2 The Nursing Care of Children

Question 1

Health Promotion of the Infant and Family
1. After reading the vaccine information sheets, the parent of a 2-month-old infant is hesitant to
consent to the recommended vaccinations. The nurse should first ask the parent:
1. “Did you know that vaccinations are required by law for school entry?”
2. “What personal beliefs or safety concerns do you have about vaccinations?”
3. “Would you prefer that fewer vaccines are given at a time?”
4. “Can you please sign this vaccine waiver form?”

Answer 1

Health Promotion of the Infant and Family
1. 2. By trying to determine the source of parents’ concerns, the nurse is able to acknowledge their
feelings and provide the most appropriate information. This approach increases the likelihood parents
will listen to the health care provider’s views. Exemptions for vaccines vary by state, province, or
territory, and many parents feel legal requirements for vaccinations take away parental rights. The
number of vaccinations given at one time may not be the issue. Waivers are used only if clients refuse
vaccination after a discussion of risks and benefits.
CN: Health promotion and maintenance; CL: Synthesize

Question 2

2. Which of the following is appropriate language development for an 8-month-old? The child
   should be:
3. Saying “dada” and “mama” specifically (“dada” to father and “mama” to mother).
4. Saying three other words besides “mama” and “dada.”
5. Saying “dada” and “mama” nonspecifically.
6. Saying “ball” when parents point to a ball.

Answer 2

2. 3. It is important for the nurse to assist parents in assessing speech development in their child
      so that developmental delays can be identified early. According to the Denver Developmental
      Screening Examination, at 8 months of age, the child should say “mama” and “dada” nonspecifically
      and imitate speech sounds. Children cannot say “dada” or “mama” specifically or use more than three
      words until they are about 12 months of age. A child cannot respond to specific commands or point to
      objects when requested until about 17 months of age.
      CN: Health promotion and maintenance; CL: Apply

Question 3

3. The nurse should refer the parents of an 8-month-old child to a health care provider if the child
   is unable to:
4. Stand momentarily without holding onto furniture.
5. Stand alone well for long periods of time.
6. Stoop to recover an object.
7. Sit without support for long periods of time.

Answer 3

3. 4. According to the Denver Developmental Screening Examination, a child of 8 months should
      sit without support for long periods of time. An 8-month-old child does not have the ability to stand
      without hanging on to a stationary object for support. His muscles are not developed enough to
      support all his weight without assistance. His balance has not developed to the point that he can stand
      and stoop over to reach an object.
      CN: Health promotion and maintenance; CL: Synthesize

Question 4

4. The nurse is teaching the parents of an 8-month-old about what the child should eat. The nurse
   should include which of the following points in the teaching plan?
5. Items from all food groups should be introduced to the infant by the time the child is 10 months
   old.
6. Solid foods should not be introduced until the infant is 10 months old.
7. Iron deficiency rarely develops before 12 months of age, so iron-fortified cereals should not
   be introduced until the infant is 12 months old.
8. The infant’s diet can be changed from formula to whole milk when the infant is 12 months old.

Answer 4

4. 4. Infants should be kept on formula or breast milk until 1 year of age. The protein in cow’s
      milk is harder to digest than that found in formula. The infant cannot digest fats well, so some foods
      from the four food groups are not necessary in his diet during infancy. Solids are introduced into the
      infant’s diet around 4 to 6 months, after the extrusion reflex has diminished and when the child will
      accept new textures. Iron deficiency develops in term infants between 4 to 6 months when the prenatal
      iron stores are depleted. Fortified cereals can be added to the infant’s diet at 4 to 6 months to prevent
      iron deficiency anemia.
      CN: Health promotion and maintenance; CL: Create

Question 5

5. A 10-month-old looks for objects that have been removed from his view. The nurse should
   instruct the parents that:
6. Neuromuscular development enables the child to reach out and grasp objects.
7. The child’s curiosity has increased.
8. The child understands the permanence of objects even though the child cannot see them.
9. The child is now able to transfer objects from hand to hand.

Answer 5

5. 3. Understanding object permanence means that the child is aware of the existence of objects
      that are covered or displaced. Neuromuscular development, curiosity, and the ability to transfer
      objects are not associated with the principle of object permanence. Although, at 10 months,neuromuscular development is sufficient to grasp objects and a child’s curiosity has increased, neither
      are related to the thought process involved in object permanence.
      CN: Health promotion and maintenance; CL: Apply

Question 6

6. Which of the following structures should be closed by the time the child is 2 months old?
7. A.
8. B.
9. C.
10. D.

Answer 6

6. 3. The posterior fontanel should be closed by age 2 months. The anterior fontanel and sagittal
      and frontal sutures should be closed by age 18 months.
      CN: Health promotion and maintenance; CL: Apply

Question 7

7. Which statement by a parent reflects the need for further teaching regarding car seat safety?
8. “My baby should stay in a rear-facing car seat until he is 1 year old.”
9. “I should check my old car seat’s expiration date before using it for this baby.”
10. “My older child will need to stay in a booster seat until he is 4 feet 9 inches (144.8 cm).”
11. “My children should ride in the back seat until they are 13 years old.”

Answer 7

7. 1. New guidelines from the American Academy of Pediatrics and Canadian Pediatric Society
      recommend that parents keep their toddlers in a rear-facing car seat until 2 years of age. Car seats are
      marked with an expiration date because the integrity of the plastic may deteriorate with age. Booster
      seats are recommended for older children until they are 4 feet 9 inches (144.8 cm). This typically
      occurs between the ages 8 and 12 years. Children should ride in the back seat until they are 13 years
      of age to minimize injury should airbags be deployed.
      CN: Health promotion and maintenance; CL: Evaluate

Question 8

8. The parents of a 3-week-old healthy newborn ask the nurse why their daughter is intermittently
   cross-eyed. The nurse’s best response is:
9. “An eye patch may be necessary for 6 weeks to correct her vision.”
10. “Your daughter will likely need an ophthalmology consult.”
11. “It is normal to have eye-crossing in the newborn period.”
12. “Surgery may be necessary to correct your daughter’s vision.”

Answer 8

8. 3. During the first few months of life, an infant’s eyes may wander and appear to be crossing.
      As the eye muscles mature, between 2 and 3 months of age, both eyes will focus on the same thing. No
      intervention is necessary, as crossing of the eyes is normal in the first few months of life.
      CN: Health promotion and maintenance; CL: Apply

Question 9

9. A parent brings a 4-month-old to the clinic for a regular well visit and expresses concern that
   the infant is not developing appropriately. Which findings in the infant would indicate the need for
   further developmental screening?
10. Has no interest in peek-a-boo games.
11. Does not turn front to back.
12. Does not babble.
13. Continues to have head lag.

Answer 9

9. . 3. By the end of 3 months, infants should babble. Lack of babbling suggests a language delay
   and warrants further investigation. Infants typically would begin playing peek-a-boo around 7 months.
   The ability to roll front to back typically occurs at 5 months. Head lag is expected to resolve by 5
   months.
   CN: Health promotion and maintenance; CL: Analyze

Question 10

10. The nurse assesses a 6-month-old for vaccination readiness. Which finding would most likely
    indicate the need to delay administering the diphtheria, tetanus, and acellular pertussis (DTaP)
    vaccine?
11. A family history of sudden infant death syndrome (SIDS).
12. A fever of 38.5°C following the 4-month vaccinations.
13. An acute bilateral ear infection.4. Living with a family member who is immunosuppressed.

Answer 10

10. 3. Vaccination in the presence of a moderate to severe infection, with or without fever,
       increases the risk of injury and decreases the chance of mounting good immunity. There is currently no
       evidence to suggest vaccines raise the risk of SIDS. A mild temperature may be expected with the
       DTaP. A fever of >40.5°C within 48 hours of vaccination would warrant caution. The DTaP is not a
       live vaccine. No special precautions are needed regarding immunosuppressed family members.
       CN: Reduction of risk potential; CL: Synthesize

Question 11

11. The parents of a 9-month-old bring the infant to the clinic for a regular checkup. The infant
    has received no immunizations. Which vaccine order would the nurse question?
12. Diphtheria, tetanus, and acellular pertussis (DTaP).
13. Haemophilus influenzae type B (Hib).
14. Measles, mumps, and rubella (MMR).
15. Hepatitis B (Hep B).

Answer 11

11. 3. The MMR is a live vaccine. Neither the American Academy of Pediatrics nor the Public
       Health Agency of Canada recommends routine vaccination with the MMR (either alone or combined
       with the varicella vaccine) to children younger than 12 months. The DTaP, Hib, and Hep B are all
       indicated.
       CN: Health promotion and maintenance; CL: Synthesize

Question 12

12. To assess the development of a 1-month-old, the nurse asks the parent if the infant is able to:
13. Smile and laugh out loud.
14. Roll from back to side.
15. Hold a rattle briefly.
16. Hepatitis B (Hep B).

Answer 12

12. 4. A 1-month-old infant is usually able to lift the head and turn it from side-to-side from a
       prone position. The full-term infant with no complications has probably been able to do this since
       birth. Smiling and laughing is expected behavior at 2 to 3 months. Rolling from back to side and
       holding a rattle are characteristics of a 4-month-old.
       CN: Health promotion and maintenance; CL: Analyze

Question 13

13. The mother of a 6-month-old states that she started her infant on 2% milk. The nurse should
    first ask the mother:
14. “Do you think your baby will be fine with this milk?”
15. “Is it possible for you to switch your baby to whole milk?”
16. “Can you tell me more about the reason you switched your baby to 2% milk?”
17. “You cannot switch to 2% milk right now. Did your pediatrician tell you to do this?”

Answer 13

13. 3. The American Academy of Pediatrics and Canadian Pediatric Society recommend that
       infants remain on iron-fortified formula or breast milk until 1 year of age. The nurse needs to firstassess if the mother switched the baby prematurely to due to lack of information or lack of resources.
       Then appropriate teaching or referrals may be determined. At 1 year of age, the infant may be
       switched to whole milk, which has a higher fat content than 2%. The higher fat content is needed for
       brain growth. Demanding clients change behaviors without addressing the cause is unlikely to
       produce desired results.
       CN: Health promotion and maintenance; CL: Analyze

Question 14

14. The nurse notes that an infant stares at an object placed in his/her hand and takes it to his/her
    mouth, coos and gurgles when talked to, and sustains part of his/her own weight when held in a
    standing position. The nurse correctly interprets these findings as characteristic of an infant at which
    of the following ages?
15. 2 months.
16. 4 months.
17. 7 months.
18. 9 months.

Answer 14

14. 2. Holding the head erect when sitting, staring at an object placed in the hand, taking the
       object to the mouth, cooing and gurgling, and sustaining part of her body weight when in a standing
       position are behaviors characteristic of a 4-month-old infant. A 2-month-old typically vocalizes,
       follows objects to the midline, and smiles. A 7-month-old typically is able to sit without support,
       turns toward the voice, and transfers objects from hand to hand. Usually, a 9-month-old can crawl,
       stand while holding on, and initiate speech sounds.
       CN: Health promotion and maintenance; CL: Analyze

Question 15

15. An 8-month-old infant is seen in the well-child clinic for a routine checkup. The nurse should
    expect the infant to be able to do which of the following? Select all that apply.
16. Say “mama” and “dada” with specific meaning.
17. Feed self with a spoon.
18. Play peek-a-boo.
19. Walk independently.
20. Stack two blocks.
21. Transfer object from hand to hand.

Answer 15

15. 3, 6. Typical abilities demonstrated by 8-month-old infants include playing peek-a-boo and
    transferring objects from one hand to another. The ability to say “dada” and “mama” is more typical
    of 10-month-old infants. Infants usually are at least 12 months old when they achieve the ability to
    walk independently. Infants who are 15 months old commonly can feed themselves with a spoon and
    stack two blocks.
    CN: Health promotion and maintenance; CL: Analyze

Question 16

16. The parent of a 9-month-old infant is concerned that the infant’s front soft spot is still open.
    The nurse should tell the parent:
17. “I will measure your baby’s head to see if it is a normal size.”
18. “Your infant will need to be referred for more testing.”
19. “You should contact your primary health care provider immediately.”
20. “This is normal because this soft spot usually closes between 12 and 18 months.”

Answer 16

16. 4. The anterior fontanel, commonly known as the soft spot, closes between 12 to 18 months in
       most infants. The nurse normally measures an infant’s occipital frontal circumference at each well-
       child visit. This action alone does not relieve the parent’s concerns. Referrals would be indicated for
       premature or delayed closures of the fontanel especially if there were other abnormal findings.
       Closure of the anterior fontanel by 12 months can only be expected to occur in approximately a third
       of all infants.
       CN: Health promotion and maintenance; CL: Synthesize

Question 17

17. A mother states that she thinks her 9-month-old “is developing slowly.” When assessing the
    infant’s development, the nurse is also concerned because the infant should be demonstrating which ofthe following characteristics?
18. Vocalizing single syllables.
19. Standing alone.
20. Building a tower of two cubes.
21. Drinking from a cup with little spilling.

Answer 17

17. 1. Normally, a 9-month-old infant should have been voicing single syllables since 6 months of
       age. Absence of this finding would be a cause for concern. An infant usually is able to stand alone at
       about 10 months of age. An infant usually is able to build a tower of two cubes at about 15 months of age. An infant usually is able to drink from a cup with little spilling at about 15 months of age.
       CN: Health promotion and maintenance; CL: Analyze

Question 18

18. Which infant most needs a developmental referral for a gross motor delay?
19. The 2-month-old who does not roll over.
20. The 4-month-old who does sit without support.
21. The 6-month-old who does not creep.
22. The 9-month-old who does not stand holding on.

Answer 18

18. 4. More than 90% of 9-month-olds are able to stand holding on to objects. Rolling over is
       expected at 4 to 6 months, and sitting without support is expected at 6 months. Creeping is expected at
       9 months.
       CN: Health promotion and maintenance; CL: Analyze

Question 19

19. Which intervention should the nurse employ to reduce trauma caused by vaccine
    administration to an infant?
20. Use a 5/8-inch (1.6-cm) needle.
21. Simultaneously administer vaccines at separate sites.
22. Aspirate to verify needle placement.
23. Breast-feed right before administering the vaccines.

Answer 19

19. 2. Simultaneous injection reduces the anxiety from anticipation of the next injection. Needle
       length must be long enough to deposit the vaccine into the muscle. A 5/8-inch (1.6-cm) needle is
       appropriate for newborns, but is not long enough for infants older than 1 month or other children.
       Aspirating for blood return does not confirm needle placement and is no longer recommended by the
       American Council on Immunization Practices for vaccine administration. The Public Health Agency
       of Canada does not recommend aspiration to confirm needle placement. Breast-feeding duringvaccinations, not before, has been found to reduce pain.
       CN: Basic care and comfort; CL: Apply

Question 20

Health Promotion of the Toddler and Family
20. An uncle is shopping for a toy to give his niece. He has no children of his own and asks his
neighbor, a nurse, what would be the most appropriate toy to give a 15-month-old child. Which toy
should the nurse recommend to facilitate learning and development?
1. A stuffed animal.
2. A music box.
3. A push-pull toy.
4. A nursery mobile.

Answer 20

Health Promotion of the Toddler and Family
20. 3. A push-pull toy will aid in development of gross motor skills and muscle development. A
stuffed animal is age appropriate for a toddler but is not the best toy to promote development. A
music box is most appropriate to stimulate development for an infant. A nursery mobile is most
appropriate to stimulate development for an infant.
CN: Health promotion and maintenance; CL: Apply

Question 21

21. A 2-year-old tells his mother he is afraid to go to sleep because “the monsters will get him.”
    The nurse should tell his mother to:
22. Allow him to sleep with his parents in their bed whenever he is afraid.
23. Increase his activity before he goes to bed, so he eventually falls asleep from being tired.
24. Read a story to him before bedtime and allow him to have a cuddly animal or a blanket.
25. Allow him to stay up an hour later with the family until he falls asleep.

Answer 21

21. 3. Behavior problems related to sleep and rest are common in young children. Consistent
       rituals around bedtime help to create an easier transition from waking to sleep. Allowing a child to
       sleep with his parents commonly creates more problems for the family and child and does not
       alleviate the problem or foster autonomy. Increasing activity before bedtime does not alleviate the
       separation anxiety in the toddler and causes further anxiety. Allowing him to stay up later than his
       normal time for bed will increase his anxiety, make it more difficult for him to fall asleep, and do
       nothing to lessen his fear.
       CN: Psychosocial integrity; CL: Synthesize

Question 22

22. A 2-year-old always puts his teddy bear at the head of his bed before he goes to sleep. The
    parents ask the nurse if this behavior is normal. The nurse should explain to the parents that toddlers
    use ritualistic patterns to:
23. Establish a sense of identity.
24. Establish control over adults in their environment.
25. Establish sequenced patterns of learning behavior.
26. Establish a sense of security.

Answer 22

22. 4. Toddlers establish ritualistic patterns to feel secure, despite inconsistencies in their
       environment. Establishing a sense of identity is the developmental task of the adolescent. The
       toddler’s developmental task is to use rituals and routines to help in making autonomy easier to
       accomplish. Ritualistic patterns do involve patterns of behavior, but they are not utilized to develop
       learning behaviors.
       CN: Psychosocial integrity; CL: Apply

Question 23

23. Which development is necessary for toilet training readiness for a 2-year-old? Select all that
    apply.
24. Adequate neuromuscular development for sphincter control
25. Appropriate chronological age.
26. Ability to communicate the need to use the toilet.
27. Desire to please the parents.
28. Ability to play with other 2-year-olds.

Answer 23

23. 1, 3, 4. Readiness for toilet training is based on neurological, psychological, and physical
    developmental readiness. The nurse can introduce concepts of readiness for toilet training and
    encourage parents to look for adaptive and psychomotor signs such as the ability to walk well,
    balance, climb, sit in a chair, dress oneself, please the parent, and communicate awareness of the
    need to urinate or defecate. Chronological age is not an indicator for toilet training. Two-year-olds
    engage in parallel play, which is not an indicator of readiness for toilet training.
    CN: Health promotion and maintenance; CL: Apply

Question 24

24. A mother of a toilet-trained 3-year-old expresses concern over her child’s bed-wetting while
    hospitalized. The nurse should tell the mother:
25. “He was too immature to be toilet trained. In a few months he should be old enough.”
26. “Children are afraid in the hospital and frequently wet their bed.”
27. “It’s very common for children to regress when they’re in the hospital.”
28. “This is normal. He probably received too much fluid the night before.”

Answer 24

24. 3. A child will regress to a behavior used in an earlier stage of development in order to cope
       with a perceived threatening situation. Readiness for toilet training should be based on neurological,
       physical, and psychological development, not the age of the child. Children are afraid of
       hospitalization but the bed-wetting is a compensatory mechanism done to regress to a previous stage
       of development that is more comfortable and secure for the child. Telling the mother that bed-wetting
       is related to fluid intake does not provide an adequate explanation for the underlying regression to an
       earlier stage of development.
       CN: Psychosocial integrity; CL: Synthesize

Question 25

25. A nurse working in the nursery identifies a goal for a mother of a newborn to demonstrate
    positive attachment behaviors upon discharge. Which intervention would be least effective in
    accomplishing this goal?
26. Provide opportunities for the mother to hold and examine the newborn.
27. Engage the mother in the newborn’s care.
28. Create an environment that fosters privacy for the mother and newborn.
29. Identify strategies to prevent difficulties in parenting.

Answer 25

25. 4. Identifying ways to prevent difficulties in parenting would be helpful in reducing the
       incidence of child abuse and reducing the stress of child rearing. However, it would not help to
       develop positive attachment behaviors. Providing opportunities for the mother to hold and examinethe newborn and help with care helps establish a positive emotional bond between the mother and
       newborn. Providing time for the mother to be alone with the infant further allows the mother and
       newborn to bond.
       CN: Psychosocial integrity; CL: Synthesize

Question 26

26. A mother brings her 18-month-old to the clinic because the child “eats ashes, crayons, and
    paper. ” Which of the following information about the toddler should the nurse assess first?
27. Evidence of eruption of large teeth.
28. Amount of attention from the mother.
29. Any changes in the home environment.
30. Intake of a soft, low-roughage diet.

Answer 26

26. 3. A craving to eat nonfood substances is known as pica. Toddlers use oral gratification as a
       means to cope with anxiety. Therefore, the nurse should first assess whether the child is experiencing
       any change in the home environment that could cause anxiety. Teething or the eruption of large teeth
       and the amount of attention from the mother are unlikely causes of pica. Nutritional deficiencies,
       especially iron deficiency, were once thought to cause pica, but research has not substantiated this
       theory. A soft, low-roughage diet is an unlikely cause.
       CN: Physiological adaptation; CL: Analyze

Question 27

27. When assessing a 2-year-old child brought by his mother to the clinic for a routine checkup,
    which of the following should the nurse expect the child to be able to do?
28. Ride a tricycle.
29. Tie his shoelaces.
30. Kick a ball forward.
31. Use blunt scissors.

Answer 27

27. 3. A 2-year-old child usually can kick a ball forward. Riding a tricycle is characteristic of a
       3-year-old child. Tying shoelaces is a behavior to be expected of a 5-year-old child. Using blunt
       scissors is characteristic of a 3-year-old child.
       CN: Health promotion and maintenance; CL: Analyze

Question 28

28. A 2-year-old child brought to the clinic by her parents is uncooperative when the nurse tries
    to look in her ears. Which of the following should the nurse try first?
29. Ask another nurse to assist.
30. Allow a parent to assist.
31. Wait until the child calms down.
32. Restrain the child’s arms.

Answer 28

28. 2. Parents can be asked to assist when their child becomes uncooperative during a procedure.
       Most commonly, the child’s difficulty in cooperating is caused by fear. In most situations, the child
       will feel more secure with a parent present. Other methods, such as asking another nurse to assist or
       waiting until the child calms down, may be necessary, but obtaining a parent’s assistance is the
       recommended first action. Restraints should be used only as a last resort, after all other attempts have
       been made to encourage cooperation.
       CN: Health promotion and maintenance; CL: Synthesize

Question 29

29. When observing the parent instilling prescribed ear drops prescribed twice a day for a
    toddler, the nurse decides that the teaching about positioning of the pinna for instillation of the drops
    is effective when the parent pulls the toddler’s pinna in which of the following directions?
30. Up and forward.
31. Up and backward.
32. Down and forward.
33. Down and backward.

Answer 29

29. 4. In a child younger than 3 years of age, the pinna is pulled back and down, because the
       auditory canals are almost straight in children. In an adult, the pinna is pulled up and backward
       because the auditory canals are directed inward, forward, and down.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 30

30. The mother asks the nurse for advice about discipline for her 18-month-old. Which of the
    following should the nurse suggest that the mother use?
31. Structured interactions.
32. Spanking.
33. Reasoning.
34. Time-out.

Answer 30

30. 4. Time-out is the most appropriate discipline for toddlers. It helps to remove them from the
       situation and allows them to regain control. Structuring interactions with 3-year-olds helps minimize
       unacceptable behavior. This approach involves setting clear and reasonable rules and calling
       attention to unacceptable behavior as soon as it occurs. Physical punishment, such as spanking, does
       cause a dramatic decrease in a behavior but has serious negative effects. However, slapping a child’s
       hand is effective when the child refuses to listen to verbal commands. Reasoning is more appropriate
       for older children, such as preschoolers and those older, especially when moral issues are involved.
       Unfortunately, reasoning combined with scolding often takes the form of shame or criticism and
       children take such remarks seriously, believing that they are “bad.”
       CN: Health promotion and maintenance; CL: Synthesize

Question 31

31. When assessing for pain in a toddler, which of the following methods should be the most
appropriate?
1. Ask the child about the pain.
2. Observe the child for restlessness.
3. Use a numeric pain scale.
4. Assess for changes in vital signs.

Answer 31

31. 2. Toddlers usually express pain through such behaviors as restlessness, facial grimaces,
       irritability, and crying. It is not particularly helpful to ask toddlers about pain. In most instances, they
       would be unable to understand or describe the nature and location of their pain because of their lack
       of verbal and cognitive skills. However, preschool and older children have the verbal and cognitive
       skills to be able to respond appropriately. Numeric pain scales are more appropriate for childrenwho are of school age or older. Changes in vital signs do occur as a result of pain, but behavioral
       changes usually are noticed first.
       CN: Physiological adaptation; CL: Analyze

Question 32

32. When planning a 15-month-old toddler’s daily diet with the parents, which of the following
    amounts of milk should the nurse include?
33. 1⁄2 to 1 cup (125 to 250 mL).
34. 2 to 3 cups (500 to 750 mL).
35. 3 to 4 cups (750 to 1,000 mL).4. 4 to 5 cups (1,000 to 1,250 mL).

Answer 32

32. 2. Toddlers around the age of 15 months need 2 to 3 cups (500 to 750 mL) of milk per day to
       supply necessary nutrients such as calcium. A daily intake of more than 3 cups (750 mL) of milk may
       interfere with the ingestion of other necessary nutrients.
       CN: Health promotion and maintenance; CL: Apply

Question 33

Health Promotion of the Preschooler and Family

33. To encourage autonomy in a 4-year-old, the nurse should instruct the mother to:
34. Discourage the child’s choice of clothing.
35. Button the child’s coat and blouse.
36. Praise the child’s attempts to dress herself.
37. Tell the child when the combination of clothes is not appropriate.

Answer 33

Health Promotion of the Preschooler and Family
33. 3. At age 4, the child should be learning to dress without supervision. A child will feel more
autonomous if allowed to try to take on tasks herself. Such attempts should be encouraged to increase
self-esteem. Allowing choices encourages the child’s capacity to control her behavior. Continued
dependency may cause the child to doubt her own abilities. Telling the child that a combination of
clothes is not appropriate may cause the child to doubt her abilities. Feelings of guilt can develop
from not being able to accomplish what the child feels the adult expects of her.
CN: Health promotion and maintenance; CL: Synthesize

Question 34

34. The mother of a 4-year-old expresses concern that her child may be hyperactive. She
    describes the child as always in motion, constantly dropping and spilling things. Which of the
    following actions would be appropriate at this time?
35. Determine whether there have been any changes at home.
36. Explain that this is not unusual behavior.
37. Explore the possibility that the child is being abused.
38. Suggest that the child be seen by a pediatric neurologist.

Answer 34

34. 2. Preschool-age children have been described as powerhouses of gross motor activity who
       seem to have endless energy. A limitation of their motor ability is that in moving as quickly as they
       do, they are not always able to judge distances, nor are they able to estimate the amount of strength
       and balance needed for activities. As a result, they have frequent mishaps. This level of activity
       typically is not associated with changes at home. However, if the behavior intensifies, a referral to a
       pediatric neurologist would be appropriate. Children who have been abused usually demonstrate
       withdrawn behaviors, not endless energy.
       CN: Health promotion and maintenance; CL: Synthesize

Question 35

35. The mother of a preschooler reports that her child creates a scene every night at bedtime. The
    nurse and the mother decide that the best course of action would be to do which of the following?
36. Allow the child to stay up later one or two nights a week.
37. Establish a set bedtime and follow a routine.
38. Encourage active play before bedtime.
39. Give the child a cookie if bedtime is pleasant.

Answer 35

35. 2. Bedtime is often a problem with preschoolers. Recommendations for reducing conflicts at
       bedtime include establishing a set bedtime; having a dependable routine, such as story reading; and
       conveying the expectation that the child will comply. Allowing the child to stay up late one or two
       nights interferes with establishing the needed bedtime rituals. Excitement, such as active play, just
       before bedtime should be avoided because it stimulates the child, making it difficult for the child to
       calm down and prepare for sleep. Using food such as a cookie as a reward if bedtime is pleasant
       should be avoided because it places too much importance on food. Other rewards, such as stickers,
       could be used as an alternative.
       CN: Health promotion and maintenance; CL: Synthesize

Question 36

36. The parents of a preschooler ask the nurse how to handle their child’s temper tantrums. Which
    of the following should the nurse include in the teaching plan? Select all that apply.
37. Putting the child in “time-out.”
38. Telling the child to go to his bedroom.
39. Ignoring the child.
40. Putting the child to bed.
41. Spanking the child.
42. Trying to reason with the child.

Answer 36

36. 1, 3. Some parents find that putting the child in time-out until control is regained is very
    effective. Others find that ignoring the behaviors works just as well with their child. Both suggestions
    are appropriate to include in the teaching plan. Sending the child to his bedroom means the child is
    being punished for having a tantrum. Spanking the child is never an option. Attempting to reason with
    a child having a temper tantrum does not work because the child is out of control. A more appropriate
    time to discuss it with the child is when the child regains control.
    CN: Health promotion and maintenance; CL: Create

Question 37

37. After teaching a group of parents of preschoolers attending a well-child clinic about oral
    hygiene and tooth brushing, the nurse determines that the teaching has been successful when the
    parents state that children can begin to brush their teeth without help at which of the following ages?
38. 3 years.
39. 5 years.
40. 7 years.
41. 9 years.

Answer 37

37. 3. Children younger than 7 years of age do not have the manual dexterity needed for toothbrushing. Therefore, parents need to help with this task until that time.
       CN: Health promotion and maintenance; CL: Evaluate

Question 38

38. After having a blood sample drawn, a 5-year-old child insists that the site be covered with a
    bandage. When the parent tries to remove the bandage before leaving the office, the child screams that
    all the blood will come out. The nurse encourages the parent to leave the bandage in place and tells
    the parent that the child:
39. Fears another procedure.
40. Does not understand body integrity.
41. Is expressing pain.4. Is attempting to regain control.

Answer 38

38. 2. The preschool-age child does not have an accurate concept of skin integrity and can view
       medical and surgical treatments as hostile invasions that can destroy or damage the body. The child
       does not understand that exsanguinations will not occur from the injection site. Here, the child is
       verbalizing a fear consistent with the developmental age. The child would most likely verbalize
       concerns of not wanting another procedure or exhibit other symptoms associated with pain if those
       were the underlying issues. If control was the main issue, the child would try to control more than just
       the bandage removal.
       CN: Psychosocial integrity; CL: Analyze

Question 39

39. The family of a 5-year-old, only child has just moved to a rural setting. At the well-child
    visit, the father expresses concern that his child seems prone to minor accidents such as skinning his
    elbow and knees or falling off his scooter. The nurse tells the father:
40. “Only children use accidents as a way to seek parental attention.”
41. “Children who live in the suburbs typically have more accidents.”
42. “Children frequently have more accidents when families experience change.”
43. “We see a relationship between accidents and parental education.”

Answer 39

39. 3. Family changes and stresses (e.g., moving, having company, taking a vacation, adding a
       new member) can distract parents and contribute to accidents. Only children typically receive more
       attention than those with siblings. Thus, the risk would be less. Families who live in the suburbs
       frequently are more affluent and, therefore, better able to maintain a home less conducive to
       accidents. A parent’s formal education is unrelated to accidents.
       CN: Health promotion and maintenance; CL: Synthesiz

Question 40

40. When developing the teaching plan about illness for the mother of a preschooler, which of the
    following should the nurse include about how a preschooler perceives illness?
41. A necessary part of life.
42. A test of self-worth.
43. A punishment for wrongdoing.
44. The will of God.

Answer 40

40. 3. Preschool-age children may view illness as punishment for their fantasies. At this age
       children do not have the cognitive ability to separate fantasies from reality and may expect to be
       punished for their “evil thoughts.” Viewing illness as a necessary part of life requires a higher level
       of cognition than preschoolers possess. This view is seen in children of middle school age and older.
       Perceiving illness as a test of self-worth or as the will of God is more characteristic of adults.
       CN: Health promotion and maintenance; CL: Apply

Question 41

Health Promotion of the School-Age Child and
Family
41. To determine if a blood pressure reading is normal, the nurse must know which information
about the child? Select all that apply.
1. Age.
2. Body mass index (BMI).
3. Gender.
4. Height.
5. Occipital frontal circumference (OFC).
6. Weight.

Answer 41

Health Promotion of the School-Age Child and Family
41. 1, 3, 4. Blood pressures percentiles for children are referenced by the age, sex, and height.
Measurements at or above the 95th percentile are considered indicative of hypertension. Weight and
elevated BMI contribute to hypertension but are not used to define it. The OFC is not routinely
measured in children over 2 years of age.
CN: Health promotion and maintenance; CL: Analyze

Question 42

42. A nurse is assessing the growth and development of a 10-year-old. What is the expected
    behavior of this child?
43. Enjoys physical demonstrations of affection.
44. Is selfish and insensitive to the welfare of others.
45. Is uncooperative in play and school.
46. Has a strong sense of justice and fair play.

Answer 42

42. 4. School-age children are concerned about justice and fair play. They become upset when
       they think someone is not playing fair. Physical affection makes them embarrassed and uncomfortable.
       They are concerned about others and are cooperative in play and school.
       CN: Health promotion and maintenance; CL: Analyze

Question 43

43. To assess a 9-year-old’s social development, the nurse asks the parent if the child:
44. Thinks independently.
45. Is able to organize and plan.
46. Has a best friend.
47. Enjoys active play.

Answer 43

43. 3. During the school-age years children learn to socialize with children of the same age. The
       “best friend” stage, which occurs around 9 or 10 years of age, is important in providing a foundation
       for self-esteem and later relationships. Thinking independently, organizing, and planning are cognitive
       skills. Active play relates to motor skills.
       CN: Health promotion and maintenance; CL: Analyze

Question 44

44. A 10-year-old child proudly tells the nurse that brushing and flossing her teeth is her
    responsibility. The nurse interprets this statement as indicating which of the following about the
    child?
45. She is too young to be given this responsibility.
46. She is most likely capable of this responsibility.
47. She should have assumed this responsibility much sooner.
48. She is probably just exaggerating the responsibility

Answer 44

44. 2. Children are capable of mastering the skills required for flossing when they reach 9 years
       of age. At this age, many children are able to assume responsibility for personal hygiene. She is nottoo young to assume this responsibility, and she should not have been expected to assume this
       responsibility much earlier. It is not likely that she is exaggerating; this is an expected behavior at this
       age.
       CN: Health promotion and maintenance; CL: Analyze

Question 45

45. The mother tells the nurse that her 8-year-old child is continually telling jokes and riddles to
    the point of driving the other family members crazy. The nurse should explain this behavior is a sign
    of:
46. Inadequate parental attention.
47. Mastery of language ambiguities.
48. Inappropriate peer influence.
49. Excessive television watching.

Answer 45

45. 2. School-age children delight in riddles and jokes. Mastery of the ambiguities of language
       and of sentence structure allows the school-age child to manipulate words, and telling riddles and
       jokes is a way of practicing this skill. Children who suffer from inadequate attention from parents
       tend to demonstrate abnormal behavior. Peer influence is less important to school-age children, and
       while the child may learn the joke from a friend, he is telling the joke to master language. Watching
       television does not influence the extent of joke telling.
       CN: Health promotion and maintenance; CL: Analyze

Question 46

46. The mother asks the nurse about her 9-year-old child’s apparent need for between-meal
    snacks, especially after school. When developing a sound nutritional plan for the child with the
    mother, the nurse should advise the mother:
47. The child does not need to eat between-meal snacks.
48. The child should eat the snacks the mother thinks are appropriate.3. The child should help with preparing his or her own snacks.
49. The child will instinctively select nutritional snacks.

Answer 46

46. 3. Snacks are necessary for school-age children because of their high energy level. School-
       age children are in a stage of cognitive development in which they can learn to categorize or classify
       and can also learn cause and effect. By preparing their own snacks, children can learn the basics of
       nutrition (such as what carbohydrates are and what happens when they are eaten). The mother and
       child should make the decision about appropriate foods together. School-age children learn to make
       decisions based on information, not instinct. Some knowledge of nutrition is needed to make
       appropriate choices.
       CN: Health promotion and maintenance; CL: Synthesize

Question 47

47. A nurse compares a child’s height and weight with standard growth charts and finds the child
    to be in the 50th percentile for height and in the 25th percentile for weight. The nurse interprets these
    findings as indicating that the child is:
48. Average height and weight.
49. Overweight for height.
50. Underweight for height.
51. Abnormal in height.

Answer 47

47. 1. The values of height and weight percentiles are usually similar for an individual child.
       Measurements between the 5th and 95th percentiles are considered normal. Marked discrepancies
       identify overweight or underweight children.
       CN: Health promotion and maintenance; CL: Analyze

Question 48

Health Promotion of the Adolescent and Family
48. The nurse is assessing an 11-year-old female, using the Tanner staging of puberty. Which of
the following indicates preadolescent development of the breasts?
1.
2.
3.
4.

Answer 48

Health Promotion of the Adolescent and Family
48. 3. This figure indicates elevation of the papilla, without breast buds, considered stage 1 and
typical of a preadolescent. Figure 1 shows stage 2, breast bud enlargement; there is elevation of the
breast and the diameter of the areola has increased. Figure 2 shows stage 3, enlargement of the breast
and areola. Figure 4 shows stage 4, in which there is projection of areola and papilla to form a
secondary mound above the level of the breast.
CN: Physiological adaptation; CL: Analyze

Question 49

49. The parents of a 12-year-old girl ask why their nonsexually active daughter should receive
    the human papillomavirus (HPV) vaccine. The nurse should tell the parents:
50. “The vaccine is most effective against cervical cancer if given before becoming sexually
    active.”2. “Parents are never sure when their child might become sexually active.”
51. “HPV is most common is teens and women in their late 20s.”
52. “If your daughter is sexually assaulted, she may be exposed to HPV.”

Answer 49

49. 1. Vaccines are preventative in nature and ideally given before exposure. Focusing on the
       benefits of cancer prevention is most appropriate, as opposed to discussing with parents the potential
       that their child may become sexually active without their knowledge. It is true HPV is most common
       in adolescents and women in their late twenties, but parents still may not perceive that their child is at
       risk. Discussing the possibility of exposure through assault raises fears and does not focus on
       prevention.
       CN: Health promotion and maintenance; CL: Apply

Question 50

50. The nurse is teaching an adolescent with asthma how to use an inhaler. In which order should
    the nurse instruct the client to follow the steps from first to last?
51. Inhale through an open mouth.
52. Breathe out through the mouth.
53. Hold the breath for 5 to 10 seconds.
54. Press the canister to release the medication.

Answer 50

50.
2. Breathe out through the mouth.1. Inhale through an open mouth.
4. Press the canister to release the medication.
3. Hold the breath for 5 to 10 seconds.
When dispensing medication from an inhaler, the client should first breathe out through the mouth.
Next the client inhales through an open mouth and then presses the canister to dispense the medication
while continuing to inhale and holds the breath for 5 to 10 seconds. The client can then exhale and
breathe normally.
CN: Pharmacological and parenteral therapies; CL: Apply

Question 51

51. The school nurse develops a plan with an adolescent to provide relief of dysmenorrhea to aid
    in her development of which of the following?
52. Positive peer relations.
53. Positive self-identity.
54. A sense of autonomy.
55. A sense of independence.

Answer 51

51. 2. Relieving dysmenorrhea in adolescence is crucial for the female’s development of positive
       self-identity, of which positive body image and sexual identity are important components.
       Menstruation should not be viewed as painful and debilitating. Positive peer relations and a sense of
       independence would develop with a positive self-identity. Sense of autonomy, according to Erikson,
       is the developmental task of toddlers that, if successfully mastered, leads to a sense of self-control.
       CN: Psychosocial integrity; CL: Apply

Question 52

52. An adolescent tells the school nurse that she would like to use tampons during her period.
    The nurse should first:
53. Assess her usual menstrual flow pattern.
54. Determine whether she is sexually active.
55. Provide information about preventing toxic shock syndrome.
56. Refer her to a specialist in adolescent gynecology.

Answer 52

52. 3. The nurse should provide the adolescent with information about toxic shock syndrome
       because of the identified relationship between tampon use and the syndrome’s development.
       Additionally, about 95% of cases of toxic shock syndrome occur during menses. Most adolescent
       females can use tampons safely if they change them frequently. Using tampons is not related to
       menstrual flow or sexual activity. There is no need to refer the girl to a gynecologist; a nurse can
       provide health teaching about tampon use.
       CN: Reduction of risk potential; CL: Synthesize

Question 53

53. Several high-school seniors are referred to the school nurse because of suspected alcohol
    misuse. When the nurse assesses the situation, what would be most important to determine?
54. What they know about the legal implications of drinking.
55. The type of alcohol they usually drink.
56. The reasons they choose to use alcohol.
57. When and with whom they use alcohol.

Answer 53

53. 3. Information about why adolescents choose to use alcohol or other drugs can be used to
       determine whether they are becoming responsible users or problem users. The senior students likely
       know the legal implications of drinking, and the nurse will establish a more effective relationship
       with the students by understanding motivations for use. The type of alcohol and when and with whom
       they are using it are not the first data to obtain when assessing the situation.
       CN: Health promotion and maintenance; CL: Analyze

Question 54

Common Childhood Problems and
Adolescent Health
54. Which of the following actions initiated by the parents of an 8-month-old indicates they need further teaching about preventing childhood accidents?
1. Placing a fire screen in front of the fireplace.
2. Placing a car seat in a front-seat, front-facing position.
3. Inspecting toys for loose parts.
4. Placing toxic substances out of reach or in a locked cabinet.

Answer 54

Common Childhood and Adolescent Health Problems
54. 2. It is recommended that children up to 2 years of age ride in a rear-facing car seat. The
middle of the back seat is considered the safest area of the car. Burns are a major cause of childhood
accidents, and using fire screens in front of fireplaces can help prevent children from getting too close
to a fire in a fireplace. Toys that contain loose parts or plastic eyes that can be swallowed or
aspirated by small children should be avoided. Parents should inspect all toys for these parts before
giving one to a child. Poisonings are most commonly caused by improper storage of a toxic substance.
Keeping toxic substances in a childproof container in a locked cabinet and continually observing thechild’s activities can prevent most poisonings.
CN: Safety and infection control; CL: Evaluate

Question 55

55. A nurse is assessing the growth and development of a 14-year-old boy. He reports that his
    13-year-old sister is 2 inches taller than he is. The nurse should advise the boy that the growth spurt
    in adolescent boys, compared with the growth spurt of adolescent girls:
56. Occurs at the same time.
57. Occurs 2 years earlier.
58. Occurs 2 years later.
59. Occurs 1 year earlier.

Answer 55

55. 3. Adolescent boys lag about 2 years behind adolescent girls in growth. Most girls are 1 to 2
       inches taller than boys at the beginning of adolescence but tend to stop growing approximately 2 to 3
       years after menarche with the closure of the epiphyseal lines of the long bones.
       CN: Health promotion and maintenance; CL: Apply

Question 56

56. Parents of a 15-year-old state that he is moody and rude. The nurse should advise his parents
    to:
57. Restrict his activities.
58. Discuss their feelings with their child.
59. Obtain family counseling.
60. Talk to other parents of adolescents.

Answer 56

56. 2. Parents need to discuss with their adolescent how they perceive his behavior and how they
       feel about it. Moodiness is characteristic of adolescents. The adolescent may have a reason for or not
       be aware of his behavior. Restricting the adolescent’s activities will not change his mood or the way
       he responds to others. It may increase his unacceptable responses. Counseling may not be needed at
       this time if the parents are open to communicating and listening to the adolescent. Talking to other
       parents may be of some help, but what is helpful to others may not be helpful to their child.
       CN: Health promotion and maintenance; CL: Synthesize

Question 57

57. A parent asks the nurse about head lice (pediculosis capitis) infestation during a visit to the
    clinic. Which of the following symptoms should the nurse tell the parent is most common in a child
    infected with head lice?
58. Itching of the scalp.
59. Scaling of the scalp.
60. Serous weeping on the scalp surface.
61. Pinpoint hemorrhagic spots on the scalp surface.

Answer 57

57. 1. The most common characteristic of head lice infestation (pediculosis capitis) is severe
       itching. The head is the most common site of lice infestation. If the child scratches, scaling may occur.
       Itching also occurs when lice infest other parts of the body. Scratch marks are almost always found
       when lice are present. Weeping on the scalp surface may be an indication of an infection or other
       dermatologic condition. Hemorrhagic spots are not a symptom of head lice, but may be caused by
       scratch marks.
       CN: Physiological adaptation; CL: Analyze

Question 58

58. A parent asks, “Can I get head lice too?” The nurse indicates that adults can also be infested
    with head lice but that pediculosis is more common among school-age children, primarily for which
    of the following reasons?
59. An immunity to pediculosis usually is established by adulthood.
60. School-age children tend to be more neglectful of frequent handwashing.
61. Pediculosis usually is spread by close contact with infested children.
62. The skin of adults is more capable of resisting the invasion of lice.

Answer 58

58. 3. Lice are spread by close personal contact and by contact with infested clothing, bed and
       bathroom linens, and combs and brushes. Lice are more common in school-age children than in adults
       because of the close contact in school and the common practice of sharing possessions. Lice are not
       commonly spread by hand contact. There is no immunity conferred by having head lice. Adults can
       have head lice, particularly if they come in close contact with their children’s infested clothing or
       linens.
       CN: Physiological adaptation; CL: Apply

Question 59

59. After teaching the parents about the cause of ringworm of the scalp (tinea capitis), which of
    the following, if stated by the father, indicates successful teaching?
60. “It results from overexposure to the sun.”
61. “It’s caused by infestation with a mite.”
62. “It’s a fungal infection of the scalp.”4. “It’s an allergic reaction.”

Answer 59

59. 3. Ringworm of the scalp is caused by a fungus of the dermatophyte group of the species.
       Overexposure to the sun would result in sunburn. Mites, such as chiggers or ticks, produce bites on
       the skin, resulting in inflammation. An allergic reaction commonly is manifested by hives, rash, or
       anaphylaxis.
       CN: Physiological adaptation; CL: Evaluate

Question 60

60. Griseofulvin was prescribed to treat a child’s ringworm of the scalp. The nurse instructs the
    parents to use the medication for several weeks for which of the following reasons?
61. A sensitivity to the drug is less likely if it is used over a period of time.
62. Fewer side effects occur as the body slowly adjusts to a new substance over time.
63. Fewer allergic reactions occur if the drug is maintained at the same level long-term.
64. The growth of the causative organism into new cells is prevented with long-term use.

Answer 60

60. 4. Griseofulvin is an antifungal agent that acts by binding to the keratin that is deposited in the
       skin, hair, and nails as they grow. This keratin is then resistant to the fungus. But as the keratin is
       normally shed, the fungus enters new, uninfected cells unless drug therapy continues. Long-term
       administration of griseofulvin does not prevent sensitivity or allergic reactions. As the body adjusts
       to a new substance over time, side effects are variable and do not necessarily decrease.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 61

61. A mother asks the nurse, “How did my children get pinworms?” The nurse explains that
    pinworms are most commonly spread by which of the following when contaminated?
62. Food.
63. Hands.
64. Animals.
65. Toilet seats.

Answer 61

61. 2. The adult pinworm emerges from the rectum and colon at night onto the perianal area to lay
       its eggs. Itching and scratching introduces the eggs to the hands, from where they can easily reinfectthe child or infect others. Nightclothes and bed linens can be sources of infection. The eggs can also
       be transmitted by dust in the home. Although transmission through contaminated food and water
       supplies is possible, it is rare. Contaminated animals can spread histoplasmosis and salmonella. The
       spread of infections by toilet seats has not been supported by research.
       CN: Physiological adaptation; CL: Apply

Question 62

62. A mother tells the nurse that one of her children has chickenpox and asks what she should do
    to care for that child. When teaching the mother, the nurse should instruct the mother to help her child
    prevent:
63. Acid-base imbalance.
64. Malnutrition.
65. Skin infection.
66. Respiratory infection.

Answer 62

62. 3. The care of a child with chickenpox focuses primarily on preventing infection in the
       lesions. The lesions cause severe itching, and organisms are ordinarily introduced into the lesion
       through scratching. Acid-base imbalance rarely occurs with chickenpox. Malnutrition is a chronic
       problem associated with the ingestion of an inadequate diet over a long period. It is not associated
       with chickenpox. Secondary infection in the lesions, not the respiratory tract, is most common.
       CN: Physiological adaptation; CL: Synthesize

Question 63

63. A mother calls the clinic to talk to the nurse. The mother states that a primary health care
    provider described her daughter as having 20/60 vision and she asks the nurse what this means. The
    nurse responds based on the interpretation that the child is experiencing which of the following?
64. A loss of approximately one-third of her visual acuity.
65. Ability to see at 60 feet what she should see at 20 feet.
66. Ability to see at 20 feet what she should see at 60 feet.
67. Visual acuity three times better than average.

Answer 63

63. 3. A child with 20/60 vision sees at 20 feet what those with 20/20 vision see at 60 feet. A
       visual acuity of 20/200 is considered to be the boundary of legal blindness.
       CN: Physiological adaptation; CL: Analyze

Question 64

64. After teaching a group of parents about temper tantrums, the nurse knows the teaching has
    been effective when one of the parents states which of the following?
65. “I will ignore the temper tantrum.”
66. “I should pick up the child during the tantrum.”
67. “I’ll talk to my daughter during the tantrum.”
68. “I should put my child in time-out.”

Answer 64

64. 1. Children who have temper tantrums should be ignored as long as they are safe. They should
       not receive either positive or negative reinforcement to avoid perpetuating the behavior. Temper
       tantrums are a toddler’s way of achieving independence.
       CN: Health promotion and maintenance; CL: Evaluate

Question 65

65. The nurse discusses the eating habits of school-age children with their parents, explaining
    that these habits are most influenced by:
66. Food preferences of their peers.
67. Smell and appearance of foods offered.
68. Examples provided by parents at mealtimes.
69. Parental encouragement to eat nutritious foods.

Answer 65

65. 3. Although children may be influenced by their peers and smell and appearance of foods may
       be important, children are most likely to be influenced by the example and atmosphere provided by
       their parents. Coaxing and badgering a child to eat most likely will aggravate poor eating habits.
       CN: Health promotion and maintenance; CL: Apply

Question 66

66. When discussing the onset of adolescence with parents, the nurse explains that it occurs at
    which of the following times?
67. Same age for both boys and girls.2. 1 to 2 years earlier in boys than in girls.
68. 1 to 2 years earlier in girls than in boys.
69. 3 to 4 years later in boys than in girls.

Answer 66

66. 3. Girls experience the onset of adolescence about 1 to 2 years earlier than boys. The reason
       for this is not understood.
       CN: Health promotion and maintenance; CL: Apply

Question 67

67. A mother has heard that several children have been diagnosed with mononucleosis. She asks
    the nurse what precautions should be taken to prevent this from occurring in her child. The nurse
    should instruct the mother to:
68. Take no particular precautionary measures.
69. Sterilize the child’s eating utensils before they are reused.
70. Wash the child’s linens separately in hot, soapy water.
71. Wear masks when providing direct personal care.

Answer 67

67. 1. The cause of infectious mononucleosis is thought to be the Epstein-Barr virus. No
       precautionary measures are recommended for clients with mononucleosis. The virus is believed to be
       spread only by direct intimate contact.
       CN: Physiological adaptation; CL: Synthesize

Question 68

68. A father asks the nurse how he would know if his child had developed mononucleosis. The
    nurse explains that in addition to fatigue, which of the following would be most common?
69. Liver tenderness.
70. Enlarged lymph glands.
71. Persistent nonproductive cough.
72. A blush-like generalized skin rash.

Answer 68

68. 2. Mononucleosis usually has an insidious onset, with fatigue and the inability to maintain
       usual activity levels as the most common symptoms. The lymph nodes are typically enlarged, and the
       spleen also may be enlarged. Fever and a sore throat often accompany mononucleosis. A persistent
       nonproductive cough can follow an upper respiratory tract infection. A blush-like generalized skin
       rash is more characteristic of rubella.
       CN: Physiological adaptation; CL: Analyze

Question 69

69. A parent asks why it is recommended that the second dose of the measles, mumps, and rubella
    (MMR) vaccine be given at 4 to 6 years of age. The nurse should explain to the parent that the second
    dose is given at this age for what reason?
70. If the child reaches puberty and becomes pregnant when receiving the vaccine, the risks to the
    fetus are high.
71. The chance of contracting the disease is much lower at this age.
72. The dangers associated with a strong reaction to the vaccine are increased at this age.
73. A serious complication from the vaccine is swelling of the joints.

Answer 69

69. 1. After receiving the MMR vaccine, the person develops a mild form of the disease,
       stimulating the body to develop immunity. Administration to a pregnant adolescent early in pregnancy
       puts the fetus at risk for deformity or spontaneous abortion. Some authorities recommend withholding
       the immunization for rubella until after puberty because a woman does not always know when she is
       pregnant and a fetus could be placed in jeopardy. However, the risk of contracting the disease is notlower at this age. There is no difference in the reaction to the vaccine at this age or in an older child.
       Swelling of the joints is a rare complication of the rubella vaccine.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 70

Managing Care Quality and Safety
70. A 17-year-old high school senior calls the clinic because she thinks she might have
gonorrhea. She wants to be seen but wants assurances that no one will know. Which is the most
appropriate response by the nurse?
1. “Because you are underage, we will need your parent’s consent to treat you.”
2. “We can treat you without your parents’ consent, but they have the right to review your medical
record.”
3. “We can see you without your parents’ consent but have to report any positive results to the
public health department.”
4. “We can see you and will not share your results with anyone.”

Answer 70

Managing Care Quality and Safety
70. 3. While some areas may specify a minimum age for treatment (usually 12 to 14 years),
generally adolescents have the right to seek treatment for sexually transmitted infections without their
parents’ permission. These records are not shared with parents without the client’s permission.
However, adolescents must be made aware that certain infections, including gonorrhea, must be
reported by law to public health agencies. Partner notification will also take place, but methods vary.
CN: Management of care; CL: Apply

Question 71

71. A parent brings a 5-year-old child to a weekend vaccination clinic to prepare for school
    entry. The nurse notes that the child has not had any vaccinations since 4 months of age. To determine
    the current evidence for best practices for scheduling missed vaccinations, the nurse should:
72. Ask the child’s primary care provider.
73. Check nationally published immunization guidelines.
74. Read the vaccine manufacturer’s insert.
75. Contact the pharmacist.

Answer 71

71. 2. National advisory committees on immunization practices review vaccination evidence and
       update recommendations yearly. Current vaccination catch-up schedules are readily available on their
       Websites. The lack of vaccinations is a strong indicator that the child probably does not have a
       primary care provider. Even if the client had a provider, however, that person might be difficult to
       reach on a weekend during the timeframe of a vaccination clinic. If consulted, the pharmacist would
       most likely have to review the latest guidelines that are equally available to the nurse. Reading the
       manufacturer’s inserts for multiple vaccines would be time consuming and synthesis of the information
       could possibly lead to errors.
       CN: Management of care; CL: Apply

Question 72

72. A 13-month-old has a febrile seizure 1 month after the administration of the chickenpox
    vaccine. The nurse should:
73. Recognize that the events are unrelated.
74. Report the event through a national immunization surveillance system.
75. Explain to the parents that this is a rare but acceptable risk.
76. Report the incident through the vaccine manufacturer’s hotline.

Answer 72

72. 2. Any unusual event that occurs after the administration of a vaccination should be reported
       through a national immunization surveillance system. In the United States, it is the Vaccine Adverse
       Event Reporting System (VAERS). In Canada, it is Canadian Adverse Events Following Immunization
       Surveillance System (CAEFISS). A high fever, with or without a seizure, that occurs within 6 weeks
       of vaccination may have been caused by the vaccine. A febrile seizure is considered a moderate
       reaction that warrants caution with future chicken pox vaccination. Reporting the incident to the
       manufacturer does not help build the same body of knowledge as reporting the problem through the
       national surveillance system.
       CN: Safety and infection control; CL: Synthesize

Question 73

73. The school nurse is invited to attend a meeting with several parents who express frustration
    with the amount of time their adolescents spend in front of the mirror and the length of time it takes
    them to get dressed. The nurse explains that this behavior indicates:
74. An abnormal narcissism.
75. A method of procrastination.
76. A way of testing the parents’ limit-setting.
77. A result of developing self-concept.

Answer 73

73. 4. An adolescent’s body is undergoing rapid changes. Adolescence is a time of integrating
       these rapidly occurring physical changes into the self-concept to achieve the developmental task of a
       positive self-identity. Thus, most adolescents spend much time worrying about their personal
       appearance. This behavior is not abnormal narcissism, a method of procrastination, or a way of
       testing the parents’ limits.
       CN: Health promotion and maintenance; CL: Analyze