Which nursing action is most appropriate to gain information about how a child is feeling?

The nurse is seeing an adolescent boy and his parents in the clinic for the first time. What should the nurse do first?

What action is most likely to encourage parents to talk about their feelings related to their child’s illness?

Use open-ended questions.

What is the single most important factor to consider when communicating with children?

The child’s developmental level

What is an important consideration for the nurse who is communicating with a very young child?

Use transition objects such as a doll.

When introducing hospital equipment to a preschooler who seems afraid, the nurse’s approach should be based on which principle?

The child may think the equipment is alive.

Which age group is most concerned with body integrity?

An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is to:

Explain in simple terms how it works.

When the nurse interviews an adolescent, it is especially important to:

Allow an opportunity to express feelings.

The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique might be most helpful?

Ask the child to draw a picture.

The nurse is taking a health history on an adolescent. What best describes how the chief complaint should be determined?

Ask adolescent, “Why did you come here today?”

Where in the health history should the nurse describe all details related to the chief complaint?

The nurse is interviewing the mother of an infant. She reports, “I had a difficult delivery, and my baby was born prematurely.” This information should be recorded under which heading?

When interviewing the mother of a 3-year-old child, the nurse asks about developmental milestones such as the age of walking without assistance. This should be considered because these milestones are:

An important part of the child’s past growth and development.

The nurse is taking a sexual history on an adolescent girl. The best way to determine whether she is sexually active is to:

Ask her, “Are you having sex with anyone?”

When doing a nutritional assessment on an Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet:

May provide sufficient amino acids.

Which parameter correlates best with measurements of the body’s total protein stores?

An appropriate approach to performing a physical assessment on a toddler is to:

Use minimal physical contact initially.

With the National Center for Health Statistics (NCHS) criteria, which body mass index (BMI)–for-age percentile indicates a risk for being overweight?

The nurse is using the NCHS growth chart for an African-American child. The nurse should consider that:

The NCHS charts are accurate for U.S. African-American children.

Which tool measures body fat most accurately?

By what age do the head and chest circumferences generally become equal?

The earliest age at which a satisfactory radial pulse can be taken in children is:

Where is the best place to observe for the presence of petechiae in dark-skinned individuals?

When palpating the child’s cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. The best explanation for this is:

Infection or inflammation close to the site.

The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child’s head (opisthotonos) with pain on flexion. The most appropriate action is to:

Refer for immediate medical evaluation.

The nurse should expect the anterior fontanel to close at age:

During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is:

Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is normally present by what age?

The most frequently used test for measuring visual acuity is the:

The nurse is testing an infant’s visual acuity. By what age should the infant be able to fix on and follow a target?

The appropriate placement of a tongue blade for assessment of the mouth and throat is the:

What type of breath sound is normally heard over the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium?

What term is used to describe breath sounds that are produced as air passes through narrowed passageways?

The nurse must assess a child’s capillary filling time. This can be accomplished by:

Palpating the skin to produce a slight blanching.

What heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood?

Examination of the abdomen is performed correctly by the nurse in this order:

Inspection, auscultation, and palpation

The nurse has a 2-year-old boy sit in “tailor” position during palpation for the testes. The rationale for this position is that:

It prevents cremasteric reflex.

During examination of a toddler’s extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is:

Normal because the lower back and leg muscles are not yet well developed.

Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the “finger-to-nose" test. The nurse is testing for:

The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup. Which criteria should the nurse use in determining the appropriate-size blood pressure cuff? Choose all that apply.

The cuff bladder width is approximately 40% of the circumference of the upper arm.

The cuff bladder length covers 80% to 100% of the circumference of the upper arm.

Which data would be included in a health history? Choose all that apply

Nutritional assessment

Family medical history

Sexual history

Review of systems

Which statement best describes the infant’s physical development?

Birth weight doubles by age 5 months and triples by age 1 year.

The nurse is assessing a 6-month-old healthy infant who weighed 7 pounds at birth. The nurse should expect the infant to now weigh approximately:

The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is closed. This should be interpreted as

A normal finding.

Because the anterior fontanel normally closes between ages 12 and 18 months,

By what age does the posterior fontanel usually close?

The parents of a 9-month-old infant tell the nurse that they have noticed foods such as peas and corn are not completely digested and can be seen in their infant’s stool. The nurse bases her explanation on knowing that:

This is normal because of the immaturity of digestive processes at this age.

A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her hands, but she will not voluntarily grasp it. The nurse should interpret this as:

In terms of fine motor development, the infant of 7 months should be able to:

Transfer objects from one hand to the other.

In terms of gross motor development, what would the nurse expect a 5-month-old infant to do?

Roll from abdomen to back

At which age can most infants sit steadily unsupported?

By what age should the nurse expect that an infant will be able to pull to a standing position?

11 to 12 months

they can pull themselves up by 9 months

According to Piaget, the 6-month-old infant would be in what stage of the sensorimotor phase

Secondary circular reactions

What behavior indicates that an infant has developed object permanence?

Actively searches for a hidden object

Most infants begin to fear strangers at age:

The nurse is interviewing the father of 10-month-old Megan. She is playing on the floor when she notices an electrical outlet and reaches up to touch it. Her father says “No” firmly and removes her from near the outlet. The nurse should use this opportunity to teach the father that Megan:

Is old enough to understand the word “No.”

Sara, age 4 months, was born at 35 weeks’ gestation. She seems to be developing normally, but her parents are concerned because she is a “more difficult” baby than their other child, who was term. The nurse should explain that:

Infants’ temperaments are part of their unique characteristics.

What information could be given to the parents of a 12-month-old child regarding appropriate play activities for this age?

Give large push-pull toys for kinetic stimulation.

An appropriate play activity for a 7-month-old infant to encourage visual stimulation is:

The best play activity for a 6-month-old infant to provide tactile stimulation is to:

At what age should the nurse expect an infant to begin smiling in response to pleasurable stimuli?

Latasha is a breastfed infant being seen in the clinic for her 6-month checkup. Her mother tells the nurse that she recently began to suck her thumb. The best nursing intervention is to:

Reassure the mother that this is very normal at this age.

Austin, age 6 months, has six teeth. The nurse should recognize that this is:

Earlier-than-normal tooth eruption.

The nurse notices that a 10-month-old infant being seen in the clinic is wearing expensive, inflexible, high-top shoes. The nurse should explain that:

Soft and flexible shoes are generally better.

A mother tells the nurse that she is discontinuing breastfeeding her 5-month-old infant. The nurse should recommend that the infant be given:

Commercial iron-fortified formula.

When is the best age for solid food to be introduced into the infant’s diet?

The parents of a 4-month-old infant tell the nurse that they are getting a microwave oven and will be able to heat the baby’s formula faster. The nurse should recommend to:

Always leave bottle top uncovered to allow heat to escape.

Parents tell the nurse that their 1-year-old son often sleeps with them. They seem unconcerned about this. The nurse’s response should be based on knowing that:

This is a common and accepted practice, especially in some cultural groups.

The parent of 2-week-old Sarah asks the nurse if Sarah needs fluoride supplements because she is exclusively breastfed. The nurse’s best response is:

She may need to begin taking them at age 6 months.”

A mother tells the nurse that she doesn’t want her infant immunized because of the discomfort associated with injections. The nurse should explain that:

A topical anesthetic, eutectic mixture of local anesthetic (EMLA), can be applied before injections are given.

The parents of a 12-month-old child ask the nurse if the child can eat hot dogs. The nurse’s reply should be based on knowing that:

Hot dogs must be cut into small, irregular pieces to prevent aspiration.

The clinic is lending a federally approved car seat to an infant’s family. The nurse should explain that the safest place to put the car seat is:

Rear facing in back seat.

Pacifiers can be extremely dangerous because of the frequency of use and the intensity of the infant’s suck. In teaching parents about appropriate pacifier selection, the nurse should explain that a pacifier should have which characteristics? Choose all that apply

Easily grasped handle

One-piece construction

Sturdy, flexible material

In terms of gross motor development, what would the nurse expect a 5-month-old infant to do? Choose all that apply.

Roll from abdomen to back

Put feet in mouth when supine

A chest x-ray film is ordered for a child with suspected cardiac problems. The child’s parent asks the nurse, “What will the radiograph show about the heart?” The nurse’s response should be based on knowledge that the x-ray film will:

Provide a permanent record of heart size and configuration.

A complication that may occur after a cardiac catheterization is:

José is a 4-year-old child scheduled for a cardiac catheterization. Preoperative teaching should be:

Adapted to his level of development so that he can understand.

The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is “too wet.” The nurse finds the bandage and bed soaked with blood. The most appropriate initial nursing action is to:

Apply direct pressure above the catheterization site.

Which defect results in increased pulmonary blood flow?

Which structural defects constitute tetralogy of Fallot?

Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy

What is best described as the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures?

A clinical manifestation of the systemic venous congestion that can occur with congestive heart failure is:

A beneficial effect of administering digoxin (Lanoxin) is that it:

Which drug is an angiotensin-converting enzyme (ACE) inhibitor?

A common sign of digoxin toxicity is:

The parents of a young child with congestive heart failure tell the nurse that they are “nervous” about giving digoxin. The nurse’s response should be based on knowing that:

Parents must learn specific, important guidelines for administration of digoxin.

As part of the treatment for congestive heart failure, the child takes the diuretic furosemide. As part of teaching home care, the nurse encourages the family to give the child foods such as bananas, oranges, and leafy vegetables. These foods are recommended because they are high in:

An 8-month-old infant has a hypercyanotic spell while blood is being drawn. The nurse’s first action should be to

Place the child in the knee-chest position

The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes that a risk of cerebrovascular accidents (strokes) exists. An important objective to decrease this risk is to:

Parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse’s reply should be based on knowing that:

The child needs opportunities to play with peers.

When preparing a school-age child and the family for heart surgery, the nurse should consider:

Letting child hear the sounds of an electrocardiograph monitor.

Seventy-two hours after cardiac surgery, a young child has a temperature of 37.7° C (101° F). The nurse should:

Report findings to physician.

An important nursing consideration when suctioning a young child who has had heart surgery is to:

Administer supplemental oxygen before and after suctioning

The nurse is caring for a child after heart surgery. What should he or she do if evidence is found of cardiac tamponade?

Immediately report this to the physician.

An important nursing consideration when chest tubes will be removed from a child is to:

Administer analgesics before procedure.

The most common causative agent of bacterial endocarditis is:

What painful, tender, pea-sized nodules may appear on the pads of the fingers or toes in bacterial endocarditis?

The primary nursing intervention to prevent bacterial endocarditis is to:

Counsel parents of high-risk children about prophylactic antibiotics.

A common, serious complication of rheumatic fever is:

A major clinical manifestation of rheumatic fever is:

Polyarthritis, is swollen, hot, red, and painful joints. The affected joints will change every 1 to 2 days. Primarily the large joints are affected

When discussing hyperlipidemia with a group of adolescents, the nurse should explain that high levels of what substance are thought to protect against cardiovascular disease?

High-density lipoproteins (HDLs).

The leading cause of death after heart transplantation is:

When caring for the child with Kawasaki disease, the nurse should know that:

Therapeutic management includes administration of gamma globulin and aspirin.

High-dose intravenous gamma globulin and aspirin therapy are indicated to reduce the incidence of coronary artery abnormalities when given within the first 10 days of the illness. The

One of the most frequent causes of hypovolemic shock in children is:

What type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy?

What occurs in septic shock?

A child is brought to the emergency department experiencing an anaphylactic reaction to a bee sting. While an airway is being established, what medication should the nurse prepare for immediate administration?

Nursing interventions for the child after a cardiac catheterization include (choose all that apply):

Assess the affected extremity for temperature and color.

Maintain a patent peripheral intravenous catheter until discharge.

Which clinical manifestations would the nurse expect to see as shock progresses in a child and becomes decompensated shock? Choose all that apply.

Tachypnea and poor capillary refill time

Cool extremities and decreased skin turgor

Confusion and somnolence

A child is brought to the emergency department experiencing an anaphylactic reaction to a bee sting. Place in correct sequence what the nurse should do after the airway has been established. Place in correct order.

Obtain vascular access.

Administer epinephrine

Keep child warm and calm.

Which factor is most important in predisposing toddlers to frequent infections such as otitis media, tonsillitis, and upper respiratory tract infections?

Short, straight internal ear/throat structures and large tonsil/adenoid lymph tissue are present.

The psychosocial developmental tasks of toddlerhood include:

Ability to withstand delayed gratification

If the need for basic trust has been satisfied, toddlers can give up dependence for control, independence, and autonomy. One of the tasks that the toddler is concerned with is the ability to withstand delayed gratification

A parent of an 18-month-old boy tells the nurse that he says “no” to everything and has rapid mood swings. If he is scolded, he shows anger and then immediately wants to be held. The nurse’s best interpretation of this behavior is that:

This is normal behavior for his age.

A 17-month-old child would be expected to be in what stage according to Piaget?

Tertiary circular reaction

What describes a toddler’s cognitive development at age 20 months?

Realizes that “out of sight” is not out of reach

Although a 14-month-old girl received a shock from an electrical outlet recently, her parents find her about to place a paper clip in another outlet. The best interpretation of this behavior is:

This is typical behavior because of inability to transfer knowledge to new situations.

Two toddlers are playing in a sandbox when one child suddenly grabs a toy from the other child. The best interpretation of this behavior is that:

This is typical behavior because toddlers are egocentric.

Which statement is correct about toilet training?

Wanting to please the parent helps motivate the child to use the toilet.

Which characteristic best describes the gross motor skills of a 24-month-old child?

In the clinic waiting room a nurse observes a parent showing an 18-month-old child how to make a tower out of blocks. In this situation the nurse should recognize that:

Toddlers are capable of building a tower of blocks.

The parents of a newborn say that their toddler “hates the baby . . . he suggested that we put him in the trash can so the trash truck could take him away.” The nurse’s best reply is:

That is a normal response to the birth of a sibling. Let’s look at ways to deal with this.”

A toddler’s parent asks the nurse for suggestions on dealing with temper tantrums. The most appropriate recommendation is to:

Ignore the behavior, provided that it is not injurious.

A parent asks the nurse about negativism in toddlers. The most appropriate recommendation is to:

Reduce the opportunities for a “no” answer.

The parents of a 2-year-old tell the nurse that they are concerned because the toddler has started to use “baby talk” since the arrival of their new baby. The nurse should recommend that the parents:

Parents tell the nurse that their toddler daughter eats little at mealtime, only sits at the table with the family briefly, and wants snacks “all the time.” The nurse should recommend that the parents:

Give her planned, frequent, and nutritious snacks.

A father tells the nurse that his daughter wants the same plate and cup used at every meal, even if they go to a restaurant. The nurse should explain that this is:

Ritualism, common at this age.

Developmentally most children at age 12 months:

Eat the same food as the rest of the family.

The most effective way to clean a toddler’s teeth is for the:

Parent to stabilize the chin with one hand and brush with the other

The nurse is discussing with a parent group the importance of fluoride for healthy teeth. The nurse should recommend that the parents:

Determine whether water supply is fluoridated.

An appropriate recommendation in preventing tooth decay in young children is to:

Serve sweets after a meal.

The leading cause of death during the toddler period is:

Kimberly’s parents have been using a rearward-facing convertible car seat since she was born. Most car seats can be safely switched to the forward-facing position when the child weighs:

The nurse recommends to parents that peanuts are not a good snack food for toddlers.

They can be easily aspirated.

The parent of 16-month-old Chris asks, “What is the best way to keep Chris from getting into our medicines at home?” The nurse should advise that:

All medicines should be locked securely away.”

The most fatal type of burn in the toddler age group is:

Flame burn from playing with matches.

Which is characteristic of physical development of a 30-month-old child? Choose all that apply.

Primary dentition is complete.

Sphincter control is achieved.

What best describes why children have fewer respiratory tract infections as they grow older?

Repeated exposure to organisms causes increased immunity.

Cool-mist vaporizers rather than steam vaporizers are recommended in home treatment of respiratory tract infections because:

Decongestant nose drops are recommended for a 10-month-old infant with an upper respiratory tract infection. Instructions for nose drops should include:

Avoiding use for more than 3 days.

When caring for an infant with an upper respiratory tract infection and elevated temperature, an appropriate nursing intervention is to:

Give small amounts of favorite fluids frequently to prevent dehydration.

The parent of an infant with nasopharyngitis should be instructed to notify the health professional if the infant:

Shows signs of an earache.

It is generally recommended that a child with acute streptococcal pharyngitis can return to school:

After taking antibiotics for 24 hours.

A child is diagnosed with influenza, probably type A disease. Management includes:

Amantadine hydrochloride to reduce symptoms.

Chronic otitis media with effusion (OME) is differentiated from acute otitis media (AOM) because it is usually characterized by:

A feeling of fullness in the ear.

Which statement is characteristic of acute otitis media (AOM)?

It is treated with a broad range of antibiotics.

An infant’s parents ask the nurse about preventing otitis media (OM). What should the nurse recommend?

Which type of croup is always considered a medical emergency?

Epiglottitis is always a medical emergency needing antibiotics and airway support for treatment

The nurse encourages the mother of a toddler with acute laryngotracheobronchitis to stay at the bedside as much as possible. The nurse’s rationale for this action is primarily that:

The mother’s presence will reduce anxiety and ease child’s respiratory efforts.

A school-age child has had an upper respiratory tract infection for several days and then began having a persistent dry, hacking cough that was worse at night. The cough has become productive in the past 24 hours. This is most suggestive of:

Skin testing for tuberculosis (the Mantoux test) is recommended:

Periodically for children who reside in high-prevalence regions.

The mother of a toddler yells to the nurse, “Help! He is choking to death on his food.” The nurse determines that lifesaving measures are necessary based on:

Which important event does the nurse understand is essential to the development of a toddler?

What should the nurse recommend to help a toddler cope with the birth of a new sibling quizlet?

Which intervention is considered inappropriate when disciplining preschool children quizlet?

Which of the following will best facilitate trust relationship between the infant and parents during hospitalization of the infant?