A mother brings her 8 mo. old baby boy to clinic because he has been vomiting and had diarrhea for last 3
days. Which assessment is most important for nurse to make?
A.Assess infant abdomen for tenderness
b.Determine if the infant was exposed to a virus
C. Measure the infant’s pulse
d. Evaluate the infant’s cry
C. Measure the infant’s pulse
While obtaining the vital signs of a 10-year-old who had a tonsillectomy this morning, the nurse observes
the child swallowing every 2-3 minutes. Which assessment should the nurse implement?
Inspect the posterior oropharynx
parents of a 3-year old boy who has Duchenne muscular dystrophy ask, “How can our son have this
disease? We are wondering if we should have any more children.” What information should the nurse
provide to parents?
This is an inherited X-linked recessive disorder, which primarily affects male children in the
family
2-weck-old female infant is hospitalized for the surgical repair of an umbilical hernia. After retuming to the postoperative neonatal unit, her R and HR have increased during the last hour. Which intervention should the nurse implement?
Administer a PRN analgesic prescription
2-year-old girl is brought to the clinic by her 17-year-old mother. When the nurse observes that the child
is drinking sweetened soda from her bottle, what information should the nurse discuss with this mother?
-Dental caries is associated with drinking soda
-Toddlers should be drinking from a cup by age 2
mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night.
Which finding is most significant in planning care for this family?
a.The mother is a single parent and lives with her parents
b.The mother states the baby is irritable during feedings
C the infant’s formula has been changed twice
D.The diaper area shows severe skin breakdown
D.The diaper area shows severe skin breakdown
The nurse determines that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis. What action should the nurse take?
Document the finding
16-year-old with acute myelocytic leukemia is receiving chemotherapy (CT) via an implanted
medication port at the out-patient oncology clinic. What action should the nurse implement when the
infusion is complete?
Flush mediport w/ saline and heparin solution
mother brings her 3-week old infant to the clinic because the baby vomits after eating and always seems
hungry. Further assessment indicates that the infant’s vomiting is projectile, and the child seems listless.
Which additional assessment finding indicates the possibility of a life-threatening complication?
Irregular palpable pulse
nurse is performing a routine assessment of a &-year old at a sommunity health center. Which behavior
by the child should alert she nurse to request a
follow up for a posaible autism spectrum disorder?
Perform odd repetitive behaviors
Following admission for cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with tetralogy of Fallot. What instruction should the nurse give the parents if their
child becomes pale, cool, lethargic?
Contact their HCP immediately
mother brings her 2-year-old son to the clinic because he has been crying and pulling on his earlobe for
the past 12 hours. The child’s oral temperature is 101.2 F. Which intervention should the nurse implement?
Ask the mother if the child has had a runny nose
- During a follow up olinical visit a mother tells tia nurse that her 5-monih-old son who had surgical
correction for tetralogy of fallot has rapid breathing, often takes a long time to eat, and requires frequent
rest periods. The infant is not crying while being held and his growth is in the expected range. Which
intervention should the nurse implement?
Auscultate heart and lungs while infant is held
The mother of an 11-year old boy who has juvenile arthritis tells the nurse, “I really don’t want my son to
become dependent on pain medication, so I only allow him to take it when he is really hurting.” Which
information is most important for the nurse to provide this mother?
Giving pain medication around the clock helps control the pain
mother of a 4-month-old baby girl asks the nurse when she should introduce solid foods to her infant.
The mother states, “My mother says I should put rice cereal in the baby’s bottle now.” The nurse should
instruct the mother
to introduce solid foods when her child exhibits which behavior?
Opens mouth when food comes her way
A 6-year-old boy with bronchial asthma takes the beta-adrenergic agonist agent albuterol (Proventil). The child’s mother tells the nurse that she uses this medication to open her son’s airway when he is having trouble breathing. What is the nurse’s best response?
Assure the mother that she is using the medication correctly
mother brings her school-aged daughter to the pediatric clinic for evaluation of her anti-epileptic
medication regimen. What information should the nurse provide to the mother?
medication dose will be tapered over a period of 2 weeks when being discontinued
A child receives a prescription for amantadine 42 mg PO BID. Amantadine is available as a 50 mg/5 mL
syrup. Using a supplied calibrated measuring device, how many mL should the nurse administer per dose?
(round to nearest tenth)
0.5 ml
male toddler is brought to the emergency center approximately three hours after swallowing tablets from his grandmother’s bottle of digoxin (Lanoxin). What prescription should the nurse implement first?
Administer activated charcoal orally
Give IV digoxin immune fab (Digibind)
An 8-year-old male client with nephrotic syndrome is receiving salt-poor human albumin IV. Which
findings indicate to the nurse that the child is manifesting a therapeutic response?
Decreased periorbital edema
A mother of a 3-year old boy has just given birth to a new baby girl. The little boy asks the nurse, “why is
my baby sister eating my mommy’s breast?” how should the nurse respond? Select all that apply
-Remind him that his mother breastfed him too
-Reassure the older brother that it does not hurt his mother
-Explain that newborns get milk from their mothers in this way
middle school male student was recently diagnosed with attention-deficit hyperactivity disorder (ADHD)
and is having trouble with his grades. He is referred to the school nurse by the teacher because he continues
to have learning problems. Which action should the school nurse take?
Ask the parents to have the child seen by a clinical psychologist
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is
irritable, refuses to eat, and has skin peeling on both his hands and feet. Which intervention should the
nurse instruct the mother to implement first?
Place the child in a quiet environment
The nurse is preparing a teaching plan for the parents of a 6-month-old infant with GERD. What instruction
should the nurse include when teaching the parents measures to promote adequate nutrition?
Mix the formula with rice cereal
A child with pertussis is receiving azithromycin (Zithromax Injection) IV. Which intervention is most
important for the nurse to include in the child’s plan of care?
Assess for abdominal pain and vomiting
nurse is conducting an admission assessment of an 11-month old infant with CHF who is scheduled for
repair of restenosis of coarction of the aorta hat was repaired 4 days after birth. Findings include blood
pressure higher in the arms than the lower extremities, pounding brachial pulses, and slightly palpable
femoral pulses. What pathophysiologic mechanisms support these findings?
The lumen of the aorta reduces the volume of the blood flow to the lower extremities
A child who is admitted to the hospital with anemia is anxious, fearful, and hyperventilating. The nurse
anticipates the child developing which acid base imbalance?
Respiratory alkalosis
mother of a toddler reports to the nurse working in the pediatric clinic that her child has had a fever
and sore throat for the past two days. The nurse observes several swollen red spots in the child’s body, a few of which are fluid filled blisters. Which action should the nurse implement?
Implement transmission precautions
The mother of a 14-year old who had a below-the-knee amputation for osteosarcoma tells the nurse that her child is angry and blaming her for allowing the amputation to occur. Which response is best for the nurse to
provide?
reaction of anger is your child’s attempt to cope with this loss”
nurse provides information about the human papilloma virus (HPV) vaccine to the mother of a 14-
year-old adolescent who came to the clinic this morning complaining of menstrual cramping. Which
explanation should the nurse provide to support administering the HPV vaccine to the adolescent who came to the clinic this morning complaining of menstrual cramping. Which explanation should the nurse provide to support administering the HPV vaccine to the adolescent at this visit?
Use of protective barriers during sexual activity prevents most strains of HPV infection
An adolescent’s mother calls the primary HCP’s office to inquire about the results of her daughter’s serum
test results that were drawn last week. Since it is the teenager’s 18th birthday, how should the nurse respond to this mother’s inquiry?
Explain that the information cannot be released without the 18-year olds permission
parents of 15-month old boy tell the nurse that they are concerned because their son brings his spoon to
his mouth but does not turn it over. What action should the nurse implement first?
Question the parents about their concern
A child with Grave’s disease who is taking propranolol (Inderal) is seen in the clinic. The nurse should
monitor the child for which therapeutic response?
Decreased heart rate
10-year-old girl who has had type 1 diabetes mellitus (DM) for the past two years tells the nurse that she
would like to use a pump instead of insulin injections to manage her diabetes. Which assessment of the girl
is most important for the nurse to obtain?
Ability to perform the pump for basal insulin with mealtime boluses
developing a behavior modification program for an extremely aggressive 10-year-old boy, what should
the nurse do first?
Determine what activities, foods, and toys the child enjoys
In assessing a 10-year old newly diagnosed with osteomyelitis, which informations most important for the nurse to obtain?
Recent occurrence of infection
6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless
movements of the arms and legs). Which information should the nurse provide to the parents?
The chorea or movements are temporary and will eventually disappear
3-year-old boy is receiving a weekly chemotherapy treatment. Which toy is best for the nurse to provide
for this child?
Coloring book with crayons
A 9-week-old infant is scheduled for cleft lip repair. Which information is most important for the nurse to
convey to the surgeon before transporting the infant to the surgical suite?
Red blood cell count of 2.3 million/mm3
The nurse is caring for a 3-year old child who has been recently diagnosed with cystic fibrosis, which
discharge instruction by the nurse is most important to promote pulmonary function?
Chest physiotherapy should be performed before meals and at bedtime
adolescent who is taking antiretroviral therapy for HIV infection arrives at the clinic for a follow up
visit. Which information is most important for the nurse to obtain?
Missed medication doses
A S-ycar-old boy with leukemin is receiving chemotherapy through a peripherally inserted central catheter
(PICC), Twenty minutes after the infusion is begun, the child feels dizzy and complains of itching. Which
intervention should the nume implement finer?
Discontinue the medication infuxion
A school-aged male is brought to the school nurse after he was thrown off his bicycle into the trunk of a
pine tree. The child’s face and arms are speckled with embedded pine bark. He has copious tearing and
complains that “there is stuff in my eyes.” Which action should the nurse implement?
a. Patch both of child’s eyes and send him to the family ophthalmologist
Patch both of child’s eyes and send him to the family ophthalmologist
A nurse is teaching a class for mothers of premature infants, and is asked about “a shot for respiratory
virus.” What information about plaibizumab (Synagis) is correct?
It is recommended for infants who meet established high-risk criteria
When assessing a 5-year-old, which ability should the nurse expect the child to be developing at this age?
Tying shoelaces
mother brings her 2-month old son to the clinic for a well-baby exam. During the assessment the nurse
finds that the right testicle is, not distended into the scrotum but the left is palpable. Which action should the nurse take?
Ask if the right testis has been seen in the scrotum before
An 8-year-old girl with precocious sexual development is being treated medically with injections of luteinizing hormone-releasing hormone (LRHR) to regulate the pituitary gland. Which statement by the parents indicates that they understand the treatment?
“Sexual maturity differences between my daughter and her peers will disappear within a few
years”
While auscultating the lung sounds of a 5-year-old Chinese boy who recently completed antibiotic therapy for pneumonia, the nurse notices symmetrical, round, bruise-like blemishes on his chest. Which action is best for the nurse to take?
Inquire about the use of alternative methods of treatment
Which instructions should the nurse include in the discharge teaching plan of 7-year-old girl with history of frequent urinary tract infections?
Monitor for changes in urinary odor
A male infant with bronchiolitis is brought to the clinic by his mother. The infant is congested and febrile
with a capillary refill of 2 seconds. Which information should the nurse discuss with the mother?
Keep infant isolated from others
During a routine physical exam, a male adolescent client tells the nurse, “sometimes, my mother gets angry because I want to be with my own friends.” What is the best initial response by the nurse?
Ask about the client’s response to his mother’s anger