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A nurse determines that premature infant receiving oxygen

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					A nurse determines that a premature infant receiving oxygen therapy has an arterial PO2
of 89 mm Hg. The nurse caring for the infant should report this information to which
health team member first?
         Correct: Since the safe range for PO2 in a premature infant is between 50 and 80
mm Hg, it is the physician's responsibility to change the order for titration of oxygen
administration to prevent complications related to oxygen toxicity.
Incorrect: It is not within the scope of the respiratory therapist's practice to adjust the
titration of oxygen being administered to a premature infant.Incorrect: The nursing
supervisor does not need to be involved in this decision-making process and therefore
would not need to be notified first.Incorrect: The charge nurse does not have to be
notified first since it is beyond the charge nurse's scope of practice to change orders for
oxygen administration.
                 Neonatologist
                 Respiratory therapist
                 Nursing supervisor
                 Charge nurse
2

A 15-year old is hospitalized for a spinal fusion. He has a history of asthma and will
continue using a salmeterol (Serevent) inhaler twice a day during the hospitalization.
Which is the most developmentally appropriate nursing intervention for this adolescent?

       Incorrect: Telling the adolescent what time he will take a medication he takes at
home does not facilitate independence nor does it foster a sense of control.
Incorrect: Salmeterol is a long-acting bronchodilator used to prevent asthma
exacerbations. It is not to be used as a rescue medication during exacerbations.
Correct: According to Erikson, the adolescent is striving for independence. Working with
the adolescent to meet his health care needs in an appropriate, pre-established pattern to
which he is accustomed allows the adolescent to maintain a sense of control.
Incorrect: Scheduling medication administration times is a nursing action. The provider's
order usually specifies intervals or blocks of time, such as "at bedtime," but not specific
times.
               Schedule the salmeterol administration times according to hospital policy.
               Schedule the salmeterol inhaler to be used PRN when he feels he needs it.
               Schedule salmeterol administration times to match his usual
administration schedule.
               Consult his physician about scheduling appropriate administration times.

3

Identify the congenital heart defects that result in increased pulmonary blood flow and
therefore cause signs and symptoms of congestive heart failure (CHF). (Check all that
apply.)
        Correct: Atrial septal defect is a correct response. This abnormal opening in the
wall between the two atria allows blood from the high-pressure left side of the heart to
move into the low-pressure right side. This left-to-right shunt increases pulmonary blood
flow, resulting in congestive heart failure (CHF).

Patent ductus arteriosus is a correct response. This is an accessory fetal channel between
the pulmonary artery and the aorta that fails to close after birth, allowing blood from the
higher-pressure aorta to move into the lower-pressure pulmonary artery. This left-to-right
shunt increases pulmonary blood flow, resulting in CHF.

Ventricular septal defect is a correct response. It is an abnormal opening in the wall
between the two ventricles that allows blood from the high-pressure left side of the
heart to move into the low-pressure right side. Anything that shunts will cause a left-
right shunt d/t pressure. This left-to-right shunt increases pulmonary blood flow, resulting
in CHF.

Tricuspid atresia is an incorrect response. there is a complete absence of the tricuspid
valve. This failure of the valve between the right atrium and the left ventricle to develop
results in varying amounts of pulmonary obstruction, thus decreasing pulmonary blood
flow. (little R sided pumping=less to the lungs]. Children with this anomaly do not
typically develop CHF.

Hypoplastic left heart syndrome is an incorrect response. This is an underdevelopment of
the left side of the heart. Pulmonary blood flow is variable depending on the differences
between the pulmonary and the systemic vascular resistance, classified as a defect that
decreases pulmonary blood flow. Some infants do develop CHF initially, but this
condition proceeds quickly to cardiovascular collapse.

Tetralogy of Fallot is an incorrect response. It is actually four defects that alter
hemodynamics to widely varying degrees. Shunting can be in either direction depending
on the degree of the defects and the differences between the pulmonary and the systemic
vascular resistance. It is classified as a defect that decreases pulmonary blood flow and
does not typically lead to CHF.
                Atrial septal defect
                Patent ductus arteriosus
                Ventricular septal defect
                Tricuspid atresia
                Hypoplastic left heart syndrome
                Tetralogy of Fallot
4

A nurse is caring for a 10-year-old client diagnosed with type I diabetes. The nurse would
expect to find moderate to high ketones in the child's urine if she:
        Correct: Warm, dry, flushed skin are signs of hyperglycemia, which if
uncontrolled, can lead to ketones in the urine indicating ketoacidosis.
Incorrect: Cool, clammy, pale skin is a classic manifestation of hypoglycemia. At the
onset of the hypoglycemic episode, the parasympathetic nervous system is activated.
This results in sweating and constriction of the peripheral vessels of the skin.
Incorrect: Anxiety is a classic manifestation of hypoglycemia. At the onset of the
hypoglycemic episode, the parasympathetic nervous system is activated. This results in
anxiety.
Incorrect: This is a classic sign of hypoglycemia. The kidneys do not excrete ketones
during hypoglycemia.
               has dry, flushed skin.
               has cold, clammy skin.
               seems very nervous.
               says that she is hungry.
5

A nurse assessing a 13-year-old girl observes that the bottom edges of the client's pants
legs are uneven when she stands upright. The adolescent also has a 25-degree lateral
curvature of the spine and asymmetric shoulder heights. These findings:
        Incorrect: Kyphosis is a round-back alteration characterized by a convex
curvature of the thoracic spine of more than 40 degrees (hunch back). This adolescent has
a lateral curvature.
Incorrect: A curvature of less than 10 degrees is considered a postural variation. Lateral
curvatures between 10 and 20 degrees are mild and might not require intervention. But
this child has a 25-degree curvature.
Correct: Normal findings would be symmetric shoulder heights, pants lengths of equal
distance from the floor, and a straight spine with a lateral curvature of less than 10
degrees. When clustered, these signs indicate scoliosis and warrant referral for medical
diagnosis and treatment.
Incorrect: Signs of spinal alteration are clearly present and the earlier these are identified,
the earlier treatment can begin and further progression can be interrupted. Observing for
progression might be warranted for a curvature less than 20 degrees, but this child has a
25-degree curvature.
                 are signs of kyphosis.
                 reflect a simple postural variation.
                 are signs of scoliosis.
                 warrant follow-up in 6 months.


The mother of a child diagnosed with type I diabetes mellitus asks, "Why does my child's
breath sometimes smell like fruity gum?" The nurse explains that this odor is a sign of
diabetic ketoacidosis and is due to the body's release of:
         Incorrect: Glycogen is the form in which excess carbohydrate is stored in the
liver. It is not something that is excreted.Correct: In a client who has developed diabetic
ketoacidosis, fats break down into fatty acids and glycerol in the liver, and are then
converted to acetone, a simple ketone. Ketones are expelled by the kidneys through the
urine, and by the lungs as acetone, which causes a fruity breath odor.Incorrect: Serum
glucose is high in clients who have developed diabetic ketoacidosis. It results in increased
breakdown of fats, but glucose itself is not expelled by the lungs.Incorrect: Urea is a
normal urine component, and is not expelled by the lungs.
                  glycogen.
               acetone.
               glucose.
               urea.
7

A 6-week-old infant is diagnosed with congestive heart failure due to a ventricular septal
defect. An oral digitalizing dose is prescribed. Half of the total digitalizing dose is to be
administered orally as the initial dose, one quarter of the total digitalizing dose is to be
administered orally 8 hours later, and one quarter of the total digitalizing dose is to be
administered orally 16 hours after the initial dose. The recommended total digitalizing
dose of oral digoxin (Lanoxin) for an infant 1 month to 2 years of age is 30 to 50 mcg/kg.
What is the maximum oral dose in micrograms that this infant, who weighs 4 kg (8.8 lb),
can receive for each dose of the second and third components of the digitalizing dose?
         mcg Correct: To determine the maximum correct dosage, multiply the child's
weight in kg times the maximum amount of drug prescribed per kg (50 mcg). So, 50 X 4
= 200. The child cannot receive more than 200 mcg of digoxin as a digitalizing regimen.
The initial dose is not to exceed one half of 200 mcg, or 100 mcg. The next two doses,
each one quarter of total dose, cannot exceed one quarter of 200 mcg, or 50 mcg,
calculated by multiplying ¼ by 200 to equal 50. Any calculation that yields a response
other than 50 would be incorrect.To determine the maximum correct dosage, multiply the
child's weight in kg times the maximum amount of drug prescribed per kg (50 mcg). So,
50 X 4 = 200. The child cannot receive more than 200 mcg of digoxin as a digitalizing
regimen. The initial dose is not to exceed one half of 200 mcg, or 100 mcg. The next two
doses, each one quarter of total dose, cannot exceed one quarter of 200 mcg, or 50 mcg,
calculated by multiplying ¼ by 200 to equal 50. Any calculation that yields a response
other than 50 would be incorrect.
                50


8

A child is scheduled for resection of a brain tumor. An important preoperative nursing
intervention is to:
        Incorrect: Honest communication is a key factor in developing a therapeutic
relationship. The surgeon might not be able to remove the entire tumor.

Correct: Baseline assessment data are used to identify postoperative changes in the child.
Areas to assess include but are not limited to pain, motor skills, behavioral changes,
visual and auditory abilities, and onset and pattern of seizure activity.

Incorrect: Proper positioning postoperatively plays a role in decreasing or preventing
increased intracranial pressure. However, the child may assume a position of comfort
preoperatively.

Incorrect: Pain management is an important nursing function. A safe and effective pain
management plan can be implemented using an age-appropriate pain scale;
nonpharmacologic techniques (distraction, guided imagery); and nonopioid, opioid, and
combination medications. Sedatives can be used in conjunction with antiseizure
medications to prevent seizures. Sedation might play a role in relieving increased
intracranial pressure.
                assure the child the tumor will be gone after the surgery.
                document the child's baseline assessment data.
                discourage the child from lying on the side of the head with the tumor.
                withhold pain medication to assess level of consciousness.
9

The mother of a 12-month old who has just been admitted to a pediatric unit must leave
the hospital to meet her other children at the school bus stop. Which action will the nurse
suggest to the mother to make the transition easiest for the infant?
       Correct: Leaving a security or transitional object, such as a favorite toy or blanket,
will minimize fear by keeping an aspect of the environment familiar to the child.

Incorrect: This could make the baby distrust the nurse and the mother.

Incorrect: Most children this age cannot be forced to nap.

Incorrect: This will not address the transition the baby will have to make whenever the
mother must leave. Children will learn to adapt when separated from their parents.
               Providing a security item before leaving
               Slipping away while the nurse is playing with the baby
               Putting the baby in bed for a nap before leaving
               Arranging for someone else to meet the other children
10

While assessing an 8-month old, the nurse observes increased muscle tone and tongue
thrusting. The infant shows a preference for the right hand when reaching for objects. The
Moro reflex is present. This group of symptoms most clearly relates to:

        Incorrect: Muscular dystrophy is characterized by muscle weakness leading to
muscle wasting. Muscular dystrophy is not associated with early preferential hand use or
persistence of infant reflexes.

Incorrect: Infants who have Down syndrome display hypotonia and tongue thrusting.
Down syndrome is not associated with early preferential hand use or persistence of infant
reflexes.

Incorrect: Juvenile rheumatoid arthritis (JVA) is characterized by stiff, swollen joints
resulting in loss of motion. JVA is not associated with early preferential hand use or
persistence of infant reflexes.

Correct: Increased or decreased muscle tone is a characteristic of cerebral palsy.
Children tend to show a preference for the right or left hand during the preschool
years. Infants with cerebral palsy may show a preference for their right or left hand
as early as at 6 months of age. Persistent infant reflexes are another characteristic of
cerebral palsy. The Moro reflex normally disappears by 3 to 4 months of age.
               muscular dystrophy.
               Down syndrome.
               juvenile rheumatoid arthritis.
               cerebral palsy.


11

A 5-five-year old is about to have her left long-arm cast removed and the nurse is
preparing the parents for the procedure. He knows that his teaching has been successful
when the child acts very fearful and her father responds by:
        Correct: Young children think of a cast they have worn for a while as part of their
body. They usually adapt well, but might fear its removal.Incorrect: The parent should be
helped to understand that this procedure can be overwhelming or frightful for a child. It
will not help the child to minimize her crying as though this experience were
commonplace or that she would handle the situation more appropriately if she were
older.Incorrect: Actually, she might not feel better soon. The cast removal procedure will
be over, but casted extremities can be quite tender in the injured area after cast removal.
Also, the cast protected it from minor bumps and pressure and now this child will no
longer have that protective shield.Incorrect: Rewarding desirable behavior is a common
method parents use to control children's behavior. However, in this case, the child should
be allowed to cry. This is a traumatic event, and a 5-year-old child should not be expected
to endure it without expressing emotion.
                stating that she is so used to the cast that she is afraid to have it removed.
                explaining that she always cries "like that" and will be better when she is
older.
                telling the child not to cry because she will feel better soon.
                telling the child that he will buy her a toy if she stops crying.
12

A 3-year old with acute lymphocytic leukemia, severe stomatitis, and thrombocytopenia
is admitted to a pediatric unit. Which is an important nursing intervention for meeting
this child's daily needs?
        Correct: Oral hygiene is a priority for a child who has cancer. Due to the
stomatitis and thrombocytopenia, the child's mouth will be sensitive and at risk for
bleeding. A soft sponge toothbrush should decrease the trauma a soft-bristle toothbrush
might cause to her gums.Incorrect: Pain caused by stomatitis can prevent the child from
eating a well-balanced diet. Putting pressure on a child with stomatitis to eat food that
hurts the mouth is inappropriate. A soft, moist, and bland diet is generally
recommended.Incorrect: Lemon glycerin swabs cause a burning or stinging sensation
when applied to broken, ulcerated skin. They can also have a drying effect on oral
mucosa, and they can cause tooth decay.Incorrect: This type of solution is not given to
young children because they might swallow the mixture instead of spitting it out of the
mouth. Swallowing a local anesthetic such as lidocaine can temporarily depress the
child's gag reflex.
                Help her brush her teeth gently with a soft sponge toothbrush.
                Encourage the child to eat a well-balanced diet.
                Clean the child's mouth frequently with lemon glycerin swabs.
                Administer a swish-and-spit local anesthetic solution.

13

A 7-year old is sent to the school's health office because the teacher states that she has
been asking to go to the restroom every hour. The nurse examines her and notes
abdominal pain with palpation. The child's urine is foul-smelling and the test strip is
positive for hematuria. Based on these findings, the nurse suspects that the most likely
reason for these symptoms is:
        Incorrect: Although child abuse can cause these symptoms, the nurse would not
suspect this as the most likely cause unless there were other physical or behavioral
manifestations of abuse.Incorrect: Pyelonephritis is an infection of the kidneys and the
renal pelvis. A child with this disorder would also have fever and chills, and pain in either
or both flanks rather than abdominal pain.Correct: These are classic signs of urinary tract
infection. Other manifestations include incontinence, dysuria, and urgency.Incorrect: A
child with nephrotic syndrome would have generalized edema. Some children with this
disorder also develop hematuria, but they would not have urinary frequency, as urine
output is decreased.
                child abuse.
                pyelonephritis.
                urinary tract infection.
                nephrotic syndrome.
14

An 8-year old is brought to an outpatient clinic with his mother. The mother tells the
nurse that her son is not eating well and says he is tired all the time. According to his
chart, the child has lost approximately 8 lb (3.6 kg) since his last visit to the clinic 6
months ago. The nurse finds palpable, nontender lymph nodes in the child's axilla and in
the neck. The nurse suspects that the physician will:
        Incorrect: This child does not report a sore throat, nor a change in swallowing or
dysphagia. These symptoms would indicate possible tonsillitis.Incorrect: This child is not
presenting with dysphagia, drooling, nor complaints of sore throat - hallmark signs of
epiglottitis. With epiglottitis, children tend to sit upright and lean forward, with the chin
thrust out, the mouth open, and the tongue protruding. This is the tripod position.Correct:
This child has several warning signs of Hodgkin's lymphoma. Along with other
laboratory tests, a biopsy will be done on the lymph nodes to determine the presence of
one of the hallmarks of diagnosis of this malignant disease - Sternberg-Reed
cells.Incorrect: This child does not have symptoms suggestive of exercise-induced
asthma.
                check the child's tonsils for pustular streaks or pockets.
                assess the child's ability to breathe when not in the tripod position.
               arrange a biopsy to determine the presence of Sternberg-Reed cells.
               inquire about wheezing episodes during or following exercise or activity.
15

Teaching the parents of a child diagnosed with impetigo should include:
        Correct: Impetigo is a highly contagious infection spread by direct
contact.Incorrect: Debridement should only be done after soaking and should be
performed gently. Vigorous debridement can cause bleeding and pain.Incorrect: Impetigo
is not an eye condition. It is a skin infection.Incorrect: Squeezing vesicles to rupture them
will not hasten healing, plus it can worsen the lesions and spread the infection.
                preventing transmission to playmates and siblings.
                debriding lesions vigorously with a soft scrubbing brush.
                patching the affected eye because of photophobia.
                rupturing vesicles to release fluid and promote healing.



16

To assess a child for strabismus, the nurse uses the cover-uncover test. He observes the
left eye move when tested uncovered. He concluded that this child's eye is:
         Incorrect: Amblyopia is a condition that develops when strabismus is left
untreated. If the child's left eye had developed this complication, she would have no
vision in it at all.
Incorrect: Myopia, or nearsightedness, is the ability to see close objects clearly but not
distant ones. This is because light rays fall in front of the retina instead of on it. The
Snellen letter chart is used to test distant visual acuity as a client stands 20 feet away and
reads lines of letters that decrease progressively in size. Pediatric adaptations are
available for younger children. This chart is useful for identifying myopia, but is not
useful for identifying strabismus.
Correct: The cover-uncover test interrupts the fusion reflex, which normally keeps the
eyes parallel. When one eye is covered, the other should remain in a fixed position,
focused straight ahead. If it moves to establish focus, there is a deviation in alignment of
the eyes due to muscle weakness. Strabismus is a constant misalignment of the eyes,
resulting in monocular vision.
Incorrect: Hyperopia, or farsightedness, is the ability to see distant objects clearly but not
close ones. This is because light rays fall beyond the retina instead of on it. The Snellen
letter chart is used to test distant visual acuity as a client stands 20 feet away and reads
lines of letters that decrease progressively in size. Pediatric adaptations are available for
younger children. This chart is useful for identifying hyperopia, but is not useful for
identifying strabismus.
                 amblyopic.
                 myopic.
                 misaligned.
                 hyperopic.
17
When planning a teaching session for a 9-year-old child newly diagnosed with diabetes,
the nurse should plan to teach:
        Incorrect: This is a communication pattern used more commonly with preschool
children.
Correct: This will foster the child's need for initiative in learning new terms and phrases.
School-age children take pride in learning the correct labels for a medical condition as
well as its treatment approaches and medications.
Incorrect: This learning strategy is better focused on adolescents, as it can overwhelm a
school-age child.
Incorrect: This is often thought to be a good strategy because it takes advantage of many
children's tendencies toward competition, when in fact it can trigger feelings of inferiority
when one child's abilities are singled out.
                 in relationship to the child's sensory perceptions.
                 terminology related to treatment and medication.
                 independence in performing self-care skills and activities.
                 this child in a group to compare his learning abilities with others'.
18

During a tonic-clonic seizure, which client assessment data are essential to collect and
document if the client becomes cyanotic?
        Correct: Seizure activity increases oxygen consumption. Noting the length of time
of the seizure is important for estimating the degree of oxygen compromise in a cyanotic
client.
Incorrect: This information is important to document; however, it is not related to the
client becoming cyanotic.
Incorrect: Assessment of the client for any possible injuries sustained during seizure
activity is essential and must be documented and treated appropriately. Although
important, this information is not related to the cause of seizure activity nor to the client's
cyanosis.
Incorrect: Neurological changes might occur during seizure activity, but they do not
directly affect oxygen consumption.
                The time the seizure began and the time it ended
                Significant precipitating events prior to seizure activity
                Any injuries the client sustained during seizure activity
                Neurological changes such as fixed pupils or posturing
19

A nurse assessing a 7-year old just admitted with a diagnosis of acute glomerulonephritis
would expect to find (check all that apply):

Increased urinary output is an incorrect response. With acute glomerulonephritis, urinary
output is decreased due to an impaired filtration of plasma by the kidneys that causes an
excessive accumulation of water and retention of sodium.
Periorbital edema is a correct response. Moderate edema due to accumulation of water is
most prominent around the eyes in the morning and then spreads during the day to the
abdomen and the extremities.
Dark-colored urine is a correct response. The urine of a child who has acute
glomerulonephritis is cloudy and smoky brown, resembling tea or cola.
Anorexia is a correct response. Loss of appetite is a common manifestation of acute
glomerulonephritis.
Hypertension is a correct response. Blood pressure is typically mildly to moderately
elevated.
Lethargy is a correct response. Children who have acute glomerulonephritis are usually
lethargic. They appear pale and unwell but often cannot express specific symptoms.
               Increased urinary output
               Periorbital edema
               Dark-colored urine
               Anorexia
               Hypertension
               Lethargy
20

While performing a physical examination on a 7-year-old child, the nurse notes a classic
symptom of acute allergic rhinitis when she finds:
        Incorrect: Wheezing in the bronchial tree indicates air moving through
constrictive airways. This is not considered a classic symptom of allergic rhinitis and is
more likely related to asthma.
Correct: On physical examination, children who have allergic rhinitis have dark circles or
"allergic shiners" under their eyes from obstruction of the usual outflow from regional
lymphatics and veins.
Incorrect: A frequent and persistent cough is not a typical finding with allergic rhinitis
and is more likely related to an upper respiratory infection.
Incorrect: Inflammation around the nose is possible if the child persistently rubs the nose
vigorously due to itchiness, but it is not a classic symptom. A related classic sign is the
"allergic salute," the actual rubbing of the nose to alleviate itching.
                wheezing in the bronchial tree.
                dark circles under the eyes.
                frequent, persistent cough.
                inflammation around the nose.



21

A nurse is teaching a 15-year-old client who is newly diagnosed with type I diabetes
mellitus. When discussing how to adjust activity and exercise, the nurse concludes that
the teen understands what she must do when she states:
        Incorrect: The client would need less, not more, insulin due to increased activity,
which lowers blood sugar.
incorrect: A child who is active in team sports might need to increase food intake or
decrease insulin dosage because exercise helps move glucose into the cells and out of the
bloodstream, causing hypoglycemia. Eating a complex carbohydrate snack about 30
minutes before the child engages in team sports is usually recommended.
Incorrect: If activity is decreased, insulin needs increase.
Correct: A blood sugar of 240 mg/dL or above can be dangerous. Urine should be
checked for ketones and the activity postponed until blood glucose is under control.
                "I need to take extra insulin right before soccer practice."
                "I need to eat a snack about 2 hours before soccer practice."
                "I will need less insulin on the days I don't play soccer."
                "I should skip soccer practice if my blood sugar is too high."

     22    Which illustration represents activity that infants demonstrate in later stages of
           motor development?



23

A 5-year old in skeletal traction for multiple lower-extremity fractures has been found to
have head lice. The client is treated and removed from isolation after 24 hours. One week
later, the nurse finds lice while performing routine care. Which item in the child's bed is
the most likely transport agent?
         Incorrect: With treatment and isolation initiation, all items in contact with the
client at the time would have been replaced.
Correct: Lice can live up to 48 hours on personal items that have been in contact with
human hair infested with lice.
Incorrect: The traction apparatus would not have been in contact with the child's head.
Incorrect: With treatment and isolation initiation, all items in contact with the client at the
time would have been replaced. The child's gown or pajamas would have been changed
daily.
                 Hospital pillow
                 Sibling's baseball cap
                 Traction device
                 Hospital gown
24

A nurse reviews a care plan for a child diagnosed with Wilms' Tumor (nephroblastoma).
The nurse will appropriately add which intervention?
        Correct: Movement of the tumor can cause cells to travel to adjacent and distant
sites and metastasize.Incorrect: Auscultation must be done to determine bowel status and
to monitor for obstruction.Incorrect: Only quiet play would be appropriate, as the child
could be injured if play becomes increasingly physical.Incorrect: Quiet play is essential
for normal socialization and to decrease the stress of hospitalization and the trauma of the
diagnosis.
               Bathe gently avoiding abdominal pressure.
               Avoid abdominal auscultation of bowel sounds.
               Encourage play with all children on the unit.
               Discourage all unnecessary play activities.
25

A nurse caring for a client diagnosed with anorexia nervosa carefully monitors vital signs
because severe malnutrition can lead to:
        Incorrect: A client with severe malnutrition will experience hypothermia, not a
temperature elevation, unless there is another cause, such as infection.
Incorrect: A client with anorexia nervosa is prone to severe dehydration and therefore
will neither have high circulatory volumes nor high blood pressure to cause increased
intracranial pressure.
Correct: A client who has anorexia nervosa is at high risk for fluid volume deficit. This
can cause electrolyte imbalances such as hypokalemia, which can lead to bradycardia and
dysrhythmias.
Incorrect: A client with anorexia nervosa is likely to have a fluid volume deficit and will
therefore be hypotensive.
                hyperthermia.
                increased intracranial pressure.
                bradycardia.
                hypertension.

26

Which is an essential reason why children diagnosed with bronchopulmonary dysplasia
(BPD) and chronic respiratory failure are at risk for failure to thrive?
        Incorrect: Infants with BPD do not usually have malabsorption from impaired
digestion.Incorrect: Many infants with BPD have a good appetite.Incorrect: Infants with
BPD may have difficulty with weight gain despite adequate caloric intake.Correct:
Infants with BPD must work harder to breathe. This leads to an increased use of calories.
               Impaired digestion leads to decreased absorption of nutrients.
               A decreased appetite leads to poor weight gain patterns.
               An inadequate caloric intake leads to malnutrition.
               An increased work of breathing leads to increased use of calories.
27

A 7-month-old baby diagnosed with a pinworm infestation is prescribed pyrantel
(Antiminth), 11 mg/kg orally as a single dose. The child weighs 20 lb (9 kg). The drug is
available in liquid form with 50 mg in 1 mL. Indicate (in numerals with no punctuation,
rounded to the nearest mL) the amount in milliliters of pyrantel liquid to be administered
to this child. 2 ml
         mL Correct: To determine the correct dosage, multiply the child's weight in kg
times the amount of drug prescribed per kg. 9 X 11 = 99. So, the child must receive 99
mg of drug in a single dose. To determine how much liquid to give, knowing that the
drug comes with 50 mg in each mL of liquid, various methods can be used. A common
one is as follows: The desired amount of drug is 99 mg. The amount of drug on hand is
50 mg. The unknown quantity is X. The known quantity is 1 mL. So, 99 mg/50 mg = X/1
mL. Cross-multiply and 50 mg (X) = 99 mg (1 mL). Then divide each side of the
equation by 50 to obtain X = 1.98 mL, which would be given as 2 mL, the appropriate
dosage for this child. Any calculation that yields a response other than 2 would be
incorrect.To determine the correct dosage, multiply the child's weight in kg times the
amount of drug prescribed per kg. 9 X 11 = 99. So, the child must receive 99 mg of drug
in a single dose. To determine how much liquid to give, knowing that the drug comes
with 50 mg in each mL of liquid, various methods can be used. A common one is as
follows: The desired amount of drug is 99 mg. The amount of drug on hand is 50 mg. The
unknown quantity is X. The known quantity is 1 mL. So, 99 mg/50 mg = X/1 mL. Cross-
multiply and 50 mg (X) = 99 mg (1 mL). Then divide each side of the equation by 50 to
obtain X = 1.98 mL, which would be given as 2 mL, the appropriate dosage for this child.
Any calculation that yields a response other than 2 would be incorrect.
28

A nurse has completed her initial assessment of a 6-year old with type 1 diabetes
mellitus, admitted with bronchitis. He is irritable, reports a headache, and states he is just
not feeling good. His urinalysis reveals negative glucose and negative ketones, and his
mother reports a normal urine output. His vital signs include a temperature of 100.8° F
(38.2° C), apical heart rate of 118/min, and shallow respirations with a rate of 24/min.
Based on this assessment, which nursing diagnosis would be most pertinent at this time?
        Incorrect: Though the child is experiencing a subtle change in level of
consciousness, this is not the most pertinent nursing diagnosis at this time.

Incorrect: Hyperglycemia typically causes lethargy, confusion, nausea, vomiting,
abdominal pain, ketonuria, polyuria with resultant positive glucose, and weak, rapid
pulse, with deep, rapid respirations.

Incorrect: This child's respiratory rate is within the acceptable range of breathing pattern
changes. Shallow breathing could be the result of bronchiolitis or pain with breathing.

Correct: All of these assessment findings are typical with hypoglycemia.
               High risk for injury related to decreased level of consciousness
               Altered nutrition, more than body requirements related to high circulating
blood glucose levels
               Altered breathing pattern related to ineffective respiratory effort
               Altered nutrition, less than body requirements related to low
circulating blood glucose levels
29

Which assessment finding is a hallmark sign indicative of bacterial meningitis?
        Incorrect: Although many children with bacterial infection develop petechial or
purpuric rashes, these are specific to the infecting organism and not to bacterial
meningitis in general.
Incorrect: Many disease processes, including bacterial meningitis, cause irritability and
agitation in children. But these are not diagnostic indicators of bacterial meningitis.
Correct: A hallmark sign of bacterial meningitis is that the child resists flexion of the
neck and stiffness results. The neck stiffness becomes marked until the head is drawn into
extreme overextension (opisthotonos).
Incorrect: A headache is symptom of bacterial meningitis. However, many disease
processes cause headaches in children. A headache is not a specific diagnostic indicator
of bacterial meningitis.
               Petechial rash
               Irritability
               Nuchal rigidity
               Headache
        Fuck this question anyway!

30

An infant with bilateral talipes equinovarus is plaster-casted for the first time, shortly
after birth. Which statement by the mother indicates that she has understood what the
nurse has taught her about caring for the infant at home?
        Incorrect: Casted extremities should be elevated on a pillow until completely dry.
The infant's position should be changed at least every 2 hours, to better expose the
opposite side of the cast to air and to facilitate drying. It is important to remind the
mother that she should not place the infant on his abdomen while he is sleeping, due to
this position's association with sudden infant death syndrome.
Incorrect: Immersing a plaster cast causes it to soften and dissolve.
Correct: Swollen or dark toes indicate circulatory impairment. This requires immediate
medical evaluation and intervention.
Incorrect: Pressure from fingertips can depress the wet cast, causing dents and pressure
areas to develop inside the cast. This can cause skin breakdown.
                 "I'll place my baby on a pillow on his abdomen, with his legs lowered,
until the casts are dry."
                 "I can wash my baby in the baby bathtub as soon as the casts are
completely dry."
                 "If my baby's toes become swollen or dark, I will call the doctor
immediately."
                 "I'll be sure to probe the casts with my fingertips so I can tell when they
are completely dry."



31

Which is a classic manifestation of cystic fibrosis?
        Incorrect: This is characteristic of an acute viral infection rather than of cystic
fibrosis.
Correct: The primary factor responsible for the multi-organ effects of cystic fibrosis is the
mechanical obstruction caused by the production of thick, viscous mucoprotein rather
than thin, freely flowing secretions.
Incorrect: This is characteristic of acute epiglottitis rather than of cystic fibrosis.
Incorrect: This is characteristic of pneumonia rather than of cystic fibrosis.
               Dry, persistent cough
               Abnormally thick mucus
               Cherry-red epiglottis
               Fine crackles
32

A nurse has provided instructions to the parent of a child being discharged following a
tonsillectomy. Which statement by the parent indicates a good understanding of
postoperative care?
         Incorrect: Activities following this surgical procedure should be limited because
the child is at increased risk for bleeding for about 10 days.
Incorrect: The child should not be allowed to eat foods that are highly seasoned, rough in
texture (like pizza crust), or irritating since they can precipitate bleeding
Correct: Continuous swallowing is the most obvious early sign of hemorrhage, which can
occur up to 10 days after surgery. Any sign of bleeding requires immediate medical
attention, thus this statement indicates a good understanding of postoperative priorities.
Incorrect: Gargling, coughing, and clearing the throat are contraindicated, since these
actions can precipitate bleeding. An ice collar and analgesics are effective approaches to
pain control.
                 "I don't have to limit my child's activities since this wasn't a serious
surgery."
                 "My child will be able to eat the cheese pizza I promised to get for him
tonight."
                 "If I notice that my child is swallowing continuously, I will notify the
doctor immediately."
                 "My child should gargle with warm salt water solution to relieve his sore
throat."
33

When instructing the parent of a child who has early symptoms of bronchitis, it would be
most appropriate to teach the parent to:
        Incorrect: Eating a diet high in fruits and vegetables is an acceptable way to
maintain a balanced diet and promote immune system function, but does not help with
treating the early symptoms of bronchitis.
Incorrect: Elevating the head of the bed at night helps with nasal stuffiness. This is not a
symptom of bronchitis.
Correct: Bronchitis is characterized by a dry, hacking, nonproductive cough that worsens
at night and becomes productive within 2 to 3 days. Bronchitis is a mild, self-limiting
disease that requires only symptomatic treatment. Cough suppressants are useful for
allowing uninterrupted rest in the early stage of the illness and while the cough is
nonproductive in nature.
Incorrect: Administering a saline nasal spray soothes nasal mucosa but does not help with
treating the early symptoms of bronchitis.
                feed the child a diet high in fruits and vegetables.
               elevate the child's head during the night.
               administer a cough suppressant.
               administer a saline nasal spray.
34

When administering a liquid medication to a 6-month old, how should the nurse proceed?
        Incorrect: Medication should not be mixed with essential foods like formula
because the taste of the medication might keep children from taking sufficient amounts of
the essential food. Also, they might later associate the essential food with the taste of the
medicine.
Incorrect: At this point in time, this baby's extrusion reflex might still be present. That
would make the infant push the medication out with his tongue. Plus, teaspoons do not
measure liquid medications precisely.
Incorrect: Medication should not be blended with favorite foods, because children might
continue to associate the previously preferred food with the taste of the medicine. This
might keep them from eating a food they previously enjoyed. Also, at this age, this baby
might not be eating baby food.
Correct: This will allow the baby to swallow the medication a little at a time and will help
prevent aspiration.
                Mix the liquid preparation in the baby's formula.
                Use a teaspoon to spoon-feed the medication to the infant.
                Blend the medicine into one of the baby's favorite foods.
                Place a few drops at a time alongside the baby's tongue.
35

A 4-year-old client with extensive burn injuries is scheduled for hydrotherapy. What is
the nurse's highest assessment priority before sending the client to hydrotherapy?
         Incorrect: This is routine care for any child with extensive burn injuries and
would be documented before and after therapeutic procedures, however, it is not the
highest assessment priority at this time.
Incorrect: The wounds are covered and the dressings removed during hydrotherapy. At
that time, the progression of healing would be assessed and documented.
Correct: Hydrotherapy usually involves debridement and the entire process can be
extremely painful. Children must be medicated prior to this therapy for maximum
analgesic effect during therapy. The effectiveness of analgesic must be assessed using a
pediatric pain rating scale appropriate for the child's age before the child is taken to the
hydrotherapy room.
Incorrect: This would be part of the ongoing care of the child and not the highest priority
at this time.
                Checking the child's vital signs
                Noting the stage of wound healing
                Evaluating the effectiveness of pain management
                Assessing the parent's ability to comfort the child


36
A nurse is initiating a blood transfusion for a 16-month old being treated following
injuries sustained in a motor-vehicle accident. Which nursing diagnosis is of highest
priority for this toddler during the transfusion?
        Correct: Circulatory overload in children is common, even with small amounts of
blood. This is more common when the blood is transfused too rapidly or if the child's
status is not monitored closely enough during the transfusion.
Incorrect: Blood transfusions are less painful in children as a result of slower transfusion
rates and due to the small amount of blood being transfused.
Incorrect: Hemolytic reactions are the most serious type of transfusion reaction, but
they are rare in children.
Incorrect: With the implementation of donor-specific typed whole blood and blood
products for transfusion, allergic reactions, though common in adults, are rare in children.
Antihistamines are given prophylactically to children prior to transfusion to prevent this
complication.
                 Fluid volume excess related to circulatory overload
                 Pain related to transfusion rate and vessel irritation
                 Fluid volume deficit related to a hemolytic reaction
                 Hyperthermia related to an allergic reaction to the donor's blood
37

A 17-year old diagnosed with iron-deficiency anemia is to begin taking oral iron
supplements. She is a vegetarian and is eager to take her supplements in conjunction with
herbal remedies her peers have recommended to her. The nurse explains to this teen that:
        Incorrect: Iron is best taken between meals, when the most free hydrochloric acid
is available in the stomach.
Correct: Substances in some herbal teas can interfere with the absorption of iron. Tea in
general contains tannins, substances that form an insoluble complex with iron that is
contained in non-meat sources.
Incorrect: Milk phosphates decrease the absorption of iron. The client should take her
iron supplement with juice or water.
Incorrect: Evidence does not support the use of one form of iron supplement over
another. Additionally, liquid preparations are not very palatable, and for teens, a tablet is
most appropriate.
                 she should take the iron with meals to improve absorption.
                 the use of some herbal teas can decrease the absorption of iron.
                 iron preparations are best absorbed when taken with milk.
                 iron absorption is best with liquid preparations rather than tablets.
38

Which information about osteoporosis is most appropriate to include when teaching an
adolescent female diagnosed with anorexia nervosa?
        Correct: Research has demonstrated that more than 90% of females with anorexia
nervosa have had bone loss in at least one skeletal site. Based on this, routine bone
mineral density screening and counseling related to the effect of anorexia on the bones is
highly recommended.
Incorrect: Loss of bone is believed to be related to malnutritional causes. However,
calcium and Vitamin D supplementation does not necessarily result in a decreased
incidence of bone loss in clients who have anorexia nervosa.
Incorrect: Bone mineral density does not usually have a significant effect on body weight.
Incorrect: Loss of bone is believed to be related to malnutritional causes. However,
calcium and Vitamin D supplementation does not necessarily result in a decreased
incidence of bone loss in clients who have anorexia nervosa.
               Females with anorexia are at a high risk of bone loss and fractures.
               Taking calcium supplements will prevent loss of bone mineral density.
               Loss of bone mineral density can usually help people weigh less.
               Bone loss is due to a nutritional deficit of vitamins and minerals.
39

When caring for a child with suspected epiglottitis, which order should the nurse question
with the provider?
        Correct: With a suspected diagnosis of acute epiglottitis, visualization of the
epiglottis directly with a tongue depressor could precipitate obstruction of the
airway.Incorrect: A portable chest x-ray is appropriate for this child.Incorrect:
Continuous pulse oximetry measures the oxygen saturation of the blood and is safe and
noninvasive.Incorrect: Placing the child in Fowler's position is appropriate for facilitating
air exchange.
                Obtain a throat culture immediately.
                Arrange a portable chest x-ray at the bedside.
                Place the child on a continuous pulse oximeter.
                Maintain the child in Fowler's position.
40

A nurse in a pediatric primary care practice knows to begin doing annual blood pressure
measurements when children reach what age?
        Correct: This is the standard for beginning routine blood pressure measurement in
children. Prior to age 3, blood pressure would only be measured in certain high-risk
situations.
Incorrect: There are many possible causes of hypertension in children that can occur
virtually at any age, including stress and the effects of medications. This would not be an
appropriate age to begin routine blood pressure measurements.
Incorrect: There are many possible causes of hypertension in children that can occur
virtually at any age, including stress and the effects of medications. This would not be an
appropriate age to begin routine blood pressure measurements.
Incorrect: At this age, a child could already have blood vessel damage due to
uncontrolled hypertension. Due to the many possible causes of hypertension in children
that can occur virtually at any age, including stress and the effects of medications, this
would not be an appropriate age to begin routine blood pressure measurements.
                3 years
                6 years
                10 years
                13 years
41

When using the standard adult rule of nines to estimate the total body surface area
(TBSA) injured in a child who has sustained burns, it must be modified to reflect
pediatric proportions. The proportions of a child's arms and trunk are roughly the same as
an adult's, but an infant's head accounts for twice the body surface area percentage as an
adult's head does, while the infant's legs are only about 14% each. These percentages are
adjusted as the child grows. Based on this information and on the standard rule of nines,
the TBSA injured of an infant who has sustained burns over the entire head and both
upper extremities would be:
         % Correct: Using the standard rule of nines for an adult, the head represents 9%,
while each upper extremity represents 9%. An infant's arm proportions are roughly the
same as an adult's (9% each), while the head percentage is twice that of an adult (twice
9%) Thus 9 + 9 + 2(9) = 18 + 18 = 36. Any calculation that yields a response other than
36% would be incorrect.Using the standard rule of nines for an adult, the head represents
9%, while each upper extremity represents 9%. An infant's arm proportions are roughly
the same as an adult's (9% each), while the head percentage is twice that of an adult
(twice 9%) Thus 9 + 9 + 2(9) = 18 + 18 = 36. Any calculation that yields a response other
than 36% would be incorrect.


     42    A 7-year-old child is brought to an emergency department because the parents
           discovered that the child has been passing stools that fit the description of
           melena. In assessing this child, the nurse knows that the most likely source of
           this child's alterations in elimination is pathology in which area?



43

While a nurse is assessing a 6-year-old boy, he climbs down from the exam table five
times and wanders around the room. He requires repeated reminders to hold a card in
front of his eyes during the visual exam, speaks continuously, needs questions repeated,
and is easily distracted by office sounds. His mother states that he has "been like this" for
about 6 months. The nurse identifies that this child's behavior is typical of:
        Incorrect: This disorder causes severe deviations in ego functioning.
Hyperactivity is one possible manifestation, but others include language disturbances,
temper tantrums, inappropriate affect, and bizarre behavior patterns such as robot-like
walking.
Correct: These behavioral manifestations match the diagnostic criteria for attention
deficit/hyperactivity disorder.
Incorrect: There is no indication from these behavioral manifestations of any cognitive or
intellectual impairment. Diagnosis of mental retardation requires tests related to
developmental screening and additional intelligence tests.
Incorrect: Although increased intracranial pressure causes irritability and restlessness, the
child would also be drowsy and would demonstrate diminished physical activity and
motor performance.
                childhood schizophrenia.
                attention deficit/hyperactivity disorder.
                mild cognitive impairment.
                increased intracranial pressure.
44

A nurse is planning care for a child admitted with diabetic ketoacidosis. A priority
intervention for this child will be:
        Incorrect: The client is in a state of severe hyperglycemia. It would be
inappropriate to administer dextrose at this time.
Incorrect: This would be an appropriate measure to follow up and assure knowledge once
the child is stable, but it is not a priority intervention at this point.
Incorrect: Comfort is important for this client, but it is not the highest priority
intervention at this time.
Correct: The client in diabetic ketoacidosis is in a state of fluid volume deficit and
electrolyte imbalance. Fluid replacement is a high priority to prevent hypovolemic shock.
Close monitoring of intake and output is essential for measuring progress toward the goal
of fluid balance.
                administering an intravenous dextrose infusion.
                assessing the family's knowledge of insulin administration.
                controlling pain with the prescribed PRN analgesic.
                monitoring intake and output on an hourly basis.
45

When planning for the discharge of an infant undergoing treatment for clubfoot, the nurse
explains to the parents that the infant will need:
        Typically it takes considerably longer than that to achieve maximum correction
with serial casting.
Correct: The infant will need manipulation and casting every few days for 1 to 2 weeks
and then every 1 to 2 weeks to accommodate the rapid growth of early infancy.
Incorrect: Serial casting that is ineffective in correcting this deformity would not continue
for that long a period of time.Incorrect: Eight weeks is not enough time to make a
decision about surgical correction.
                casting for about 4 to 6 weeks until maximum correction is achieved.
                manipulation and casting every few days for 1 to 2 weeks.
                casting for about 6 months until maximum correction is achieved.
                surgery at the age of 8 weeks if normal alignment is not achieved.
46      A nurse assessing an adolescent diagnosed with a group A beta-hemolytic
streptococci (GABHS) infection expects to find the initial manifestations of this infection
in which area of the body?
        Correct: Children with a GABHS infection usually have fever, pharyngitis, and
headache. The severity of throat pain varies from mild to severe. The throat is inflamed
and exudate sometimes covers the tonsils. Lymph nodes in the neck are often tender and
the child usually has dysphagia (difficulty swallowing).

Incorrect: Back pain is uncommon with a GABHS infection, although increased muscle
tone or spasticity is an abnormal finding and warrants further medical attention. Swollen
joints in the neck or shoulder areas can also contribute to back pain, are more serious in
nature, and could be early signs of juvenile rheumatoid arthritis.
Incorrect: A GABHS infection can progress to acute rheumatic fever, a disease of the
heart, joints, and central nervous system. Symptoms include chest pain and tachycardia.
However, this is a complication or progression of a GABHS infection, and its symptoms
would not be the initial findings with this type of infection.
Incorrect: Abdominal pain is more common among younger children with GABHS, as
opposed to adolescents. As there are many sources of abdominal pain in children,
including hernias, intestinal obstruction, food allergies, and some gastrointestinal
infections, the cause must be considered carefully.
47

A child with hemophilia is bleeding from an abrasion on his leg after a fall from his
bicycle. Which would be the most appropriate emergency intervention for the family to
initiate first?
         Incorrect: Not all bleeding episodes in a child with hemophilia require immediate
transportation to an emergency department.
Incorrect: Warm compresses would increase the blood supply to the injured area and thus
promote bleeding.
Incorrect: Although this might be appropriate first aid for an abrasion, it is not the
family's first priority for this child's injury.
Correct: The first priority is to stop the bleeding. Supportive measures such as RICE
(rest, ice, compression, and elevation) can be taught to family members and initiated
before blood loss becomes substantial. They should keep plastic bags of ice or cold packs
in the freezer for such situations.
                 Dialing 911 immediately
                 Applying warm compresses
                 Spraying the wound with antiseptic
                 Elevating the extremity
48

A nurse just finished teaching a mother about common triggers that might precipitate or
aggravate her child's acute asthma attacks. Which statement by the mother indicates that
she understood the nurse's teaching?
       Incorrect: The use of vaporizers or humidifiers is contraindicated because
dampness creates an environment for spore and mold growth, both of which are common
asthma triggers. Humidity levels should be maintained between 30% and 50%, and
dehumidifiers or air conditioners used when available.
Incorrect: Car windows should be closed with the air conditioner on to minimize the
child's exposure to common allergens such as pollens, dust, and grasses that can
precipitate an acute asthma exacerbation.
Incorrect: Interacting with peers is an essential part of a child's development. Any child
should be kept away from children who have active, communicable infections, but
routine isolation is not warranted.
Correct: Changing the child's clothes after returning to the house prevents continued
contact with common allergens such as pollens, dust, and grasses that can precipitate an
acute asthma exacerbation.
                "Using a humidifier in my child's room at night will prevent
nighttime asthma attacks."
                "When our child is in the car, we'll open the windows to allow fresh air to
circulate."
                "We should restrict the time our child plays with other children due to his
risk of infection."
                "Our child should change his clothes when returning to the house after
playing outdoors."
49

Identify the skin conditions common in children that are the result of bacterial infection.
(Check all that apply.)
        : Molluscum contagiosum is an incorrect response. The cause is a pox virus. The
child develops flesh-colored papules with a solid or semisolid center that are otherwise
asymptomatic. Impetigo contagiosa is a correct response. The usual cause of this itchy,
crusty, vesicular rash is infection with staphylococcal bacteria. Pediculosis capitis is an
incorrect response. This is an infestation of head lice. Cellulitis is a correct response. This
inflammation of the skin and subcutaneous tissues is usually caused by infection with
staphylococcal or streptococcal bacteria. Verruca is an incorrect response. Warts are
caused by various types of human papillomavirus. Pyoderma is a correct response. This is
a deep skin infection that extends into the dermis and can cause systemic effects such as
fever and lymphangitis. The usual cause is infection with staphylococcal or streptococcal
bacteria.
                Molluscum contagiosum
                Impetigo contagiosa
                Pediculosis capitis
                Cellulitis
                Verruca
                Pyoderma
50

Six hours postoperatively, a child who has undergone pin placement and is in skeletal
traction has not had any pain medication. He is crying and reports a pain intensity of 4 on
a pain scale of 0 to 5. Which medication would be most appropriate for the provider to
prescribe PRN at this time?
        Correct: To control moderate to severe pain in children, opioid medication is
indicated. Morphine is the drug of choice for managing this child's pain.
Incorrect: Lidocaine 2.5% and prilocaine 2.5% prepared as a cream called eutectic
mixture of local anesthetics (EMLA) is a topical analgesic used prior to invasive
procedures like intravenous catheter placement or phlebotomy. It would be an
inappropriate choice for controlling postoperative pain.
Incorrect: Meperidine is more likely than other opioids to result in delirium in children.
Its metabolite, normeperidine, can cause irritability, tremors, and seizures. Thus it is a
poor choice for managing postoperative pain in children.
Incorrect: While useful for treating mild pain in children, the nonopioid acetaminophen is
not the medication of choice for moderate to severe pain.
                Morphine sulfate
                lidocaine 2.5% and prilocaine 2.5% (EMLA)
                Meperidine (Demerol)
                Acetaminophen (Tylenol)

A nurse is preparing to teach students in a high school health class about sexually
transmitted infections. Which behavior is essential for the nurse to stress to help an
adolescent reduce the risk of contracting such infections?
        Incorrect: Regular use of oral contraceptives will prevent pregnancy but will not
prevent the transmission of sexually transmitted infections.Incorrect: Urinating following
intercourse might help prevent urinary tract infections in females, but it does not decrease
the risk of transmission of sexually transmitted infections.Incorrect: Washing after
intercourse does not keep microorganisms from entering mucous membranes during
sexual intercourse.Correct: Inconsistent use of barrier contraceptives is one of the most
common behaviors that place adolescents at increased risk for contracting sexually
transmitted infections. When used consistently and combined with a chemical
spermicide, contraceptive barrier methods can provide substantial protection from STDs.
                Regular use of oral contraceptive pills
                Urinating following intercourse
                Washing with soapy water following intercourse
                Consistent use of barrier contraceptives
52

A child newly diagnosed with juvenile rheumatoid arthritis (JRA) is about to be
discharged from the hospital with a prescription for naproxen (Naprosyn). The nurse
teaches the family that the purpose of this medication is to:
       Incorrect: In the United States, naproxen is only available in tablet or suspension
form, not as a topical preparation.Correct: Naproxen, a nonsteroidal anti-inflammatory
drug (NSAID), has both anti-inflammatory and analgesic effects.Incorrect: Naproxen is a
nonsteroidal anti-inflammatory medication (NSAID).Incorrect: Examples of medications
given for adjuvant analgesia are diazepam (Valium) and midazolam (Versed).
                provide topical analgesia.
                suppress joint inflammation.
                provide steroidal inhibition of joint swelling.
                act as an adjuvant analgesic agent.
53

A 4-year-old child is scheduled for a medicated dressing change on his right foot. Which
activity by or with the nurse would be most appropriate for this child during the dressing
change?
        Incorrect: This game is too advanced for most 4-year-old children.Correct: This
would block the child's view of the dressing change and could be easily done with the
child lying down. It also allows the child to express on the paper any aggression he might
feel.Incorrect: This task could be too advanced for the child. Also, if he has been
medicated for pain, it might be too frustrating for him to attempt this fine motor
task.Incorrect: This activity might be soothing to the child, however, reading is not
always effective at diverting a child's attention from something he can see as it happens.
                Playing checkers with the child
                Finger painting on a bed easel
                Having the child string beads
                Reading a story to the child
54

A pregnant 15-year old gained a total of 39 lb (17.7 kg) by term. Based on weight gain
recommendations for pregnant teens, she is:
        Incorrect: The acceptable weight gain range for an adult woman is 25 to 35 lb
(11.4 to 16 kg). The physiologic demands on the growing teen's body differ from that of
the adult woman, nevertheless this weight gain is not significantly above the
recommended range for a pregnant adolescent.Incorrect: The physiologic demands on the
growing teen's body are greater than that of the adult woman (25 to 35 lb or 11.4 to 16
kg), nevertheless this weight gain is not slightly above the recommended range for a
pregnant adolescent.Correct: The recommended weight gain for pregnant adolescents is
between 28 and 40 lb (12.7 to 18.2 kg) because of their increased nutritional needs. If the
teen is overweight or below 62 in (157.5 cm) in height, weight gain should approximate
the lower end of the range.Incorrect: The physiologic demands on the growing teen's
body differ from that of the adult woman (25 to 35 lb or 11.4 to 16 kg), nevertheless this
weight gain does not fall below the recommended range for a pregnant adolescent.
               significantly above the recommended range.
               slightly above the recommended range.
               within the recommend range.
               below the recommended range.
55

The father of a child diagnosed with nephrotic syndrome is observed bringing the child's
siblings for a visit. The nurse determines that one of the children has a visible skin rash
on the upper extremities. The nurse responds most appropriately by:
         Incorrect: Gauze is permeable. Organisms can wick away from the dressing and
infect the client.Incorrect: Unrestricted visits from this sibling would be inappropriate for
this client at this time.Incorrect: The rash could be due to an organism that is airborne and
the child might contract the infection.Correct: The client is at high risk for infection and
the rash could be contagious.
               covering the rash with rolled gauze before the sibling visits.
               allowing the sibling to visit without any restrictions.
               instructing the parent to prevent touching and allow the visit.
               explaining that the sibling cannot visit at all at this time.

56

An 11-month old is admitted with gastroesophageal reflux. The baby has had a 2-lb (0.9-
kg) weight loss in 4 weeks. When planning care for this child, the nurse will incorporate:
        Incorrect: This measure would only be prescribed if the baby were unable to
retain any feedings of any amount. Nasogastric tube feedings do not stop reflux.Incorrect:
Feeding formula with rice cereal will not be satisfying enough for an 11-month old and it
will lack necessary nutrients for growth.Incorrect: Feeding formula only for a meal will
not be satisfying enough for an 11-month old. Feeding every 5 hours would require more
food given at one time, which would be likely to increase regurgitation.Correct: Small,
frequent feedings can help reduce the amount of regurgitation by creating less pressure in
the stomach.
                nasogastric feedings of 10 mL/hr.
                8 oz of formula with 2 tablespoons of rice cereal.
                alternate feedings of baby food and formula every 5 hrs.
                smaller, more frequent feedings.
57

Which nursing action during morning activities of daily living (ADLs) is most beneficial
in maintaining muscular function in a client who has muscular dystrophy?
        Incorrect: Having the client move and reach for supplies encourages muscle
activity and enhances muscle tone. It is a form of therapy for a client who has muscular
dystrophy.Incorrect: The nurse should encourage the client to use muscle groups and
manage self-care for as long as possible.Incorrect: Bending and stretching the muscle
groups is an appropriate form of therapy to help a client who has muscular dystrophy
maintain muscle function.Correct: A primary goal of care for a client who has muscular
dystrophy is maintaining function in the muscle groups for as long as possible.
Encouraging the client to complete as much of the ADLs as possible will exercise the
muscle groups and also promote his self-esteem.
               Assist the client with ADLs by positioning supplies as close to the client
as possible.
               Complete ADLs for the client to help conserve energy and preserve
muscle function.
               Provide all lower extremity ADLs while encouraging the client to wash
his upper extremities.
               Encourage the client to complete as much of the ADLs as he can
independently.
58
An 8-month old is in a clinic for a well-baby checkup. Which assessment finding should
the nurse expect?
        Incorrect: This motor skill is accomplished by 11 months.Incorrect: By 7 months,
the infant should be sitting while using the hands for support.Correct: By 8 months, the
infant should be able to sit steadily without support and adjust posture to reach for
objects.Incorrect: This is a motor skill that should be accomplished by 6 months of age.
               The infant moves around the room, using the furniture for balance.
               The mother supports the infant as she sits unsteadily on the exam table.
               The infant sits upright on the floor, reaching for toys.
               The infant lies prone on a blanket, lifting her head to look around the
room.
59

Which feeding strategy is recommended for a 3-month old diagnosed with failure to
thrive who has normal renal function?
        Incorrect: Introduction of rice cereal is not recommended before 4 to 6 months of
age. This is because the extrusion or tongue-thrusting reflex is triggered when anything
touches a baby's tongue. The baby responds by pushing the tongue forward or outward.
Until this reflex disappears (between 4 and 6 months of age), the baby will appear to spit
out any food placed on the tongue.Correct: Providing additional calories is best
accomplished initially by adding less water to concentrated formula or formula powder.
For young infants, formula density should not exceed 24 kcal/oz because the higher
osmolality and renal solute load might be poorly tolerated.Incorrect: Increasing the
frequency of feedings can lead to increased use of calories and fatigue.Incorrect: Solid
foods are not recommended before 4 to 6 months of age. This is because the extrusion or
tongue-thrusting reflex is triggered when anything touches a baby's tongue. The baby
responds by pushing the tongue forward or outward. Until this reflex disappears (between
4 and 6 months of age), the baby will appear to spit out any food placed on the tongue.
                Addition of rice cereal to formula, fed via a cross-cut nipple
                Concentration of formula to 24 kcal/oz, fed every 3 to 4 hours
                Increased frequency of formula feedings to every 2 to 3 hours
                Introduction of solid foods, starting with fruits and vegetables
60

An 11-year old who sustained a fractured extremity from a fall has been placed in Dunlop
traction by using skin attachment. When planning his care, the nurse understands that the:
        Incorrect: Dunlop traction is a form of upper-extremity traction.Incorrect: With
Dunlop traction, the arm is suspended horizontally with the elbow bent at a 90-degree
angle.Incorrect: The skin should be washed and dried daily to prevent
breakdown.Correct: The bandage must only be replaced when absolutely necessary or
when permitted by the provider (as with intermittent traction). For continuous traction,
someone else must maintain traction on the limb during the rewrapping procedure.
                leg must always be kept under traction.
                elbow must be kept in extension.
                skin should be washed every 2 to 3 days.
                non-adhesive bandage is replaced only when necessary.

				
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