Which communication behavior would the nurse expect when assessing an 18 month old toddler?

NURS 420 Exam 1

The nurse is assessing the respiratory system of a newborn. Which anatomic differences place the infant at risk for respiratory compromise? Select all that apply.
a. The nasal passages are narrower.
b. The trachea and chest wall are less compliant.
c. The

Answers:
-The nasal passages are narrower
-The larynx is more funnel-shaped
-There are significantly fewer alveoli
Rationale: In comparison with the adult, in the infant, the nasal passages are narrower, the trachea and chest wall are more compliant, the

At which age would the nurse expect to find the beginning of object permanence?
a. 1 month
b. 6 months
c. 9 months
d. 12 months

Answer: 6 months
Rationale:
Object permanence begins to develop between 4 and 7 months of age and is solidified by approximately age 8 months. By age 12 months, the infant knows he or she is separate from the parent or caregiver.

The nurse caring for newborns knows that infants exhibit phenomenal increases in their gross motor skills over the first 12 months of life. Which statements accurately describe the typical infant's achievement of these milestones? Select all that apply.
a

Answers:
a. At 1 month, the infant lifts and turns the head to the side in the prone position.
d. At 7 months, the infant sits alone with some use of hands for support.
e. At 9 months, the infant crawls with the abdomen off the floor.
f. At 12 months, the

The nurse observes an infant interacting with his parents. What are normal social behavioral developments for this age group? Select all that apply.
a. Around 5 months, the infant may develop stranger anxiety.
b. Around 2 months, the infant exhibits a fir

Answers:
b. Around 2 months, the infant exhibits a first real smile.
c. Around 3 months, the infant smiles widely and gurgles when interacting with the caregiver.
d. Around 3 months, the infant will mimic the parent's facial movements, such as sticking ou

A new mother shows the nurse that her baby grasps her finger when she touches the baby's palm. How might the nurse respond to this information?
a. "This is a primitive reflex known as the plantar grasp."
b. "This is a primitive reflex known as the palmar

Answer: "This is a primitive reflex known as the palmar grasp."
Primitive reflexes are subcortical and involve a whole-body response. Selected primitive reflexes present at birth include Moro, root, suck, asymmetric tonic neck, plantar and palmar grasp, s

Which reflex, if found in a 4-month-old infant, would cause the nurse to be concerned?
a. Plantar grasp
b. Step
c. Babinski
d. Neck righting

Answer: Step
Rationale: Appropriate appearance and disappearance of primitive reflexes, along with the development of protective reflexes, indicates a healthy neurologic system. The step reflex is a primitive reflex that appears at birth and disappears at

A new mother expresses concern to the nurse that her baby is crying and grunting when passing stool. What is the nurse's best response to this observation?
a. "This is normal behavior for infants unless the stool passed is hard and dry."
b. "This is norma

Answer: "This is normal behavior for infants unless the stool passed is hard and dry."
Rationale: Due to the immaturity of the gastrointestinal system, newborns and young infants often grunt, strain, or cry while attempting to have a bowel movement. This

The nurse is assessing a 4-month-old boy during a scheduled visit. Which findings might suggest a developmental problem?
a. The child does not babble.
b. The child does not vocally respond to voices.
c. The child never squeals or yells.
d. The child does

Answer: The child does not vocally respond to voices.
Rationale: The fact that the child does not vocally respond to voices might suggest a developmental problem. At 4 to 5 months of age, most children are making simple vowel sounds, laughing aloud, doing

The nurse is caring for a 4-week-old girl and her mother. Which is the most appropriate subject for anticipatory guidance?
a. Promoting the digestibility of breast milk
b. Telling how and when to introduce rice cereal
c. Describing root reflex and latchin

Answer: Telling how and when to introduce rice cereal
Rationale: Telling the mother how to introduce rice cereal is the most appropriate subject for anticipatory guidance. Since this mother is already breast- or bottle-feeding her baby, educating her abou

The nurse is providing anticipatory guidance to a mother of a 5-month-old boy about introducing solid foods. Which statement by the mother indicates that effective teaching has occurred?
a. "I'll start with baby oatmeal cereal mixed with low-fat milk."
b.

Answer: "The cereal should be a fairly thin consistency at first."
Rationale: Iron-fortified rice cereal mixed with a small amount of formula or breast milk to a fairly thin consistency is typically the first solid food used. As the infant gets older, a t

The nurse is providing anticipatory guidance to the mother of a 9-month-old girl during a well-baby visit. Which topic would be most appropriate?
a. Advising how to create a toddler-safe home
b. Warning about small objects left on the floor
c. Cautioning

Answer: Advising how to create a toddler-safe home
Rationale: The most appropriate topic for this mother would be advising her on how to create a toddler-safe home. The child will very soon be pulling herself up to standing and cruising the house. This wi

The nurse in a community clinic is caring for a 6-month-old boy and his mother. Which intervention is priority to promote adequate growth?
a. Monitoring the child's weight and height
b. Encouraging a more frequent feeding schedule
c. Assessing the child's

Answer: monitoring the child's weight and height

The nurse is assessing a 12-month-old boy with an English-speaking father and a Spanish-speaking mother. The boy does not say mama or dada yet. What is the priority intervention?
a. Performing a developmental evaluation of the child
b. Encouraging the par

Answer: Asking the mother if the child uses Spanish words
Rationale: Infants in bilingual families may use some words from each language. Therefore, the priority intervention in this situation would be to ask the mother if the child uses Spanish words. Th

A 6-month-old girl weighs 14.7 lb during a scheduled check-up. Her birth weight was 8 lb. What is the priority nursing intervention?
a. Talking about solid food consumption
b. Discouraging daily fruit juice intake
c. Increasing the number of breastfeeding

Answer: Discussing the child's feeding patterns
Rationale: Assessing the current feeding pattern and daily intake is the priority intervention. Talking about solid food consumption may not be appropriate for this child yet. Discouraging daily fruit juice

The nurse is educating a first-time mother who has a 1-week-old boy. Which is the most accurate anticipatory guidance?
a. Describing the effect of neonatal teeth on breastfeeding
b. Explaining that the stomach holds less than 1 ounce
c. Informing that fon

Answer: Explaining that the stomach holds less than 1 ounce
Rationale: Explaining that the child's stomach holds less than 1 ounce gives the mother a reason for frequent, small feedings and is the most helpful and accurate anticipatory guidance. Telling t

A 6-month-old male is at his well-child checkup. The nurse weighs him, and his mother asks if his weight is normal for his age. The nurse ' s best response is:
1. "At 6 months, his weight should be approximately three times his birth weight."
2. "Each chi

Answer: "At 6 months, his weight should be approximately twice his birth weight."
Rationale: Infants should double their birth weight by 4 to 6 months

Which statements by an infant's mother lead the nurse to believe that she needs further education about the nutritional needs of a 6-month-old? Select all that apply.
1. "I will continue to breastfeed my son and will give him oatmeal cereal two times
a da

Answers
-"I will start my son on fruits and gradually introduce vegetables."
- "I will not give my son any more than 4 to 6 ounces of baby juice per day."
- "I will make sure my son gets cereal three times a day."
Rationale: Infants should be started on v

Which statement accurately describes the best method for assessing a 12-month-old?
1. The nurse should assess the child on the examining table.
2. The nurse should assess the child in a head-to-toe sequence.
3. The nurse should have the child's parent ass

Answer: The nurse should assess the child while she is in her parent's lap
Rationale: Infants are most secure when in proximity to the parent. The parent's lap is an excellent place to assess the child

Which toy is the best choice for a 12-month-old?
1. Baby doll.
2. Musical rattle.
3. Board book.
4. Colorful beads.

Answer: Musical rattle
Rationale: A musical rattle is the perfect toy for this child. Infants have short attention spans and enjoy auditory and visual stimulation.

The nurse is providing anticipatory guidance to a mother to help promote healthy sleep for her 3-week-old baby. Which recommended guideline might be included in the teaching plan?
a. Place the baby on a soft mattress with a firm, flat pillow for the head.

Answer: Place the baby on his or her back when sleeping.
Rationale: Sudden infant death syndrome (SIDS) has been associated with prone positioning of newborns and infants, so the infant should be placed to sleep on the back. The baby should sleep on a fir

The parents of a newborn are asking the nurse how to use the infant car seat and where it should be placed in their vehicle. Which is the most appropriate action by the nurse?
1. Give the parents a pamphlet explaining how to install the car seat.
2. Accom

Answer: Contact the hospital's car-seat safety officer and ask the officer to accompany the parents to the car for car-seat installation
Rationale: The car-seat safety officer is the best choice as that individual would have the needed information and cer

The mother of a newborn asks the nurse when the infant will receive the first hepatitis B immunization. Which is the nurse's best response?
1. "Babies receive the hepatitis B vaccine only if their mother is hepatitis B-positive."
2. "The first dose of the

Answer: "The first dose of the hepatitis B vaccine will be given prior to discharge today."
Rationale: The first dose of hepatitis B vaccine is recommended between birth and 2 months. In most hospitals, newborns are given the vaccine prior to discharge.

A mother requests that her child receive the varicella vaccine at the 9-month well child checkup. The nurse tells the mother that:
1. Children who are vaccinated will likely develop a mild case of the disease.
2. The vaccine cannot be given at that visit.

Answer: The vaccine cannot be given at that visit
Rationale: The nurse should not give the vaccine. The varicella vaccine is not usually administered prior to 1 year of age unless they are extenuating circumstances

Which should the nurse teach the parents is one of the most common causes of injury and death for a 9-month-old infant?
1. Poisoning.
2. Child abuse.
3. Aspiration.
4. Dog bites.

Answer: Aspiration
Rationale: Aspiration is a common cause of injury and death among children of this age. These children often find small objects lying on the floor and place them in their mouth.

A 12-month-old boy weighed 8 lb 2 oz at birth. Understanding developmental milestones, what should the nurse caring for the child expect the current weight to be?
1. 16 lb 4 oz
2. 20 lb 5 oz
3. 24 lb 6 oz
4. 32 lb 8 oz

Answer: 241b 6oz
Rationale: Children should triple their birth weight by 12 months of age

Which statement by the mother of an 18-month-old would lead the nurse to believe that the child should be referred for further evaluation for developmental delay?
1. "My child is able to stand but is not yet taking steps independently."
2. "My child has a

Answer: "My child is able to stand but is not yet taking steps independently."
Rationale: The child should be walking independently by 15 to 18 months.

The mother of a child who is 2 years 6 months in age has arranged a play date with the neighbor and her child who is 2 years 9 months old. During the play date the two mothers should expect that the children will do which of the following?
1. Share and tr

Answer: Play alongside one another but not actively with one another
Rationale: Toddlers engage in parallel play. They often play alongside another child but they rarely engage in activities with the other child

A 2-year-old admitted to the hospital 2 days ago has been crying and is inconsolable much of the time. The nurse's best response to the child's parents who are concerned about this behavior is that the child is in the:
1. Detachment phase of separation an

Answer: Protest stage of separation anxiety, which is normal for children during hospitalization
Rationale: During this protest stage, children are often inconsolable and often cry more than they do when they are at home

Which should the nurse do to prevent separation anxiety in a hospitalized toddler?
1. Assume the parental role when parents are not able to be at the bedside.
2. Encourage the parents to always remain at the bedside.
3. Establish a routine similar to that

Answer: Establish a routine similar to that of the child's home
Rationale: It is very important to maintain a child's home routine both when parents are present and when they have to leave the hospital. This will increase the child's sense of security and

According to developmental theories, which important event is essential to the development of the toddler?
1. The child learns to feed self.
2. The child develops friendships.
3. The child learns to walk.
4. The child participates in being potty-trained.

Answer: The child participates in being potty-trained
Rationale: Developmental theories such as Erickson and Freud believe that toilet training is the essential event that must be mastered by the toddler

Which nursing action would help foster a hospitalized 3-year-old ' s sense of autonomy?
1. Let the child choose what time to take the oral antibiotics.
2. Allow the child to have a doll for medical play.
3. Allow the child to administer her own dose of ce

Answer: Allow the child to administer her own dose of cephalexin (Keflex) via oral syringe
Rationale: Allowing preschoolers to participate in actions of which they are capable is an excellent way to enhance their autonomy

The mother of an 11-month-old with iron-deficiency anemia tells the nurse that her infant is currently taking iron and a multivitamin. Which statement made by the mother should be of concern to the nurse?
1. "I give the iron and multivitamin at the same t

Answer: "I give the iron and multivitamin in the morning 6-oz bottle"
Rationale: Medications should never be mixed in a large amount of food or formula because the parent cannot be sure that the child will take the entire feeding.

Which reaction would a nurse expect when giving a preschooler immunizations?
1. The child remains silent and still.
2. The child cries and tells the nurse that it hurts.
3. The child tries to stall the nurse.
4. The child remains still while telling the n

Answer: The child cries and tells the nurse that it hurts
Rationale: The common response of a 5 year old is to cry and protest during an immunization

A 4-year-old boy has been hospitalized because he fell down the stairs. His mother is crying and states, "This is all my fault." Which is the nurse's best response?
1. "Accidents happen. You shouldn't t blame yourself."
2. "Falls are one of the most commo

Answer: "Falls are one of the most common injuries in this age-group"
Rationale: Falls are one of the most common injuries, and it may make the parent feel better to know that this is common.

Which statements would indicate to the nurse that a school-age child is not developmentally on track for age? Select all that apply.
1. The child is able to follow a four- to five-step command.
2. The child started wetting the bed on admission to the hosp

Answers
-The child has an imaginary friend named Kelly
- The child is not able to follow rules
Rationale: Most school-age children do not have imaginary friends. This is much more common for children of 3 and 4 years of age. Most school-age children like

Which activity can the nurse provide for a 9-year-old to encourage a sense of industry?
1. Allow the child to choose what time to take his medication.
2. Provide the child with the homework his teacher has sent.
3. Allow the child to assist with his bath.

Answer: Provide the child with the homework his teacher has sent
Rationale: The school age child is focused on academic performance; therefore, the child can achieve a sense of industry by completing his homework and staying on track with his classmates

What information should a school nurse include in a discussion on nutrition with a fourth-grade class?
1. The number of calories that a fourth-grade child should consume in a day.
2. A list of high-calorie foods that all fourth-graders should avoid.
3. Ho

Answer: A list of nutritious foods with basic scientific information about how they affect the body organs and systems.
Rationale: Reviewing nutritious choices keeps the lesson on a positive note, and school age children are very interested in how food af

Which technique should the nurse suggest to the mother of an 8-year-old who does not want to complete her chores?
1. Grounding.
2. Time-out.
3. Reward system.
4. Spanking.

Answer: reward system
Rationale: School-age children usually respond very well to a reward system and often enjoy the rewards so much that they will continue chores without continual reminders

Which should the nurse recommend to the parents of a 9-year-old hospitalized following a bicycle injury? To prevent future injury, their child should:
1. Wear safety equipment while riding bicycles.
2. Read educational material on bicycle safety.
3. Watch

Answer: Wear safety equipment while riding bicycles
Rationale: Safety equipment is essential for bicycling, skateboarding, and participating in contact sports. Most injuries occur during the school age years, when children are more active and participate

A 16-year-old male is hospitalized for cystic fibrosis. He will be an inpatient for 2 weeks while he receives IV antibiotics. Which action taken by the nurse will most enhance his psychosocial development?
1. Fax the teen's teacher and have her send in hi

Answer: Encourage the teen's friends to visit him in the hospital.
Rationale: Teens are most concerned about being like their peers. Having the teen's friends visit will help him feel he is still part of the school and social environment.

To obtain an adolescent's health information, the nurse should:
1. Interview the adolescent using direct questions.
2. Gather information during a casual conversation.
3. Interview the adolescent only in the presence of the parents.
4. Gather information

Answer: Gather information during a casual conversation
Rationale: Frequently adolescents will share more information when it is gathered during a casual conversation.

An 18-year-old with a rash and itching in the groin area is concerned that he has contracted a sexually transmitted disease and does not want his parents to find out. The nurse's best response is:
1. "We will need to contact your parents to let them know.

Answer: " We will not contact your parents regarding this visit."
Rationale: An adolescent has every right to privacy as long as the situation is not life threatening

Which method is the most effective way to present an educational program on abstinence to adolescents?
1. Use peer-led programs that emphasize the consequences of unprotected sexual contact.
2. Teach students methods to resist peer pressure.
3. Offer stud

Answer: Use peer-led programs that emphasize the consequences of unprotected sexual contact
Rationale: Adolescents are most concerned with what their peers think and feel. They are more receptive to information that comes from another adolescent.

A 13-year-old boy is hospitalized for a femur fracture. He was hit by a car while he and his friends were racing bikes near a major intersection. The child ' s parents are concerned about his judgment. The nurse should tell the parents that the behavior i

Answer: Typical of young teens
Rationale: The brains of young teens are not completely developed, which often leads to poor judgment and impulse control.

The mother of a 13-year-old girl tells the nurse that she is concerned because her daughter has gained 10 lb since she began puberty. The child ' s mother asks the nurse for advice about what to do about her daughter ' s weight gain. Which should the nurs

Answer: Inform the child's mother that it is common for teen girls to gain weight during puberty.
Rationale: The nurse should tell the child's mother that this is a normal finding in teenage girls as they enter puberty.

A 13-year-old tells the nurse that he is worried because his breasts are growing. They hurt, and he is embarrassed to take his shirt off during gym class. What should the nurse tell him?
1. "The pediatrician will draw some blood to fi nd out why your brea

Answer: "This is a normal condition of puberty that will resolve within a year or two."
Rationale: Gynecomastia and breast tenderness are common for about a third of boys during middle puberty. Gynecomastia usually resolves in 2 years.

The mother of a 15-year-old is frustrated because he spends much of his weekend time sleeping. Which is the nurse ' s best response to the mother ' s frustration?
1. "Your son may be trying to catch up on the sleep missed during the week."
2. "Development

Answer: Teens require more sleep because of the rapid physical growth that is occurring."
Rationale: Teens require more sleep because of the rapid physical growth that occurs during adolescence

During an adolescent ' s initial physical assessment, the nurse notes signs and symptoms of nutritional defi cit. Which assessment led the nurse to this initial conclusion?
1. Protein level within normal limits.
2. Blood pressure is 110/66.
3. Hair and na

Answer: Hair and nails are brittle and dry
Rationale: Dry and brittle hair and nails are common among people who have a nutritional deficit.

The mother of an adolescent complains that he has had some recent behavioral changes. He comes home from school every day, closes his door, and refrains from interaction with his family. The nurse ' s best response to the mother is:
1. "You should speak w

Answer: " Your son's behavior is normal. You should listen to him without being judgemental."
Rationale: The child's behavior is typical of a teen's response to developmental and psychosocial changes of adolescence.

The nurse is teaching the parents of a 2-year-old toddler methods of dealing with their child's "negativism." Based on Erikson's theory of development, what would be an appropriate intervention for this child?
a. Discourage solitary play; encourage playin

Answer: Encourage the child to pick out his own clothes.
Rationale: Erikson defines the toddler period as a time of autonomy versus shame and doubt. It is a time of exerting independence. Allowing the child to choose his own clothes helps him to assert hi

The nurse is caring for a toddler who is in Piaget's sensorimotor stage of cognitive development. Which task would the nurse expect the toddler to be able to perform?
a. Completing puzzles with four pieces
b. Winding up a mechanical toy
c. Playing make-be

Answer: Knowing which are his or her toys
Rationale: The toddler in Piaget's sensorimotor stage of cognitive development (18 to 24 months) understands requests, is capable of following simple directions, and has a sense of ownership (knowing which toys ar

The nurse is observing a 24-month-old boy in a day care center. Which finding suggests delayed motor development?
a. The child has trouble undressing himself.
b. The child is unable to push a toy lawnmower.
c. The child is unable to unscrew a jar lid.
d.

Answer: The child is unable to push a toy lawnmower.
Rationale: Children with normal motor development are able to push toys with wheels at 24 months of age. He won't be ready to undress himself, unscrew a jar lid, or bend over without falling until about

What activity would the nurse expect to find in an 18-month-old?
a. Standing on tiptoes
b. Pedaling a tricycle
c. Climbing stairs with assistance
d. Carrying a large toy while walking

Answer: Climbing stairs with assistance
Rationale: Toddlers continue to progress with motor skills. An 18-month-old should be able to climb stairs with assistance. A 24-month-old should be able to stand on his or her tiptoes and carry a large toy while wa

The pediatric nurse is planning quiet activities for a hospitalized 18-month-old. What would be an appropriate activity for a child of this age group?
a. Painting by number
b. Putting shapes into appropriate holes
c. Stacking blocks
d. Using crayons to co

Answer: Stacking blocks
Rationale: At 18 months, the child can stack four blocks. The 24-month-old can paint (but not by number), scribble, and color, and put round pegs into holes.

The nurse is performing a cognitive assessment of a 2-year-old. Which behavior would alert the nurse to a developmental delay in this area?
a. The child cannot say name, age, and gender.
b. The child cannot follow a series of two independent commands.
c.

Answer: The child does not point to named body parts
Rationale: The 2-year-old can point to named body parts and has a vocabulary of 40 to 50 words. At 30 months old, a child can follow a series of two independent commands and at 3 years old, a child can

The nurse is interviewing a 3-year-old girl who tells the nurse: "Want go potty." The parents tell the nurse that their daughter often speaks in this type of broken speech. What would be the nurse's appropriate response to this concern?
a. "This is a norm

Answer: This is a normal, common speech pattern in the 3-year-old and is called telegraphic speech."
Rationale: Telegraphic speech is common in the 3-year-old. Telegraphic speech refers to speech that contains only the essential words to get the point acr

After teaching a group of parents about language development in toddlers, what if stated by a member of the group indicates successful teaching?
a. "When my 3-year-old asks 'why?' all the time, this is completely normal."
b. "A 15-month-old should be able

Answer: "When my 3-year old asks, why? all the time, this is completely normal."
Rationale: Language development occurs rapidly in a toddler. By age 3 years, "why" and "what" questions dominate in the child's language. Pointing to named body parts is char

The nurse is watching toddlers at play. Which normal behavior would the nurse observe?
a. Toddlers engage in parallel play.
b. Toddlers engage in solitary play.
c. Toddlers engage in cooperative play.
d. Toddlers do not engage in play outside the home.

Answer: Toddlers engage in parallel play
Rationale: Toddlers typically play alongside another child (parallel play) rather than cooperatively. Infants engage in solitary play.

The nurse is developing a teaching plan for toddler safety to present at a parenting seminar. Which safety intervention should the nurse address?
a. Encourage parents to enroll toddlers in swimming classes to avoid the need for constant supervision around

Answer: Advise parents to use a forward-facing seat with harness straps, placed in the back seat of the car.
Rationale: Safety is of prime concern throughout the toddler period. The safest place for the toddler to ride is in the back seat of the car. Pare

During a health history, the nurse explores the sleeping habits of a 3-year-old boy by interviewing his parents. Which statement from the parents reflects a recommended guideline for promoting healthy sleep in this age group?
a. "Our son sleeps through th

Answer: "We keep a strict bedtime ritual for our son, which includes a bath and bedtime story."
Rationale: Consistent bedtime rituals help the toddler prepare for sleep; the parent should be advised to choose a bedtime and stick to it as much as possible.

The nurse is teaching good sleep habits for toddlers to the mother of a 3-year-old boy. Which response indicates the mother understands sleep requirements for her son?
a. "I'll put him to bed at 7 PM, except Friday and Saturday."
b. "He needs 12 hours of

Answer: "He needs 12 hours of sleep per day including his nap."
Rationale: The mother understands her child needs 12 hours of sleep and one nap per day. Routines, such as the same bedtime every night, promote good sleep. However, a horseback ride to bed m

The parents of a 1-year-old girl, both of whom have perfect teeth, are concerned about their child getting dental caries. Which is the best advice the nurse can provide?
a. Tell the parents to limit the child's eating to meal and snack times.
b. Urge the

Answer: Telling the parents to limit the child's eating to meal and snack times
Rationale: Telling the parents to limit eating to meal and snack times is the best advice for preventing dental caries. This reduces the amount of exposure the child's teeth h

The nurse is helping parents prepare a healthy meal plan for their toddler. Which guidelines for promoting nutrition should be followed when planning meals? Select all that apply.
a. The child younger than 2 years of age should have his or her fat intake

Answers:
-Extending breastfeeding into toddlerhood is believed to be beneficial to the child.
-Adequate calcium intake and appropriate exercise lay the foundation for proper bone mineralization.
- Toddlers tend to have the highest daily iron intake of any

The nurse is choosing foods for a toddler's diet that are high in vitamin A. What foods could be added to the menu? Select all that apply.
a. Applesauce
b. Avocados
c. Broccoli
d. Sweet potatoes
e. Spinach
f. Carrots

Answers:
-Sweet potatoes
-Spinach
-Carrots
Rationale: Foods that are high in vitamin A include apricots, cantaloupe, carrots, mangos, spinach, and dark greens, and sweet potatoes. Applesauce is high in fiber, and avocados and broccoli are high in folate.

When instructing the parents of a toddler about appropriate nutrition, what would the nurse recommend?
a. About 12 to 16 ounces of fruit juice per day
b. Approximately 16 to 24 ounces of milk per day
c. Fat intake of 30% to 40% of total calories
d. An ave

Answer: Approximately 16 to 24 ounces of milk per day
Rationale: Milk intake should be limited to 16 to 24 ounces per day, with fruit juice limited to 4 to 6 ounces per day. A toddler's total fat intake should be 20% to 30% of total calories. The daily re

The nurse is teaching the parents of an overweight 18-month-old girl about diet. Which intervention will be most effective for promoting proportionate growth?
a. Remove high-calorie, low-nutrient foods from the diet.
b. Ensure 30 minutes of unstructured a

Answer: Remove high-calorie, low-nutrient foods from the diet
Rationale: The most effective intervention will be to remove high-calorie, low-nutrient foods from the diet in order to reduce the number of calories and increase the nutritional value. Exercis

The parents of a 2-year-old girl are frustrated by the frequent confrontations they have with their child. Which is the best anticipatory guidance the nurse can offer to prevent confrontations?
a. "Respond in a calm but firm manner."
b. "You need to adher

Answer: "You need to adhere to various routines."
Rationale: Making expectations known through everyday routines helps to avoid confrontations. This helps the child know what to expect and how to behave. It is the best guidance to give these parents. Calm

The nurse is providing guidance after observing a mother interact with her negative 2-year-old boy. For which interaction will the nurse advise the mother that she is handling the negativism properly?
a. Telling the child to stop tearing pages from magazi

Answer: Telling the child firmly that we don't scream in the office
Rationale: Telling the child firmly that we don't scream in the office gets the point across to the child that his behavior is unacceptable while role modeling appropriate communication.

The nurse is assessing a 2-year-old boy who has missed some developmental milestones. Which finding will point to the cause of motor skill delays?
a. The mother is suffering from depression.
b. The child is homeless and has no toys.
c. The mother describe

Answer: The child is homeless and has no toys
Rationale: Children develop through play, so a child without any toys may have trouble developing the motor skills appropriate to his age. Maternal depression is a risk factor for poor cognitive development. I

The nurse emphasizes that a toddler younger than the age of 18 months should never be spanked primarily for which reason?
a. Spanking in a child this age predisposes the child to a pro-violence attitude.
b. The child will become resentful and angry, leadi

Answer: There is an increased risk for physical injury in this age group.
Rationale: Spanking should never be used with toddlers younger than 18 months of age because there is an increased possibility of physical injury. Although spanking or other forms o

The nurse is assessing the psychosocial development of a preschooler. What are normal activities characteristic of the preschooler? Select all that apply.
a. Plans activities and makes up games.
b. Initiates activities with others.
c. Acts out roles of ot

Answers:
-Plans activities and makes up games
-Initiates activities with others
-Acts out roles of other people
Rationale: The many activities of the preschooler include beginning to plan activities, making up games, initiating activities with others, and

The nurse is caring for a 5-year-old girl posttonsillectomy. The girl looks out the window and tells the nurse that it is raining and says, "The sky is crying because it is sad that my throat hurts." The nurse understands that the girl is demonstrating wh

Answer: magical thinking
Rationale: The nurse understands that the girl is demonstrating magical thinking. Magical thinking is a normal part of preschool development. The preschool-age child believes her thoughts to be all-powerful. Transduction is reason

The parents of a 4-year-old ask the nurse when their child will be able to differentiate right from wrong and develop morals. What would be the best response of the nurse?
a. "The preschooler has no sense of right and wrong."
b. "The preschooler is develo

Answer: "The preschooler is developing a conscience."
Rationale: The preschool child can understand the concepts of right and wrong and is developing a conscience. Preschool children see morality as external to themselves; they defer to power (that of the

Which activity would the nurse least likely include as exemplifying the preconceptual phase of Piaget's preoperational stage?
a. Displays of animism
b. Use of active imaginations
c. Understanding of opposites
d. Beginning questioning of parents' values

Answer: Beginning questioning of parents' values
Rationale: In the intuitive phase of Piaget's preoperational stage, the child begins to question parents' values. Animism, active imaginations, and an understanding of opposites would characterize the preco

The nurse is assessing the motor skills of a 5-year-old girl. Which finding would cause the nurse to be concerned?
a. Can copy a square on another piece of paper
b. Can dress and undress herself without help
c. Draws a person with three body parts
d. Is b

Answer: Draws a person with three body parts
Rationale: By the age of 5 years, the child should be able to draw a person with a body and at least six body parts. She should also be able to copy triangles and other geometric patterns and dress and undress

The nurse is explaining to parents that the preschooler's developmental task is focused on the development of initiative rather than guilt. What is a priority intervention the nurse might recommend for parents of preschoolers to stimulate initiative?
a. R

Answer: Reward the child for initiative in order to build self-esteem.
Rationale: The building of self-esteem continues throughout the preschool period. It is of particular importance during these years, as the preschooler's developmental task is focused

The nurse is caring for preschoolers in a day care center. For this age group, of what developmental milestones should the nurse be aware? Select all that apply.
a. Counting 10 or more objects
b. Correctly naming at least four colors
c. Understanding the

Answers:
-Counting 10 or more objects
-Correctly naming at least four colors
-Understanding the concept of time
-Knowing everyday objects
Rationale: The child in the intuitive phase can count 10 or more objects, correctly name at least four colors, and be

When observing a group of preschoolers at play in the clinic waiting room, which type of play would the nurse be least likely to note?
a. Parallel play
b. Cooperative play
c. Dramatic play
d. Fantasy play

Answer: Parallel play
Rationale: Parallel play is associated with toddlers. Cooperative, dramatic, and fantasy play are commonly used by preschoolers.

The nurse is supervising lunch time for children on a pediatric ward. Which observation, if noted by the nurse, would require further assessment?
a. A child has a full set of primary teeth.
b. A child has no difficulty chewing and swallowing meat.
c. A ch

Answer: A child uses his fingers and refuses to use a fork
Rationale: The preschool child has learned to use utensils fairly effectively to feed himself or herself, has a full set of primary teeth, and is able to chew and swallow competently. Preschool ch

The nurse of a preschool child is helping parents develop a healthy meal plan for their child. What nutritional requirements for this age group should the nurse consider?
a. The 3- to 5-year-old requires 300 to 500 mg calcium and 10 mg iron daily.
b. The

Answer: The typical preschooler requires about 85 kcal/kg of body weight.
Rationale: The typical preschooler requires about 85 kcal/kg of body weight. The 3- to 5-year-old requires 700 to 1,000 mg calcium and 10 mg iron daily. The 3-year-old should consum

The parents of a 4-year-old who is a picky eater ask the nurse what foods to include in their child's diet to provide adequate iron consumption. Which food would the nurse recommend?
a. Cooked lentils
b. Whole milk
c. Oranges
d. Sweet potatoes

Answer: Cooked lentils
Rationale: Lentils are a good source of iron. Whole milk, oranges, and sweet potatoes are good sources of calcium.

The nurse is counseling parents of a picky eater on how to promote healthy eating habits in their child. Which intervention would be appropriate advice?
a. Allow the child to pick out his or her own foods for meals.
b. Present the food matter-of-factly an

Answer: Present the food matter-of-factly and allow the child to choose what to eat.
Rationale: The parents should maintain a matter-of-fact approach, offer the meal or snack, and then allow the child to decide how much of the food, if any, he or she is g

Which food suggestion would be most appropriate for the mother of a preschooler to ensure an adequate intake of calcium?
a. Spinach
b. White beans
c. Enriched bread
d. Fortified cereal

Answer: White beans
Rationale: To ensure an adequate intake of calcium, the nurse should suggest white beans, because 1 ounce of dried white beans when cooked provides 160 mg of calcium. Spinach, enriched bread, and fortified cereal are good sources of ir

The nurse is providing teaching about car safety to the parents of a 5-year-old girl who weighs 45 lb. What should the nurse instruct the parents to do?
a. "Place her in a booster seat with lap and shoulder belts in the front seat."
b. "Place her in the b

Answer: "Place her in a booster seat with lap and shoulder belts in the back seat."
Rationale: A child who weighs between 40 and 80 lb should ride in a booster seat that utilizes both the lap and shoulder belts in the back seat. When a child is large enou

The parents of a 5-year-old are concerned that their son is too short for his age. The nurse measures the child's height at 40 in (101.6 cm). How should the nurse respond?
a. "Some children are short for their age during the preschool years but usually ca

Answer: "The average height for a 5-year-old is 43 in tall (118.5 cm), so your son is within the normal range for height."
Rationale: The average preschool-age child will grow 2.5 to 3 in (6.5 to 7.8 cm) per year. The average 3-year-old is 37 in tall (96.

The nurse knows that the school-age child is in Erikson's stage of industry versus inferiority. Which best exemplifies a school-ager working toward accomplishing this developmental task?
a. The child signs up for after-school activities.
b. The child perf

Answer: The child signs up for after-school activities.
Rationale: Erikson (1963) describes the task of the school-age years to be a sense of industry versus inferiority. During this time, the child is developing his or her sense of self-worth by becoming

The school nurse providing school health screenings knows that the 7- to 11-year-old is in Piaget's stage of concrete operational thoughts. What should this age group accomplish when developing operations? Select all that apply.
a. Ability to assimilate a

Answers:
-Ability to assimilate and coordinate information about the world from different dimensions
-Ability to see things from another person's point of view and think through an action
-Ability to use stored memories of past experiences to evaluate and

The nurse is assessing the gross motor skills of an 8-year-old boy. Which interview question would facilitate this assessment?
a. "Do you like to do puzzles?"
b. "Do you play any instruments?"
c. "Do you participate in any sports?"
d. "Do you like to cons

Answer: "Do you participate in any sports?"
Rationale: To assess the gross motor skills of school-age children, the nurse should ask questions about participation in sports and after-school activities. For fine motor skills, the nurse could ask questions

The nurse is teaching the parents of a 9-year-old girl about the socialization that is occurring in their child through school contacts. Which information would the nurse include in her teaching plan?
a. Teachers are the most influential people in the dev

Answer: Continuous peer relationships provide the most important social interaction for school-age children.
Rationale: Continuous peer relationships provide the most important social interaction for school-age children. Peer and peer-group identification

During a well-child check-up, the parents of a 9-year-old boy tell the nurse that their son's friends told him that soccer is a stupid game, and now he wants to play baseball. Which comment by the nurse best explains the effects of peer groups?
a. "The ch

Answer: "Acceptance by friends, especially of the same sex, is very important at this age."
Rationale: Peer relationships, especially of the same sex, are very important and can influence the child's relationship with his parents. They can provide enough

After teaching the parents of a 9-year-old girl about safety, which statement indicates the need for additional teaching?
a. "She can ride in the front seat of the car once she is 10 years old."
b. "We need to buy her a helmet so she can ride her scooter.

Answer: "She can ride in the front seat of the car once she is 10 years old."
Rationale: Children younger than 12 years of age must sit in the back seat of the car. Laws in most states require helmets for riding bicycles and scooters. When riding a bike,

The nurse is teaching parents to plan nutritional meals for their 7-year-old son who is overweight. Which guideline might the nurse include in the teaching plan?
a. School-age children with an average body weight of 20 to 35 kg need approximately 90 calor

Answer: The school-age child needs 28 g of protein and 800 mg of calcium for maintenance of growth and good nutrition.
Rationale: The 4- to 8-year-old child needs 1,000 mg of calcium for maintenance of growth and good nutrition and 10% to 30% of calories

The nurse has determined that an 8-year-old girl is at risk for being overweight. Which intervention would be a priority prior to developing the care plan?
a. Determining the need for additional caloric intake
b. Asking the parents who they want to work w

Answer: Interviewing the parents about their eating habits
Rationale: The nurse would need to find out what the parents' eating habits are like. It would not be necessary to determine the need for additional caloric intake. Developing a multidisciplinary

When providing anticipatory guidance to a group of parents with school-age children, what would the nurse describe as the most important aspect of social interaction?
a. School
b. Peer relationships
c. Family
d. Temperament

Answer: Peer relationships
Rationale: Although school, family, and temperament are important influences on social interaction, peer relationships at this time provide the most important social interaction for school-age children.

The nurse is providing anticipatory guidance for parents of a school-age child on teaching the dangers of drugs and alcohol. What advice might be helpful for these parents?
a. School-age children are not ready to absorb information that deals with drugs a

Answer: School-age children can think critically to interpret messages seen in advertising, media, and sports.
Rationale: School-age children can be taught how to think critically to interpret messages seen in advertising, media, sports, and entertainment

The nurse is performing an assessment of the reproductive system of a 17-year-old girl. What would alert the nurse to a developmental delay in this girl?
a. Areola and papilla separate from the contour of the breast
b. Mature distribution and coarseness o

Answer: Absence of first menstrual period
Rationale: The first menstrual period usually begins between the ages of 9 and 15 years (average 12.8 years). Breast budding (thelarche) occurs at approximately ages 9 to 11 years and is followed by the growth of

After assessing a 10-year-old girl, the nurse documents the appearance of breast buds, identifying this as what body change?
a. Menarche
b. Thelarche
c. Puberty
d. Tanner stage 5

Answer: Thelarche
Rationale: "Thelarche" is the term used to describe breast budding. Menarche refers to the first menstrual period. Puberty refers to the biologic changes that occur during adolescence. Tanner stage 5 involves maturation of the breast tis

The school nurse is performing a physical examination on a 13-year-old boy who is on the soccer team. What is a physical quality that develops during these early adolescent years?
a. Coordination
b. Endurance
c. Speed
d. Accuracy

Answer: Endurance
Rationale: It is usually during early adolescence that teenagers begin to develop endurance. Their concentration has increased so they can follow complicated instructions. Coordination can be a problem because of the uneven growth spurts

Based on Erikson's developmental theory, what is the major developmental task of the adolescent?
a. Gaining independence
b. Finding an identity
c. Coordinating information
d. Mastering motor skills

Answer: Finding an identity
Rationale: According to Erikson, it is during adolescence that teenagers achieve a sense of identity. The toddler developed a sense of trust in infancy and is ready to give up dependence and to assert his or her sense of contro

The school nurse is conducting a seminar for parents of adolescents on how to communicate with teenagers. Which guidelines might the nurse recommend? Select all that apply.
a. Talk face to face and be aware of body language.
b. Ask questions to see why he

Answers:
-Talk face to face and be aware of body language.
-Ask questions to see why he or she feels that way.
- Don't pretend you know all the answers.
Rationale: In order to improve communication with teenagers, the parents should talk face to face and

The nurse is teaching the parents of a 12-year-old boy about appropriate approaches when raising an adolescent. Which comment should be included in the discussion?
a. "Find out if his friends are worthy of him."
b. "Try to be open to his views."
c. "Maint

Answer: "Try to be open to his views."
Rationale: It is most important to be open to the child's views. This will encourage the child to consider parental concerns and promote communication. Being judgmental about his friends will make the child defensive

The mother of a 14-year-old girl reports to the nurse that her daughter is moody, shuts herself in her room, and fights with her younger sister. Which comment is most valuable to the mother?
a. "Calmly talk to her about your concerns."
b. "This is normal

Answer: "Calmly talk to her about your concerns."
Rationale: Getting the mother and daughter talking and sharing information is the most valuable advice. Telling the mother that this is normal does nothing for the family situation. Setting rules will alie

The adolescent continues to develop self-concept and self-esteem. What is most important to a teen's self-esteem?
a. Strong authority figures
b. Spirituality
c. Morals and values
d. Body image

Answer: Body image
Rationale: Self-concept and self-esteem are tied to body image many times. Adolescents who perceive their body as being different than peers or as less than ideal may view themselves negatively. Sexual characteristics are important to t

The nurse teaching safety to teens knows that which of these is the leading cause of death among adolescents?
a. Drowning
b. Poisoning
c. Diseases
d. Unintentional injuries

Answer: Unintentional injuries
Rationale:
Unintentional injuries are the leading cause of death in adolescents. Motor vehicle accidents are the leading cause of injury death followed by poisoning, primarily due to drug overdose from opioids. Males are mor

When assessing adolescents for health risks, the nurse must keep in mind the factors related to the prevalence of adolescent injuries. What accurately describes these factors? Select all that apply.
a. Increased physical growth
b. Insufficient psychomotor

Answers:
a. Increased physical growth
b. Insufficient psychomotor coordination
c. Tiredness, lack of energy
d. Lack of impulsivity
e. Peer pressure
f. Inexperience
Rationale: Influencing factors related to the prevalence of adolescent injuries include inc

The nurse is helping the parents and their underweight adolescent collaborate on planning a healthy menu. Of which nutritional requirement of adolescents should the nurse be aware?
a. Teenagers have a need for increased calories, zinc, calcium, and iron f

Answer: Teenagers have a need for increased calories, zinc, calcium, and iron for growth.
Rationale: Teenagers have a need for increased calories, zinc, calcium, and iron for growth. However, the number of calories needed for adolescence depends on the te

The nurse is promoting nutrition to a 13-year-old boy who is overweight. Which comment should the nurse expect to include in the discussion?
a. "You need to go on a low-fat diet."
b. "Eat what your parents eat."
c. "Go out for a sport at school."
d. "Keep

Answer: "Keep a food diary."
Rationale: Having the boy keep a detailed food diary for 1 week will determine current patterns of eating. This can then be used to show him how to make small changes with results, especially if eating is done before periods o

The nurse is providing suggestions to a female adolescent about foods to help meet her nutritional requirements for iron. Which food would the nurse suggest as a good source of iron?
a. Broccoli
b. Yogurt
c. Peanut butter
d. White beans

Answer: Peanut butter
Rationale: Peanut butter is a good source of iron. Broccoli, yogurt, and white beans are good sources of calcium.

During a health maintenance visit, a 15-year-old girl mentions that she is not happy with being overweight. Which approach is best for the nurse to take?
a. "Good observation. Let's talk about diet and exercise."
b. "Don't worry; you are within the weight

Answer: "What specifically have you been noticing?"
Rationale: It is best to find out what caused the teenager to make the comment so that you can work with her about the issue. This is an assessment and must be done first. Launching into a lecture on die

The school nurse knows that dating is a milestone for adolescents. Which statement accurately describes a trend in teen dating?
a. Most late adolescents spend more time in activities with mixed-sex groups, such as dances and parties, than they do dating a

Answer: Most teens have been involved in at least one romantic relationship by late adolescence.
Rationale: By age 18, 70% of adolescents report being in at least one romantic relationship in the past 18 months. Most early adolescents spend more time in a

The nurse is preparing a class for a group of adolescents about promoting safety. What would the nurse plan to include as the leading cause of adolescent injuries?
a. Motor vehicles
b. Firearms
c. Water
d. Fires

Answer: Motor vehicles
Rationale: Although firearms, water, and fires all pose a risk for injury for adolescents, most adolescent injuries are due to motor vehicle crashes.

The nurse is discussing ways to promote discipline with parents who are becoming increasingly frustrated with their teenager. What would the nurse identify as most important?
a. Establish rules and expectations.
b. Collaborate to determine consequence.
c.

Answer: Make your responses consistent
Rationale: Consistency and predictability are the cornerstones of discipline. Establishing rules and expectations, collaborating to determine the consequences, and explaining the rules are all important, but they are

The nurse is performing a cognitive assessment on a 16-year-old client. Which behaviors demonstrated will the nurse identify as middle formal operational, according to Piaget's theory? Select all that apply.
a. Reporting that he smokes marijuana occasiona

Answers:
-Reporting that he smokes marijuana occasionally.
-Wanting to make decisions about health care independently
-Being very concerned with implications of the Affordable Care Act regarding healthcare benefits
Rationale: During the middle years (age

The nurse is assessing a 5-year-old girl who is anxious, has a high fever, speaks in a whisper, and sits up with her neck thrust forward. Based on these findings, what would be least
appropriate for the nurse to perform?
A. Providing 100% oxygen
B. Visual

Answer: visualizing the throat
Rationale: The child is exhibiting signs and symptoms of epiglottitis, which can be life threatening. Under no circumstances should the nurse attempt to visualize the throat. Reflex laryngospasm may occur, precipitating imme

The nurse is educating the parents of a 7-year-old boy with asthma about the medications that have been prescribed. Which drug would the nurse identify as an adjunct to a ?2-adrenergic agonist for treatment of bronchospasm?
A. Ipratropium
B. Montelukast
C

Answer: Ipratropium
Rationale: Ipratropium is an anticholinergic administered via inhalation to produce bronchodilation without systemic effects. It is generally used as an adjunct to a ?2-adrenergic agonist. Montelukast decreases the inflammatory respons

The nurse is caring for a 3-year-old girl with a respiratory disorder. The nurse anticipates the need for providing supplemental oxygen to the child when performing which action?
A. Suctioning a tracheostomy tube
B. Administering drugs with a nebulizer
C.

Answer: Suctioning a tracheostomy tube
Rationale: Supplemental oxygenation may be necessary before, and is always performed after, suctioning a child with a tracheostomy tube. Providing tracheostomy care, administering drugs with a nebulizer, and suctioni

The nurse is examining a 5-year-old. Which sign or symptom is a reliable first indication of respiratory illness in children?
A. Slow, irregular breathing
B. A bluish tinge to the lips
C. Increasing lethargy
D. Rapid, shallow breathing

Answer: Rapid, shallow breathing
Rationale: Tachypnea, or increased respiratory rate, is often the first sign of respiratory illness in infants and children. Slow, irregular breathing and increasing listlessness are signs that the child's condition is wor

A child requires supplemental oxygen therapy at 8 liters per minute. Which delivery device would the nurse most likely expect to be used?
A. Simple mask
B. Venturi mask
C. Nasal cannula
D. Oxygen hood

Answer: Simple mask
Rationale: A simple mask would be used to deliver a flow rate of 8 liters per minute. A Venturi mask would be used to deliver a specific percentage of oxygen, from 24% to 50%. A nasal cannula would be used to deliver no more than 4 lit

A group of nursing students are reviewing information about the variations in respiratory anatomy and physiology in children in comparison to adults. The students demonstrate understanding of the information when they identify which finding?
A. Children's

Answer: Children develop hypoxemia more rapidly than adults do.
Rationale: Children develop hypoxemia more rapidly than adults do because they have a significantly higher metabolic rate and faster resting respiratory rates than adults do, which leads to a

A parent asks the nurse about immunizing her 7-month-old daughter against the flu. Which response by the nurse would be most appropriate?
A. "She really doesn't need the vaccine until she reaches 1 year of age."
B. "She will probably receive it the next t

Since your daughter is older than 6 months, she should get the vaccine every year."
Rationale: The current recommendations are for all children older than 6 months of age to be immunized yearly against influenza.

A group of nursing students are reviewing the medications used to treat asthma. The students demonstrate understanding of the information when they identify which agent as appropriate for
an acute episode of bronchospasm?
A. Salmeterol
B. Albuterol
C. Ipr

Answer: Albuterol
Rationale: Albuterol is a short-acting ?2-adrenergic agonist that is used for treatment of acute bronchospasm. Salmeterol is a long-acting ?2-adrenergic agonist used for long-term control or exercise-induced asthma. Ipratropium is an ant

The nurse is preparing to perform a physical examination of a child with asthma. Which technique would the nurse be least likely to perform?
A. Inspection
B. Palpation
C. Percussion
D. Auscultation

Answer: Palpation
Rationale: When examining the child with asthma, the nurse would inspect, auscultate, and percuss. Palpation would not be used.

When performing the physical examination of a child with cystic fibrosis, what would the nurse expect to assess?
A. Dullness over the lung fields
B. Increased diaphragmatic excursion
C. Decreased tactile fremitus
D. Hyperresonance over the liver

Answer: Decreased tactile fremitus
Rationale: Examination of a child with cystic fibrosis typically reveals decreased tactile fremitus over areas of atelectasis, hyperresonance over the lung fields from air trapping, decreased diaphragmatic excursion, and

A child is brought to the emergency department by his parents because he suddenly developed a barking cough. Further assessment leads the nurse to suspect that the child is experiencing croup. What would the nurse have most likely assessed?
A. High fever

Answer: Inspiratory stridor
Rationale: A child with croup typically develops a bark-like cough often at night. This may be accompanied by inspiratory stridor and suprasternal retractions. Temperature may be normal or slightly elevated. A high fever, dysph

The nurse is teaching the parent of a child with cystic fibrosis about nutrition requirements for the child. What should be included in this teaching?
A. "Give your child high-calorie foods and snacks."
B. "Feed your child foods that are high in protein.

Answers:
- "Give your child high-calorie foods and snacks."
-"Feed your child foods that are high in protein."
- "Give pancreatic enzymes with meals."
Rationale: Children with cystic fibrosis (CF) have trouble digesting and absorbing nutrients. They tend

A parent with a child who has cystic fibrosis asks the nurse how to determine if the child is receiving an adequate amount of pancreatic enzymes. How should the nurse respond? Select all that apply.
A. "The dose is adequate when your child is only having

Answers:
-"The dose is adequate when your child is only having 1 to 2 stools per day."
-"The dose is adequate when your child's weight is improving."
-"When your child starts to eat more quantity of food you will need to adjust the amount of enzyme pills.

A child is in the emergency department with an asthma exaccerbation. Upon asucultation the nurse is unable to hear air movement in the lungs. What action should the nurse take first?
A. Administer a beta-2 adrenergic agonist
B. Administer oxygen
C. Start

Answer: Administer a beta-2 adrenergic agonist
Rationale: When lungs sounds are unable to be heard in a child with asthma, the child is very ill. This means there is severe airway obstruction. The air movement is so severe wheezes cannot be heard. The pri

The nurse is conducting a physical examination of a child with suspected Crohn disease. Which finding would be the most suspicious of Crohn disease?
A) Normal growth patterns
B) Perianal skin tags or fissures
C) Poor growth patterns
D) Abdominal tendernes

Answer: Perianal skin tags or fissures
Rationale: Perianal skin tags and/or fissures are highly suspicious of Crohn disease. Poor growth patterns and abdominal tenderness are common to Crohn disease but are also seen with many other conditions. Normal gro

The parents of a 6-week-old boy come to the clinic for evaluation because the infant has been vomiting. The parents report that the vomiting has been increasing in frequency and forcefulness over the last week. The mother says, "Sometimes, it seems like i

Answer: Hard, moveable, olive-shaped mass in the right upper quadrant
Rationale: With hypertrophic pyloric stenosis, a hard, moveable, olive-shaped mass would be palpated in the right upper quadrant. A sausage-shaped mass in the upper midabdomen would sug

A group of nursing students are reviewing information about inflammatory bowel disease in preparation for a class discussion on the topic. The students demonstrate understanding of the material when they identify which characteristics
of Crohn disease? Se

-Most common between the ages of 10 and 20 years
-Elevated erythrocyte sedimentation rate
-Low serum iron levels
Rationale: Crohn disease is most common between the ages of 10 and 20 years. Erythrocyte abirb.com/test
sedimentation rate is elevated, and se

The nurse is caring for a 6-month-old with a cleft lip and palate. The mother of the child demonstrates understanding of the disorder with which statements?
A) "My smoking during pregnancy didn't have anything to do with this disorder. Smoking primarily c

B) "I know my baby takes a lot longer to feed than most children this age."
abirb.com/test
C) "It really worries me that my baby may have some other disorders that haven't been detected yet."
abirb.com/test
D) "I wonder if my baby will develop speech prob

The nurse is caring for a 4-year-old with a suspected urinary tract infection. What would be most appropriate to say to the child when obtaining a urine specimen from him?
A. "I will need a urine sample."
B. "Let your mom help you tinkle in this cup."
C.

Answer: "Let your mom help you tinkle in this cup."
Rationale: The nurse needs to use familiar terms to explain to the child what is needed and to gain cooperation. The most positive approach would be to let the child's mother help rather than
demanding t

The nurse is caring for a 4-year-old girl with vulvovaginitis. After instructing the girl's mother on how to help prevent subsequent episodes, which statement by the mother indicates a need for additional teaching?
A. "She tells me she wipes from front to

Answer: "She tells me she wipes from front to back."
Rationale: At the age of 4, the mother should not assume that the girl will wipe properly. The mother will need to supervise her wiping in order to train her properly. Making sure the child changes her

The nurse is caring for a 12-year-old girl with nephrotic syndrome. The girl confides that she feels like a "freak" compared to her peers because of her weight, edema, and moon face. Which response by the nurse would be most appropriate?
A. "Let's put you

Answer: "Let's put you in touch with some other girls who are also having the same body changes."
Rationale:
Rationale: It is important to introduce the girl to other youngsters with chronic renal conditions so she does not feel so isolated. Adolescents n

The nurse is preparing a teaching plan for the parents of a child with a urinary tract infection (UTI). In educating the parents, the nurse would recommend that the child avoid:
A. a liberal fluid intake.
B. caffeine.
C. cranberry juice.
D. cotton underwe

Answer: caffeine
Rationale: Caffeine is an irritant to the bladder and should be avoided. Liberal fluid intake and cranberry juice should be encouraged. The child should wear cotton underwear to avoid perineal irritation.

The nurse is reviewing the laboratory test results of a child with nephrotic syndrome. What would the nurse least likely expect to find?
A. Hyperlipidemia
B. Hypoalbuminemia
C. Decreased blood urea nitrogen (BUN)
D. Hypoproteinemia

Answer: Decreased blood urea nitrogen (BUN)
Rationale: With nephrotic syndrome, proteinuria, hyperlipidemia, decreased serum protein levels (hypoproteinemia), and decreased serum albumin levels (hypoalbuminemia) are present. BUN
typically becomes elevated

A nurse is preparing a presentation for a local parent group about urinary tract infections (UTIs) in children. Which organism would the nurse incorporate into the presentation as the most common cause?
A. Klebsiella
B. Escherichia coli
C. Staphylococcus

Answer: Escherichia coli
Rationale: E. coli most commonly causes UTI. Other less common causative organisms include Klebsiella, S. aureus, and Pseudomonas.

While presenting a panel discussion to a group of parents about urinary tract infections (UTIs) in children, one of the parents asks the nurse, "Why would my daughter be more at risk than my son?" Which response by the nurse would be most accurate?
A. "Gi

Answer: "A girl's urethra is closer to the rectal opening."
Rationale:
In females, the urethra is shorter, which allows bacteria to enter the bladder. It also is closer in physical proximity to the rectum, leading to possible contamination. Bladder size d

The nurse is taking a health history of a child with suspected acute poststreptococcal glomerulonephritis. Which response by the client's parent will the nurse highlight for the primary health care provider as an indicator for this condition?
A. "My child

Answer: "My child just got over a head cold with laryngitis."
Rationale: Known risk factors include a recent episode of pharyngitis or other streptococcal infection, decreased urine output, rust or cola colored urine, and swelling around the eyes. Edema m

The nurse is administering an IV infusion of albumin to a child with nephrotic syndrome. What is the primary concern for the nurse when administering this medication to the child?
A. Fluid overload
B. Electrolyte imbalance
C. Increased blood pressure
D. U

Answer: Fluid overload
Rationale: Many children with nephrotic syndrome develop hypoalbuminemia and require the administration of albumin. Albumin increases the intravascular pressure, causing the movement of fluid from the interstitial space to the intra

A child is hospitalized with acute poststreptococcal glomerulonephritis. What assessments should the nurse include in the plan of care for this child?? Select all that apply.
A. Assess level of consciousness
B. Assess pain
C. Monitor blood pressure
D. Aus

Answers:
-Assess pain
-Monitor blood pressure
-Auscultate lung sounds
-Inspect the urine
Rationale: Acute poststreptococcal glomerulonephritis (APSGN) is an immune process that injures the renal glomeruli. Children come to the healthcare provider with fev

A nurse is conducting a physical examination of a 5-year-old with suspected iron-deficiency anemia. How would the nurse evaluate for changes in neurologic functioning?
A) "Open your mouth so I can look inside your cheeks and lips."
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B) "Do y

Answer: "Will you show me how you walk across the room?"
Rationale: Neurologic effects of iron deficiency may be demonstrated when the child's ability to sit, stand, and walk are impaired. Inspecting the mouth, looking for bruises, and checking the hands

The nurse is caring for a child who has been admitted for a sickle cell crisis. What would the nurse do first to provide adequate pain management?
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A) Administer a nonsteroidal anti-inflammatory drug (NSAID) as ordered. B) Use guided imagery

Answer: Initiate pain assessment with a standardized pain scale.
Rationale: The nurse should first initiate pain assessment with a standardized pain scale upon admission and provide frequent evaluations of pain. Administering NSAIDs or meperidine and the

The nurse is caring for a 2-year-old boy with hemophilia. His parents are upset by the possibility that he will become infected with hepatitis or HIV from the clotting factor replacement therapy. Which response by the nurse would be most appropriate?
A)

Answer: "Since dry heat treatment of the factor began in 1986, there have been no reports of virus transmission."
Rationale: The nurse needs to emphasize that since 1986, there have been no reports of virus abirb.com/test
transmission from factor infusion

The nurse is evaluating the laboratory test results of a 7-year-old child with a suspected hematologic disorder. Which finding would cause the nurse to be concerned?
A) WBC: 5.6 �103/mm3
B) RBC: 2.8 � 106/mm3
C) Hemoglobin: 11.4 mg/dL
D) Hematocrit: 35%

Answer: RBC: 2.8 � 106/mm3
Rationale: The RBC listed is below the normal range for a child between the ages of 6 and 16 years (4.0 to 5.2 � 106/mm3). The WBC count, hemoglobin, and hematocrit are within acceptable parameters for a child this age.

A child with suspected sickle cell disease is scheduled for a hemoglobin electrophoresis. When reviewing the child's history, what would the nurse identify as potentially interfering with the accuracy of the results?
A) Use of iron supplementation
B) Bloo

Answer: Blood transfusion 1 month ago
Rationale: Blood transfusion within the previous 12 weeks may alter the results of the hemoglobin electrophoresis. Iron supplements can increase serum ferritin levels. Children should fast for 12 hours before having a

The nurse is teaching the parents of a child diagnosed with iron-deficiency anemia about ways to increase their child's intake of iron. The parents demonstrate understanding of the teaching when they identify which foods as good choices for
the child? Sel

-Tuna
-Salmon
- Tofu
-Cow's milk
-Dried fruits
Rationale: Foods high in iron include red meats, tuna, salmon, eggs, tofu, enriched grains, abirb.com/test
dried beans and peas, dried fruits, leafy green vegetables, and iron-fortified breakfast cereals.

The nurse is caring for 3-day-old girl with Down syndrome whose mother had no prenatal care. What is the priority nursing diagnosis?
A. Imbalanced nutrition, less than body requirements related to the effects of hypotonia
B. Deficient knowledge related to

Answer: Imbalanced nutrition, less than body requirements related to the effects of hypotonia
Rationale: Children with Down syndrome may have difficulty sucking and feeding due to lack of muscle tone and the structure of their mouths and tongues. This can

The nurse is teaching the parents of a 1-month-old girl with Down syndrome how to maintain good health for the child. Which instruction would the nurse be least likely to include?
A. Getting cervical radiographs between 3 and 5 years of age
B. Adhering to

Answer: Adhering to the special dietary needs of the child
Rationale: Children with Down syndrome do not require a special diet unless underlying gastrointestinal disease is present. However, a balanced, high-fiber diet and regular exercise are important.

When teaching a class about trisomy 21, the instructor would identify the cause of this disorder as:
A. nondisjunction.
B. X-linked recessive inheritance.
C. genomic imprinting.
D. autosomal dominant inheritance.

Answer: nondisjunction
Rationale: Trisomy 21 is an example of a genetic disorder involving an abnormality in chromosomal number due to nondisjunction. X-linked recessive inheritance disorders, such as hemophilia and Duchenne muscular dystrophy, involve al

The nurse is preparing a presentation to a local community group about genetic disorders and the types of congenital anomalies that can occur. What would the nurse include as a major congenital anomaly?
A. Overlapping digits
B. Polydactyly
C. Umbilical he

Answer: Cleft palate
Rationale: Cleft palate is considered a major congenital anomaly, one that creates a significant medical problem or requires surgical or medical management. Overlapping digits, polydactyly, and umbilical hernia are considered minor co

When providing guidance to the parents of a child with Down syndrome, which interaction would be most appropriate?
A. Encourage the parents to home-school the child.
B. Advise the parents that the child will need monthly thyroid testing.
C. Instruct them

Answer: Teach the parents about the need for a high-fiber diet.
Rationale: A high-fiber intake is important for children with Down syndrome because their lack of muscle tone may decrease peristalsis, leading to constipation. Early intervention programs wi

What finding would lead the nurse to suspect that a child has Turner syndrome?
A. Webbed neck
B. Microcephaly
C. Gynecomastia
D. Cognitive delay

Answer: webbed neck
Rationale: Manifestations of Turner syndrome include webbed neck, low posterior hairline, wide-spaced nipples, edema of the hands and feet, amenorrhea, and absence of secondary sex characteristics, along with short stature and slow gro

Which intervention is appropriate for the infant hospitalized with bronchiolitis?
a. Position on the side with neck slightly flexed.
b. Administer antibiotics as ordered.
c. Restrict oral and parenteral fluids if tachypneic.
d. Give cool, humidified oxyge

Answer: Give cool, humidified oxygen.
Rationale: Cool, humidified oxygen is given to relieve dyspnea, hypoxemia, and insensible fluid loss from tachypnea. The infant should be positioned with the head and chest elevated at a 30- to 40-degree angle and the

A child has a chronic cough and diffuse wheezing during the expiratory phase of respiration. This suggests what condition?
a. Asthma
b. Pneumonia
c. Bronchiolitis
d. Foreign body in trachea

Answer: Asthma
Rationale: Asthma may have these chronic signs and symptoms. Pneumonia appears with an acute onset, fever, and general malaise. Bronchiolitis is an acute condition caused by respiratory syncytial
virus. Foreign body in the trachea occurs wi

Which finding is expected when assessing a child hospitalized for asthma?
a. Inspiratory stridor
b. Harsh, barky cough
c. Wheezing
d. Rhinorrhea

Answer: Wheezing
Rationale: Wheezing is a classic manifestation of asthma. Inspiratory stridor is a clinical manifestation of croup. A harsh, barky cough is characteristic of croup. Rhinorrhea is not associated with asthma.

What is a common trigger for asthma attacks in children?
a. Febrile episodes
b. Dehydration
c. Exercise
d. Seizures

Answer: Exercise
Rationale: Exercise is one of the most common triggers for asthma attacks, particularly in school-age children. Febrile episodes are consistent with other problems, for example, seizures. Dehydration occurs as a result of diarrhea; it doe

Following parental teaching, the nurse is evaluating the parents understanding of environmental control for their childs asthma management. Which statement by the parents indicates appropriate understanding of the teaching?
1. We will replace the carpet i

Answer: We will replace the carpet in our childs bedroom with tile.
Rationale: Control of dust in the childs bedroom is an important aspect of environmental control for asthma management. When possible, pets and plants should not be kept in the home. Smok

Parents of a child admitted with respiratory distress are concerned because the child wont lie down and wants to sit in a chair leaning forward. Which response by the nurse is the most appropriate?
1. This helps the child feel in control of his situation.

Answer: This position helps keep the airway open.
Rationale: Leaning forward helps keep the airway open. The child is not in control just because he is leaning forward. Lying flat in bed will increase the respiratory distress. This position does not confi

The nurse assessing a child with acute poststreptococcal glomerulonephritis should be alert for which finding?
a. Increased urine output
b. Hypotension
c. Tea-colored urine
d. Weight gain

Answer: Tea-colored urine
Rationale: Acute poststreptococcal glomerulonephritis is characterized by hematuria, proteinuria, edema, and renal insufficiency. Tea-colored urine is an indication of hematuria. In acute poststreptococcal glomerulonephritis, the

What is a clinical finding that warrants further intervention for the child with acute poststreptococcal glomerulonephritis?
a. Weight loss to within 1 pound of the preillness weight
b. Urine output of 1 milliliter per kilogram per hour
c. A normal blood

Answer: Inspiratory crackles
Rationale: Children with excess fluid volume may have pulmonary edema. Inspiratory crackles indicate fluid in the lungs. Pulmonary edema can be a life-threatening complication. Weight loss to within 1 pound of the preillness w

Which diagnostic finding is assessed by the nurse when a child has primary nephrotic syndrome?
a. Hyperalbuminemia
b. Positive ASO titer
c. Leukocytosis
d. Proteinuria

Answer: Proteinuria
Rationale: Large amounts of protein are lost through the urine as a result of an increased permeability of the
glomerular basement membrane. Hypoalbuminemia is present because of loss of albumin through the defective glomerulus and the

A child with secondary enuresis who complains of dysuria or urgency should be evaluated for which condition?
a. Hypocalciuria
b. Nephrotic syndrome
c. Glomerulonephritis
d. Urinary tract infection

Answer: Urinary tract infection
Rationale: Complaints of dysuria or urgency from a child with secondary enuresis suggest the possibility of a urinary tract infection. An excessive loss of calcium in the urine (hypercalciuria) can be associated with compla

A nurse is planning care for a child admitted with nephrotic syndrome. Which interventions should be included in the plan of care? Select all that apply.
a. Administration of antihypertensive medications
b. Daily weights
c. Salt-restricted diet
d. Frequen

Answers
-Daily weights
-Salt-restricted diet
-Frequent position changes
Rationale: A child with nephrotic syndrome will need to be monitored closely for fluid excess so daily weights are important. The diet is salt restricted to prevent further retention

A nurse is assessing an infant for urinary tract infection (UTI). Which assessment findings should the nurse expect? Select all that apply.
a. Change in urine odor or color
b. Enuresis
c. Fever or hypothermia
d. Voiding urgency
e. Poor weight gain

Answers:
-Change in urine odor or color
-Fever or hypothermia
-Poor weight gain

The postoperative care plan for an infant with surgical repair of a cleft lip includes which intervention?
a. A clear liquid diet for 72 hours
b. Nasogastric feedings until the sutures are removed
c. Elbow restraints to keep the infants fingers away from

Answer: Elbow restraints to keep the infants fingers away from the mouth
Rationale: Keeping the infants hands away from the incision reduces potential complications at the surgical www.testbanktank.com
site. The infants diet is advanced from clear liquid

A nurse should plan to implement which interventions for a child admitted with inorganic failure to thrive? Select all that apply.
a. Observation of parentchild interactions
b. Assignment of different nurses to care for the child from day to day c. Use of

Answers:
-Observation of parent child interactions
-Administration of daily multivitamin supplements
- Role-modeling appropriate adult child interactions
Rationale: The nurse should plan to assess parent-child interactions when a child is admitted for non

Which activity would the nurse expect an 18

Which behavior reported by a parent of an 18

How do you assess an 18

Which should the nurse expect for a toddler's language development at age 18 months?