a clinic with her toddler and tells the nurse that she has a difficult time getting the child to go to bed at night. What measure is most appropriate for the nurse to suggest to the mother?
A. Allow the child to set bedtime limits.
B. Allow the child to have temper tantrums.
C. Avoid letting the child nap during the day.
D. Inform the child of bedtime a few minutes before it is time for bed. - ANSWER D. Inform the child of bedtime a few minutes before it is time for bed.
Rationale:
Toddlers often resist going to bed. Bedtime protests may be reduced by establishing a consistent before-bedtime routine and enforcing consistent limits regarding the child's bedtime behavior. Informing the child of bedtime a few minutes before it is time for bed is the most appropriate option. Most toddlers take an afternoon nap and, until their second birthday, also may require a morning nap. Firm, consistent limits are needed for temper tantrums or when toddlers try stalling tactics.
The mother of a 3-year-old is concerned because her child still is insisting on a bottle at nap time and at bedtime. Which is the most appropriate suggestion to the mother?
A. Allow the bottle if it contains juice.
B. Allow the bottle if it contains water.
C. Do not allow the child to have the bottle.
D. Allow the bottle during naps but not at bedtime. - ANSWER B. Allow the bottle if it contains water
Rationale:
A toddler should never be allowed to fall asleep with a bottle containing milk, juice, soda pop, sweetened water, or any other sweet liquid because of the risk of nursing (bottle-mouth) caries. If a bottle is allowed at nap time or bedtime, it should contain only water.
The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child?
A. A radio
B. A sports video
C. Large picture books
D. Crayons and a coloring book - ANSWER D. Crayons and a coloring book
Rationale:
In the preschooler, play is simple and imaginative, and includes activities such as crayons and coloring books, puppets, felt and magnetic boards, and Play-Doh. A radio or sports video are most appropriate for the adolescent. Large picture books are most appropriate for the infant.
A mother of a 3-year-old asks a clinic nurse about appropriate and safe toys for the child. The nurse should tell the mother that the most appropriate toy for a 3-year-old is which?
A. A wagon
B. A golf set
C. A farm set
D. A jack set with marbles - ANSWER A. A wagon
Rationale:
Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, large trucks, and dolls are some of the appropriate toys. A farm set, a golf set, and jacks with marbles may contain items that the child could swallow.
Which interventions are appropriate for the care of an infant? SELECT ALL THAT APPLY
A. Provide swaddling.
B. Talk in a loud voice.
C. Provide the infant with a bottle of juice at nap time.
D. Hang mobiles with black and white contrast designs.
E. Caress the infant while bathing or during diaper changes.
F. Allow the infant to cry for at least 10 minutes before responding. - ANSWER A. Provide swaddling.
D. Hang mobiles with black and white contrast designs.
E. Caress the infant while bathing or during diaper changes.
The nurse is caring for a 4-year-old child with human immunodeficiency virus (HIV) infection. The nurse should plan care with the understanding that which childhood psychosocial need occurs at this age?
[Show More]
