A nurse reports an incident of suspected child abuse. One of the parents of the
child becomes upset and demands to know the reason for the nurse's
... [Show More] action. Which
of the following responses by the nurse is appropriate?
A. "As a nurse, I am required by law to report suspected child abuse."
B. "I am unable to discuss this, but I can contact my supervisor to speak with you."
C. "The provider will be coming to explain the situation."
D. "I reported the incident to my supervisor who decided to contact the
authorities."
a.
Rationale
This response defers to another authority figure, rather than providing the parent
with an answer.
A nurse is preparing to administer vaccines to a 1-year-old child. Which of the
following vaccines should the nurse give? (Select all that apply.)
A. Measles, mumps rubella (MMR)
B. Diphtheria, tetanus and acellular pertussis (DTaP)
C. Varicella (VAR)
D. Rotavirus (RV)
E. Human papillomavirus (HPV4)
A. Measles, mumps rubella (MMR)
C. Varicella (VAR)A nurse is assessing a toddler at a well-child visit. At what point in the physical
examination should the nurse examine the child's tympanic membrane?
A. At the end
B. At the beginning
C. Before examining the head and neck
D. Before auscultating the chest and abdomen
A. At the end
Rationale:
When examining a toddler, the nurse should follow a modified head-to-toe
approach, starting at the head but deferring anything that the toddler is likely to
view as invasive and traumatic to the very end. The toddler is likely to resist not
only having the ears examined, but also anything that follows.
A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a
room with contact precautions in place. Which of the following toys should the
nurse recommend in order to meet the developmental needs of the client?
A. Large building blocks
B. Hanging crib toys
C. Modeling clay
D. Crayons and a coloring book
A. Large building blocks
Rationale:
Large building blocks are age-appropriate toys for a 12-month-old toddler.
A nurse is caring for an 18-month-old toddler who has been hospitalized for 10
days. After the toddler's mother leaves the room, the nurse observes the toddler
sitting quietly in the corner of the crib, sucking her thumb. When the nurseapproaches the crib, the toddler turns away from the nurse. The nurse should
understand that these behaviors indicate which of the following developmental
reactions?
A. An anxiety reaction
B. Regression
C. Resentment toward the mother
D. Developing autonomy
A. An anxiety reaction
Rationale:
Hospitalization is stressful, regardless of the age of the client. However, for an 18-
month-old toddler, separation from parents adds to that stress. The toddler's
behavior indicates an anxiety reaction to the stress of hospitalization. Separation
anxiety initially causes demonstrations of protest. Remaining sad and quiet when a
parent leaves indicates the second response to separation anxiety, which is despair.
A nurse is assessing a 6-month-old infant at a well-child visit. Which of the
following findings should the nurse expect?
A. Closed posterior fontanel
B. Uses thumb and index fingers in a pincer grasp
C. Lateral incisors
D. Sitting steadily without support
A. Closed posterior fontanel
Rationale:
The infant's posterior fontanel should close by about 8 weeks of age.
A nurse is caring for a 2-year-old child who is hospitalized and throws a tantrum
when his parent leaves. Which of the following toys should the nurse provide toalleviate the child's stress?
A. Set of building blocks
B. Toy hammer and pounding board
C. Picture book about hospitals
D. Stuffed animal
B. Toy hammer and pounding board
Rationale:
A toy hammer and pounding board helps the child to express the anger and
frustration he feels about the parent leaving but lacks the verbal ability to express. [Show Less]