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25 Cards in this Set
- Front
- Back
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The parent of a two-year-old child reports feeling frustrated with the fact that her son is saying no to everything. The nurse should teach the parent that this behavior is a normal expression of the child’s desire to accomplish which of the following? |
Select one: a. Increase their independence. b. Finish a project they set out to do. c. Gratify their oral fixation. d. Develop their sense of trust.
The correct answer is: Increase their independence. |
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At a well-child visit, the parents report that their toddler occasionally touches and fondles her genital area. The parents ask the nurse if this behavior is something to be concerned about. Which of the following is a correct response? |
Select one: a. This is a possible infection or irritation in the genital area
b. Your child is probably imitating behaviors that she has observed
c. Awareness of body structures and sensations is normal and expected
d. This is an early emergence of sexual expression that should be discouraged
Answer
Awareness of body structures and sensations is normal and expected CORRECT. Genital self-stimulation by the toddler is normal and expected. It is a new area to explore, similar to exploring the toes at an earlier age, but it has pleasurable sensations too! It should be ignored unless the behavior becomes pervasive, and then it should still be ignored and the child should be distracted to come and do some fun and exciting activity
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A nurse is taking the health history of a school-age girl. Which statement by the client’s mother indicates a need for further teaching regarding the client’s nutritional status? |
Select one: a. “We increase her protein intake when she’s playing sports.”
b. "She enjoys helping to prepare her snacks in the kitchen.”
c. “We allow her to pick out a treat at the grocery store for good behavior.”
d. “She eats a large breakfast every morning.”
Answer
c. “We allow her to pick out a treat at the grocery store for good behavior.” CORRECT. This statement indicates a need for further teaching. This client’s mother should be educated about the importance of praising the client’s abilities and skills rather than using food as a reward, which may lead to an increased risk for obesity.
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A nurse correctly understands which of the following characteristics is a possible developmental delay for a 3-month-old client? |
Select one: a. The infant is unable to point to objects
b. The infant does not raise his head when placed on his abdomen
c. The infant demonstrates stranger anxiety
d. The infant is unable to sit with support
Answer
b. The infant does not raise his head when placed on his abdomen CORRECT. When placed on the abdomen the 3 month old should attempt to raise his head. Some sources refer to this as “tummy time” which provides the infant with the stimulation to strengthen upper body and neck muscles in preparation for good head control when sitting upright and the some of the muscles required for crawling.
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A nurse has administered the first DTaP (diphtheria toxoid, tetanus and pertussis) immunization to a two-month-old infant. For which of the following symptoms should the nurse teach the parents to seek immediate medical attention? |
Select one: a. The baby develops a localized or generalized rash
b. The baby develops swelling or redness at the injection site
c. The baby has an axillary temperature of 100.4o F. (38o C)
d. The baby is crying inconsolably for more than three hours
d. The baby is crying inconsolably for more than three hours CORRECT. Inconsolable crying lasting more than three hours and/or seizures within 48 hours of vaccination is a sign of encephalopathy that must be treated immediately.
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A nurse is educating the parents of an infant about symptoms that should be reported to the provider. What finding should be immediately reported? |
Select one: a. Abdominal distension
b. Mild diarrhea
c. Decreased urine output
d. Difficulty evacuating bowels
Answer
c. Decreased urine output CORRECT. Decreased urine output indicates dehydration and should be reported immediately to the provider. Listlessness, sunken eyes, decreased tears, and dry mucous membranes are other symptoms of dehydration that should be immediately reported.
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A nurse is changing a dressing on a pre-school-aged child who has a healing wound on a lower extremity. Which of the following nonpharmacologic comfort measures would be most appropriate for this child? |
Select one: a. Encouraging the child to watch a favorite cartoon on television.
b. Assisting the child to take deep breaths and focus on relaxing.
c. Promising the child a special treat in exchange for cooperation.
d. Teaching the child how to go ‘to a different place’ using their imagination.
a. Encouraging the child to watch a favorite cartoon on television. CORRECT. Cartoons would be a very attractive distraction, and distraction is a powerful nonpharmacologic comfort intervention which works well with this developmental age.
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A nurse is planning community education focusing on the principles of first aid. Which of the following strategies is likely to be most effective with adolescent learners? |
Select one: a. Divide the planned program into several sessions over several weeks.
b. Actively involve the participants in practice of techniques.
c. Teach the most crucial content early in the session.
d. Simple lecture format.
Answer
b. Actively involve the participants in practice of techniques. Adolescent learners will learn best when actively involved in participation and use of psychomotor skills.
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A nurse is providing education to the mother of a ten year old child about to undergo scoliosis screening. Which of the following statements by the mother indicates a need for further teaching? |
Select one: a. “The examiner will be looking for symmetry in alignment of shoulders or hips.” b. “My child should be undressed down to her under wear.” c. “My child will be asked to stand upright, arms stretched above the head.” d. “The examiner will be looking for asymmetry of the ribs and flanks.” Answer c. “My child will be asked to stand upright, arms stretched above the head.” Screening is done by observing the child from the back while they are wearing only underwear in order to best visualize the anatomical abnormalities associated with scoliosis.
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A nurse is collecting data on newborn. Which of the following is an expected finding? |
Select one: a. Babinski reflex present b. Pulse rate 70 to 80/min c. Decorticate reflex d. Respirations 21 to 24/min Answer a. Babinski reflex present The Babinski reflex is present for the first year of life. The reflex is elicited by stroking the outer edge of the sole of an infant’s foot up toward the toes. The infant’s toes fan upward and out.
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A nurse is helping parent’s select appropriate independent activities for their 8 year old child. Which of the following would be an appropriate activity? |
Select one: a. Encouraging the child to assume care of the family pet b. Allowing the child to play video games c. Playing touch football d. Providing frequent trips to the library
Answer d. Providing frequent trips to the library |
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A nurse is caring for a client being discharge home who has hemophilia. Which of the following teaching points would be reinforced to the parents prior to discharge? |
Select one: a. Dress toddlers in extra layers of clothing. b. Report to the provider a pink, nonpruritic macular rash. c. Encourage child to participate in team activity sporting events. d. Provide heat to control bleeding episodes.
Answer a. Dress toddlers in extra layers of clothing. |
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A nurse is caring for a client with respiratory syncytial virus (RSV). The nurse is aware that which of the following activities would not prevent the spread of infection? |
Select one: a. Encouraging children to participate in school activities.
b. Performing good hand hygiene.
c. Covering the nose and mouth.
d. Discouraging the sharing of eating utensils.
Answer
a. Encouraging children to participate in school activities. Correct. Infected children should be kept away from contact with well children.
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A school-aged child has been recently diagnosed with attention deficit hyperactivity disorder (ADHD). What activities can the school nurse provide to the parents to help improve school performance? |
Select one: a. Divide tasks into small projects, allowing frequent breaks.
b. Allow the child to work when they feel like it.
c. Insist that the child read quietly to himself until he understands the instructions.
d. Encourage the child to sit at the dining room table until all homework is done.
Answer
a. Divide tasks into small projects, allowing frequent breaks. Correct: Children with ADHD have a hard time focusing for extended periods of time. Parents and teachers should obtain the child’s attention prior to giving directions, and allow tasks to be completed in small increments. Efforts should be made to time tasks to time of day when the child has the best attention span. Creating ‘games’ out of homework can also help obtain academic success.
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A nurse is caring for a child who has leukemia. What discharge teaching would be reinforced with the parents prior to discharge? |
Select one: a. How to properly use vascular access devices. b. Encourage parents not to palpate the stomach. c. Side effects of radiation therapy. d. Report developmental delays to the provider.
Answer a. How to properly use vascular access devices. |
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A client is diagnosed with rheumatic fever. Which clinical manifestation would the nurse recognize associated with the presentation of rheumatic fever? |
Select one: a. Irritability, poor concentration and behavioral problems b. Polyarthritis c. Cough d. Purulent nasal discharge
Answer b. Polyarthritis |
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The nurse is collecting data for a 2-month-old with suspected pyloric stenosis. Which finding indicates pyloric stenosis? |
Select one: a. Perianal fissures and skin tags
b. Hard, moveable “olive-like mass” in the upper right quadrant
c. Abdominal pain and irritability
d. Sausage-shaped mass in the upper mid abdomen
Answer
b. Hard, moveable “olive-like mass” in the upper right quadrant Correct: A hard, moveable “olive-like mass” in the right upper quadrant is the hypertrophied pylorus. The client will experience vomiting often after feedings, demonstrates constant hunger and shows signs of dehydration and failure to gain weight.
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LA 3-month-old client has just undergone the procedure, cheiloplasty. The nurse is collecting data following the procedure. Which of the following pain collection tools should be used to collect information on pain level? |
Select one: a. FLACC b. Numeric scale c. FACES d. Oucher
Answer
a. FLACC Correct: This pain collection tool is recommended for infants and children 2 months to 7 years of age. Pain is rated on a scale of 0 to 10. Face (F), Legs (L), Activity (A), Cry (C), and Consolability(C)are assessed.
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A nurse is assisting with teaching high school students in a community health class on communicable diseases. During the discussion on infectious mononucleosis, which statement would lead the nurse to conclude that further teaching is needed? |
Select one: a. “A person with mononucleosis is at risk for a ruptured spleen.” b. “A person with mononucleosis would have flu like symptoms including a low grade fever, sore throat and fatigue.” c. “Mononucleosis can be confirmed by a blood test.” d. “Mononucleosis is a bacterial infection.” Answer d. “Mononucleosis is a bacterial infection.” correct:Mononucleosis is a viral infectious process that is transmitted via saliva and is generally self-limiting, where little treatment is needed. However, a complication of mononucleosis is splenomegaly which can result is a ruptured spleen.
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A distracted 7-year-old student is sent to the school nurse by his teacher. When the nurse checks his hair and scalp, the nurse notes the evidence of pediculosis capitis. What are recognizable manifestations of this form of skin infestation? |
Select one: a. Flaking of the scalp with pink, irritated skin expose.
b. Small white spots that adhere to the hair shaft, close to the scalp.
c. Multiple tiny pustules on the scalp with no abnormal findings on the hair shafts.
d. Scaly, circumscribed patches on the scalp, with mild alopecia in these areas.
Answer
b. Small white spots that adhere to the hair shaft, close to the scalp. Correct: The small white spots that adhere to the hair shafts are the eggs, or nits of lice (pediculosis capitis).
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There are different parenting styles that are exhibited within a family. Which of the following parenting styles is exhibited when a parent states, “My child can play video games for one hour a day after his homework is completed.” |
Select one: a. Passive
b. Democratic
c. Permissive
d. Dictatorial
Answer
b. Democratic Correct: This parent is exhibiting a democratic/authoritative parenting style. The parent directs the child’s behavior by setting rules and explaining the reason for each rule setting.
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The nurse is assisting the parents of a school-aged child with a plan to prepare him for the impending death of a family member. What would be the potential behavior of the school-aged child when faced with this stressor? |
Select one: a. Uncooperative behavior
b. Same emotional demonstration as his parents
c. Accepting behavior of this situation
d. Believe that death is temporary
Answer
a. Uncooperative behavior Correct: School-aged children will often display fear of the unknown through uncooperative behavior.
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A nurse is reinforcing teaching prior to discharge to a school-aged client and his parents following a radius fracture with cast application. Which of the following statements by the client’s parent indicates a need for additional teaching? |
Select one: a. “When we get home we will use a hair dryer to finish drying the cast.” b. “We will reposition him every 2 hours until the cast is dry.” c. “We will keep the cast elevated about his heart for the next 24 hours.” d. “We will notify the provider if his fingers become swollen and dark.” Answer a. “When we get home we will use a hair dryer to finish drying the cast.”
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A nurse concludes that additional teaching reinforcement about the Diabetic Sick Rule is needed when the mother of the child states which of the following?A nurse concludes that additional teaching reinforcement about the Diabetic Sick Rule is needed when the mother of the child states which of the following? |
Select one: a. “I will encourage my child to sugar-free, non-caffeinated liquids.” b. “I will continue to give my child the oral antidiabetic agent.” c. “I will notify my health care provider if vomiting occurs more than once.” d. “I will take my child blood sugar every 6 hours.” Answer d. “I will take my child blood sugar every 6 hours.”
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The nurse is caring for a child with cystic fibrosis what provider order would the nurse question? |
Select one: a. Limit physical activity b. High protein diet c. Oxygen via nasal cannula at 2 l/m. d. Administer flu vaccine Answer a. Limit physical activity
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