A nurse is assessing the pain level of a 3 year old toddler. Which of the following assessment scales should the nurse use?
a. FACES
b. Numeric
c. CRIES
d. Visual analog
(Ans - A
A nurse is planning an educatio
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A nurse is assessing the pain level of a 3 year old toddler. Which of the following assessment scales should the nurse use?
a. FACES
b. Numeric
c. CRIES
d. Visual analog
(Ans - A
A nurse is planning an educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include?
a. "allow your child to play outside during the hours between 10:00am and 2:00pm."
b. "choose a waterproof sunscreen with a minimum SPF of 15."
c. "dress you child in loose weave polyester fabric prior to sun exposure."
d. "reapply sunscreen every 4 hours."
(Ans - B
A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation?
a. an 18 month old toddler who has unintelligible speech
b. a 3 month old infant who has exaggerated startle response
c. a 4 year old preschooler who prefers playing with others rather than alone
d. an 8 month old infant who is not yet making babbling sounds
(Ans - D
A nurse in an emergency department is assessing a 3 month old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration?
a. HR 124
b. increased tear production
c. sunken anterior fontanel
d. capillary refill 2 seconds
(Ans - C
A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthrisis. Which of the following instructions should the nurse include in the teaching?
a. "limit movement of the child's large joints"
b. "encourage the child to perform independent self-care."
c. "provide the child with a soft mattress for sleeping."
d. "schedule a 2 hour daily nap for the child in the afternoon."
(Ans - B
A nurse is planning care for a school age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plan?
a. use sterile scissors to remove the dressing from the site
b. irrigate each lumen weekly with 10 ml of 0.9% sodium chloride solution when not in use
c. access the site suing a noncoring angle needle
d. use a semipermeable transparent depressing to cover the site
(Ans - D
A nurse is providing anticipatory guidance to the parent of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include?
a. controls impulsive feelings
b. understands right from wrong
c. easily separates from parents for long periods of time
d. expresses likes and dislikes
(Ans - D
A nurse is providing discharge teaching to the parent of a school age child who has moderate persistent asthma. Which of the following instructions should the nurse include?
a. "you should give your child their salmeterol inhaler every 4 hours when they are having an acute episode of wheezing."
b. "you should monitor your child's weight weekly while they are receiving inhaled corticosteroids therapy."
c. "pulmonary function tests will be performed every 12-24 months to evaluate how your child is responding to therapy."
d. "when using the peak expiratory flow meter, record your child's average of three readings."
(Ans - C
A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication?
a. reports an absence of nausea and vomiting
b. reports experiencing an onset of loose stools within 15 minutes of administration
c. serum potassium level 4.1 mEq/L
d. blood pressure 86/52 mm Hg
(Ans - C
A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report the provider?
a. nasal flaring
b. WBC count 11,300/mm^3
c. diarrhea
d. abdominal distension
(Ans - A
A nurse is providing discharge teaching to the guardian of a school age child who has undergone a tonsillectomy. Which of the following statements by the guardian indicates an understanding the teaching?
a. "my child can resume usual activities since this year just an outpatient surgery."
b. "my child will be able to drink the chocolate milkshake I promised to get for them tonight."
c. "I will notify the doctor if I notice that my child is swallowing frequently."
d. "I will have my child gargle with warm salt water to relieve their sore throat."
(Ans - C
A nurse is discussing organ donation with the parents of a school age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first?
a. inform the parents that written consent is required prior to organ donation
b. provide written information to the parents about organ donation
c. ask the provider to explain misconceptions of organ donation to the parents.
d. explore the parents feelings and wishes regarding organ donation
(Ans - D
A nurse is caring for a newly admitted school age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to prescribe?
a. Desmopressin
b. Luteinizing hormone-releasing hormone
c. Recombinant growth hormone
d. Levothyroxine
(Ans - C
A nurse is providing discharge teaching to he parents of a 3 month old infant following a cheiloplasty. Which of the following instructions should the nurse include?
a. "clean your baby's sutures daily with a mixture of chlorhexidine and water."
b. "expect your baby to swallow more than usual over the next few days."
c. "inspect your baby's tongue for white patches using a tongue depressor every 8 hours."
d. "apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days."
(Ans - D
A nurse is caring for a school age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema?
a. palpate the dorsum of the child's feet
b. weigh the child daily using the same scale
c. assess the child's skin turgor
d. observe the child for periorbital swelling
(Ans - A
A nurse is caring for a 10 year old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes incipidus?
a. urine specific gravity 1.045
b. sodium 155 mEq/L
c. blood glucose 45 mg/dL
d. urine output 35 mL/hr
(Ans - B
A school nurse is providing an in service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching?
a. "I will plan to increase the amount of homework I assign to students who have ADHD."
b. "I will give students who have ADHD the same amount of time as other students to complete tests."
c. "I will allow students who have ADHD one rest break throughout the day."
d. "I will teach challenging academic subjects to students who have ADHD in the morning."
(Ans - D
A nurse is providing discharge teaching to the parent of an 18 month old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching?
a. "I will offer my child small amounts of fruit juice frequently."
b. "I will avoid giving my child solid foods until the diarrhea has stopped."
c. "I will monitor my child's number of wet diapers."
d. "I will give my child polyethylene glycol daily for 7 days."
(Ans - C
A nurse is teaching a school age child and their parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include?
a. "Stay home from school for 1 week following the procedure."
b. "follow a diet that is low in fiber for 1 week."
c. "wait 3 days before taking a tub bath."
d. "apply a pressure dressing to the site for 3 days."
(Ans - C
A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan?
a. administer pancreatic enzymes 2 hours after meals
b. discontinue the use of pancreatic enzymes if steatorrhea develops
c. limit fluid intake to 750 mL per day
d. increase fat content in the child's diet to 40% of total calories.
(Ans - D
A nurse is admitting an infant who has intussesception. Which of the following findings should the nurse expect? (select all that apply)
a. steatorrhea
b. vomiting
c. lethargy
d. constipation
e. weight gain
(Ans - B, C
A nurse is assessing an 8 year old child who has early indication of shock. After establishing an airway and stabilizing the child's respirations, which of the following actions should the nurse take next?
a. insert an indwelling urinary catheter
b. measure weight and height
c. initiate IV access
d. maintain ECG monitoring
(Ans - C
A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching?
a. "I should buy plastic shoes to wear at the swimming pool."
b. "I should wear sandals as much as possible."
c. "I should place the permethrin cream between my toes twice daily."
d. "I should seal my nonwashable shoes in plastic bags for a couple of weeks."
(Ans - B
A nurse is caring for a school age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect?
a. deep respirations of 32/min
b. shallow respirations of 10/min
c. paradoxic respirations of 26/min
d. periods of apnea lasting for 20 seconds
(Ans - A
A nurse is assessing a 6 month old infant during a well child visit. Which of the following findings should the nurse report to the provider?
a. presence of a central incisor tooth
b. presence of strabismus
c. presence of an open anterior fontanel
d. presence of external cerumen
(Ans - B
A charge nurse is preparing to make a room assignment for a newly admitted school age child. Which of the following considerations is the nurse's priority?
a. length of stay
b. treatment schedule
c. disease process
d. self-care ability
(Ans - C
A school nurse is caring for a child following a tonic-clonic seizure. Which of the following actions should the nurse take first?
a. check the child for a head injury
b. observe for oral bleeding
c. check the child's respiratory rate
d. observe for extremity weakness
(Ans - C
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