1. A nurse is reinforcing teaching with the parents of preschoolers regarding the use of booster seats
in a motor vehicle. Which of the following
... [Show More] instructions should the nurse include in the teaching?
Secure the child in the booster seat using the motor vehicle’s shoulder-lap seat belt—booster
seats do not have built in straps
2. A nurse is contributing to the plan of care for a child who is in Buck’s traction. Which of the
following interventions should the nurse include in the plan?
Maintain the leg in an extended position—this position decreases the risk for further injury to the
extremity and minimizes the occurrence of muscle spasms.
3. A guardian calls the clinic nurse after his child has developed symptoms of varicella and asks
when his child will no longer be contagious. Which of the following responses should the nurse
make?
Six days after lesions appear if they are crusted—as long as they are crusted over.
4. A nurse is caring for a toddler who has otitis media and a temperature of 102.4 F. Which of the
following actions should the nurse take first?
Administer an antipyretic—to decrease the toddler’s body temperature
5. A nurse is caring for an adolescent who has acne and a new prescription for isotretinoin. For
which of the following adverse effects should the nurse monitor?
Depression—experience mental status changes, such as suicidal thoughts, aggression, emotional
lability, and depression.
6. A nurse is contributing to the plan of care for a 10 month old infant who is postoperative
following a cleft palate repair. Which of the following actions should the nurse include in the plan
of care?
Place the infant in side-lying position—promote healing and prevent injury to the surgical site.
7. A nurse is reinforcing teaching about sudden infant death syndrome (SIDS) with the parent of a 1
month old infant. Which of the following statements by the parent indicates an understanding of
the teaching?
I will allow my baby to have a pacifier while sleeping—decreases the risk for SIDS.
8. A nurse is collecting data from an infant during a well-child visit. Which of the following sites
should the nurse use when obtaining the infant’s heart rate?
Apical—to obtain the infant’s heart rate and count it for a full minute, because it gives a reliable
rate and rhythm and provides accurate baseline assessment—the apical heart rate is auscultated at
the fourth intercostal space lateral to the midclavicular line.
9. A nurse is reinforcing teaching with the guardians of a school-age child who has frequent
nosebleeds. Which of the following instructions should the nurse include?
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Apply pressure to the child’s nose—for a least 10 min to decrease bleeding—also instruct the
guardians to tilt the child’s head forward, because this position prevents aspiration of the blood.
10. During a well-child visit, the parent of a toddler expresses concern to the nurse that the toddler
takes several hours to fall asleep at night. Which of the following recommendations should the
nurse make?
Provide the toddler with a favorite toy at bedtime—help the toddler to feel more secure and
facilitate sleep.
11. A nurse is caring for a toddler who has terminal cancer and is receiving hospice care. The child’s
parent tells the nurse, “I’m a bad parent, and I can’t deal with this.” Which of the following
responses should the nurse make?
Tell me more about what you are feeling—use open-ended statements that will allow the parent
to share his feelings and emotions. During times of grief, the parent needs to express his
emotions. The use of open ended statement relays the message that it is safe to do so with the
nurse.
12. A nurse is reinforcing teaching with the family of an adolescent client who was recently
diagnosed with celiac disease. Which of the following foods should the nurse recommend?
Yellow corn—unable to process gluten, a protein found in wheat, barley, rye and oats—client’s
diet is restricted to foods that are free of gluten, such as corn, rice and millet.
13. A nurse is collecting data from a child during a well child visit. The nurse should recognize that
which of the following findings places the child at a higher risk for abuse?
The child was born at 30 weeks of gestation—children who are born prematurely are at greater
risk for abuse because of the potential for impaired bonding during early infancy.
14. A nurse is reinforcing dietary teaching with the parent of a 2 year old toddler. Which of the
following should the nurse include in the teaching?
An appropriate serving size is 1 tablespoon of food per year of age—serving size for a 2 year old
toddler is 1 tbsp of food per year of age.
15. A nurse is reviewing the plan of care for a child who has cystic fibrosis. Which of the
following is the priority goal for this child?
The child will maintain an effective breathing pattern—manifestations of cystic fibrosis, such as
chronic cough, pulmonary infection and bronchiolar obstruction lead to severely impaired
ventilation and gas exchange, which causes long-term pulmonary complications. Therefore, when
utilizing the airway, breathing, circulation approach to client care, maintaining an effective
breathing pattern is the priority goal for the child who has cystic fibrosis.
16. A nurse is collecting physical data from a 4 year old child who has diarrhea and has been
vomiting for 24 hr. which of the following sites should the nurse grasp to determine the child’s
skin turgor? [Show Less]