Unit 2 Flashcards
The nurse is conducting a health history for a 9-year-old childswith stomach pains. What is a recommended guideline when approaching the child for information?
A) Wear a white examination coat when conducting the interview.
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B) Allow the child to control the pace and order of the health history. C) Use quick deliberate gestures to get your point across.
D) Do not make physical contact with the child during the interview
B
For which children would the nurse conduct an immediateo comprehensive health history?
A) A child who is brought to the emergency room with labored breathing
abirb.com/test B) A child who is a new client in a pediatric office
C) A child who is a routine client and presents with signs of a sinus infection
D) A child whose condition is improving
B
The nurse is performing a health history on a 6-year-old boy who is having trouble adjusting to school. Which question would be most likelyr to elicit valuable
information?
A) “Do you like your new school?”
B) “Are you happy with your teacher?” C) “Do you enjoy reading a book?”
D) “What are your new classmates like?”
D
The nurse performing a health history on a child asks the parents if their child has
experienced increased appetite or thirst. What body system is the nurse assessing
with this question?
A) Endocrine
B) Genitourinary
C) Hematologic
D) Neurologic
A
The nurse is questioning the parents of a 2-year-old child to obtain a functional
history. Which topics might the nurse include? Select all that apply.
A) The child’s toileting habits
B) Use of car seats and other safety measures C) Problems with growth and development
D) Prenatal and perinatal histories E) The child’s race and ethnicity
F) Use of supplements and vitamins
A B F
The nurse is conducting a physical examination of a child following a
comprehensive health history. What should be the focus of the/physical examination?
A) The child
B) The parents
C) Chief complaint
D) Developmental age
C
The nurse is teaching the student nurse how to perform a physical assessment
based on the child’s developmental stage. Which statement accurately describes a
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recommended guideline for setting the tone of the examination for a school-age
child?
A) Keep up a running dialogue with the caregiver, explaining each step as you do it.
B) Include the child in all parts of the examination; speak to the caregiver before and after the examination.
C)Speak to the childusing mature language and appeal to his or her desire for self-care. abirb.com/test
D)Address the child by name; speak to the caregiver and do the most invasive
parts last.
B
Which would be least effective in gaining the cooperation of/ a toddler during a physical examination?
A) Tell the child that another child the same age wasn’t afraid.
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B) Allow the child to touch and hold the equipment when possible.
C) Permit the child to sit on the parent’s lap during the examination. D) Offer immediate praise for holding still or doing r whate was asked
A
The nurse is performing a physical examination on a sleepingt newborn. Which body
system should the nurse examine last? A) Heart
B) Abdomen C) Lungs
D) Throat
D
The nurse is teaching the student nurse the sequencerfor performing the assessment techniques during a physical examination. What is the appropriate
order?
A) Inspection, palpation, percussion, auscultation
B) Inspection, percussion, palpation, auscultation
C) Palpation, percussion, inspection, auscultation
D) Inspection, auscultation, palpation, percussion
A
The nurse is examining the posture of a male toddler and notes lordosis. What would be the appropriate reaction of the nurse to this finding?
A) Explain that the child will need a back brace. B) Refer the toddler to a physical therapist.
C) Do nothing; this is a normal condition for toddlers.
D) Notify the primary care healthcare provider about the condition.
C
The nurse is assessing the temperature of a diaphoretic.toddler who is crying and being uncooperative. What would be the best method to assess temperature in this
child?
A) Oral thermometer B) Axillary method
C) Temporal scanning D) Rectal route
B
The nurse is preparing to take a tympanic temperature reading of a 4-year-old. In
order to get an accurate reading, what does the nurse need to do? A) Pull the earlobe back and down.
B) Direct the infrared sensor at the tympanic membrane. C) Pull the earlobe down and forward. D) Remove any visible cerumen from inside the ear canal.
B
A mother brings her 3-year-old daughter to the emergency department because the child has been vomiting and having diarrhea for the past 36t hours. When
assessing this child’s temperature, which method would be least appropriate?
A) Oral
B) Tympanic C) Rectal
D) Axillary
C
The nurse is assessing heart rate for children on thea pediatric ward. What is a
normal finding based on developmental age? A) An infant’s rate is 90 bpm.
B) A toddler’s rate is 150 bpm.
C) A preschooler’s rate is 130 bpm.
D) A school-age child’s rate is 50 bpm
A
The nurse is assessing the heart rate of a healthy school-age child. The nurse expects that the child’s heart rate will be in what ranges?
A) 80 to 150 bpm B) 70 to 120 bpm C) 65 to 110 bpm D) 60 to 100 bpm
D
The nurse is preparing to assess the pulse of an 18-month-old child. Which pulse
would be most difficult for the nurse to palpate?
A) Radial B) Brachial C) Pedal D) Femoral
A
While auscultating the heart of a 5-year-old child, the nurse notes a murmur that is soft and quiet and heard each time the heart is auscultated. The nurse documents
this finding as what grade?
A) Grade 1 B) Grade 2 C) Grade 3 D) Grade 4
B
The parents of a 2-day-old girl are concerned because her feet and hands are slightly blue. How should the nurse respond?
A) “Your daughter has acrocyanosis; this is causing her blue hands and feet.”
B) “Let’s watch her carefully to make sure she does nott have a circulatory problem.”
C) “This is normal; her circulatory system will take a few days to adjust.”
D) “This is a vasomotor response caused by cooling or warming.”
C
A nurse is assessing the fontanels of a crying newborn and notes that theposterior fontanel pulsates and briefly bulges. What do these findings indicate?
A) Increased intracranial pressure B) Overhydration
C) Dehydration
D) These are normal findings
D
The nurse is assessing the neck of an 8-year-old child with Down syndrome. Which finding would the nurse expect during the examination?est
A) Webbing
B) Excessive neck skin C) Lax neck skin
D) Shortened neck
C
The nurse is conducting a routine health assessment of a 3-month-old boy and
notices a flat occiput.The nurse provides teaching and emphasizes the importance of
tummy time. Which response by the mother indicates a need for further teaching? A) “I should have him sleep on his tummy.”
B) “I need to watch him during his tummy time.”
C) “I need to change his head position while he isbin an t upright chair.” D) “His head has flattened due to the pressure of his head position.”
A
The nurse is measuring the blood pressure of a 12-year-old boy with an oscillometric device. The boy’s reading is greater than ther90thepercentile for gender
and height. What is the appropriate nursing action?
A) Repeat the reading with the oscillometric device..com/test B) Repeat the blood pressure reading using auscultation.
C) Measure the blood pressure in all four extremities.m/test D) Measure the blood pressure with a Doppler.
B
.The nurse is inspecting the fingernails of an 18-month-old girl. What finding
indicates chronic hypoxemia?
A) Nails that curve inward B) Clubbing of the nails
C) Nails that curve outward D) Dry, brittle nails
B
The nurse is using pulse oximetry to measure oxygen saturation in a 3-year-old
girl. The nurse understands that falsely high readings may be associated with which situation or condition?
A) A nonsecure connection B) Cold extremities
C) Hypovolemia D) Anemia
D
Assessment reveals that a child weighs 73 lb and is 4 ft 1 in tall. The nurse
calculates this child’s body mass index as: A) 19.1
B) 20.7 C) 21.4 D) 24.5
C
The nurse is teaching the student nurse about abnormal findings when assessing the breasts of children. What may be associated with renalcdisorders?
A) Swollen nipples upon inspection of a newborn’s breasts
B) Tender nodule palpated under the nipple of a 10-year-old
C) Observation of enlarged breast tissue in a male adolescent
D) Observation of a supernumerary nipple along the mammary ridge
D
The nurse is inspecting the genitals of a prepubescent girl. Which is a normal sign
of the onset of puberty?
A) Appearance of pubic hair around 11 to 13 yearsr old /test
B) Swelling or redness of the labia minora C) Presence of labial adhesions
D) Lesions on the external genitalia
A
A teenage client tells the nurse that she is being abused by her boyfriend, but she
doesn’t want her parents to know because they won’t let i her see him any longer. What is the best response by the nurse?
A) “It’s my responsibility to tell your parents if you are in danger.”
B) “I understand your fear, but I am obligated to be sure your parents know
you are in danger. Would you like for us to talk to them together?”
C) “I won’t tell them this time, but Imust inform you .that legally I must inform your parents if abuse is occurring. Next time it happens, I will have to tell
them.”
D) “You need to tell them because the abuse isn’t going to get any better. It
will only escalate no matter what your boyfriend says.”
B
The nurse is collecting information from the parents of a 3-year-old child about her sleeping patterns. Which question by the nurse will best elicit information from the parents?
A) “How are things going at home?”
B) “Is your child sleeping well at night?”
C) “How many hours does your child sleep at night?”
D) “What time does your child go to bed at night?”
C
The nurse educator working in the emergency room monitors the admission of children. For which admission diagnosis, should the nursebeducator encourage the emergency room staff to be the most prepared?
A) Mental health problems
B) Injuries
C) Respiratory disorders
D) Gastrointestinal disorders
B
The nurse is caring for a 7-year-old girl hospitalized in isolation. The nurse notices that she has begun sucking her thumb and changing her speech patterns to those of
a toddler. What condition is the girl manifesting?
A) Regression
B) Suppression
C) Repression
D) Denial
A
The nurse is caring for an 8-year-old boy hospitalized forr a bonemarrow transplant. His parents are in and out of his room throughout the day. Which behaviors of the child would alert the nurse that he is in the second stagei of separation anxiety?
A) He ignores his parents when they return to his room.
B) He cries uncontrollably whenever they leave.
C) He forms superficial relationships with his caregivers.
D) He sits quietly and is uninterested in playing and eating.
D
The nurse is caring for a 4-year-old girl who has beenahospitalized for over a week with severe burns. Which would be a priority intervention to help satisfy this preschool child’s basic needs?
A) Encourage friends to visit as often as possible.
B) Suggest that a family member be present withbher 24s hours a day.
C) Explain necessary procedures in simple language that she will understand.
D) Allow her to make choices about her meals and activities as much as
permitted.
C
The nurse is caring for a hospitalized 13-year-old girl, who is questioning everything the medical staff is doing and is resistant to treatment. How should the nurse respond?
A) “Let’s work together to plan your day along with your treatments.”
B) “The sooner you cooperate, the sooner you arei going to leave.”
C) “If you are more cooperative, perhaps we can arrange a visit from friends.”
D) “Please don’t make me call your parents about this.”
A
The nurse is caring for a 10-year-old boy who is in traction. The boy has a nursing diagnosis of deficient diversional activity related to confinement in bed that is evidenced by verbalization of boredom and lack of participation in play, reading, and schoolwork. What would be the best intervention?
A) Offer the child reading materials.
B) Enlist the aid of a child life specialist.
C) Encourage the child to complete his homework.rb.com/test
D) Ask for the parents’ assistance.
B
The nurse is caring for a 13-year-old girl hospitalized for complications from type 1
diabetes. The girl has a nursing diagnosis of powerlessness related to lack of control
of multiple demands associated with hospitalization, procedures, treatments, and
changes in usual routine. How can the nurse help promote control?
A) Ask the child to identify her areas of concern.
B) Encourage participation of parents in care activities.
C) Offer the girl as many choices as possible.
D) Enlist the family’s assistance in creating a timei schedule.
C
The nurse is caring for an 8-year-old girl who requires numerousvenipunctures and
injections daily. The nurse understands that the child is exhibiting signs of sensory
overload and enlists the assistance of the child life specialist. What should the
therapeutic play involve to best deal with the child’s stressors?
A) Puppets and dolls
B) Drawing paper and crayons
C) Wooden hammer and pegs
D) Sewing puppets with needles
D
After teaching a group of students about therapeutic play, the instructor
determines that additional teaching is needed when the students identify what as a
characteristic of therapeutic play?
A) Focus on coping
B) Use of a highly structured format
C) Dramatization of emotions
D) Expression of feelings
B
The mother of a hospitalized child reports that her daughter, who is having some
difficulty eating, just had a 4-ounce cup of ice chips. The nurse documents this on the
child’s intake flow sheet as how much?
A) 2 ounces
B) 4 ounces
C) 6 ounces
D) 8 ounces
A
.The nurse is preparing a nursing care plan for a childbhospitalized for cardiac surgery. Which are examples of interventions that nurses perform in the “building a trusting relationship” stage? Select all that apply.
A) Gathering information about the child using the child’s own toys
B) Preparing the child for a procedure by playing gamesest
C) Explaining in simple terms what will happen during surgery
D) Allowing the child to devise an exercise plan following surgery
E) Praising the child for how well he is doing following instructions
F) Giving the child a favorite toy to cuddle following a painful procedure
B C
The nurse is preparing a hospitalized 7-year-old girl for a lumbar puncture. Which
actions would help reduce her stress related to the procedure? Select all that apply.
A) Pretend to perform the procedure on her doll.
B) Explain the procedure to her in medical terms.
C) Do not allow her to see or touch the equipment.
D) Teach her the steps of the procedure.
E) Tell her not to pay attention to any sounds she might hear.
F) Introduce her to the health care personnel.
A D F
The nurse is completing an admission of a 10-year-old boy. Which actions will help the nurse establish a trusting and caring relationship with the child and his family? Select all that apply.
A) The nurse should not minimize the child’s fears by smiling.
B) The nurse should initiate introductions.
C) The nurse should not use formal titles at the introduction.
D) The nurse should maintain eye contact at the appropriate level.
E) The nurse should start communication with the child first and then move on
to the family.
F) The nurse should use age-appropriate communication with the child.
B D F
The nurse is caring for an 11-year-old girl preparingato undergo a magnetic resonance imaging (MRI) scan. Which statement would best help prepare the girl for the diagnostic test and decrease anxiety?
A) “You won’t hear a sound if you wear your headphones.”
B) “The machine makes a very loud rattle; however,c headphones will help.”
C) “There are a variety of loud sounds you will hear.”
D) “The MRI scanner sounds like a machine gun.”
B
The nurse is caring for a 10-year-old girl who is in an isolation room. Which intervention would be a priority intervention for this child?om/test
A) Reduce noise as much as possible.
B) Provide age-appropriate toys and games.
C) Discourage visits from family members.
D) Put on mask prior to entering the room.
B
An adolescent is scheduled for outpatient arthroscopic surgery on his knee next week. As part of preparing him for the procedure, which action would be most appropriate?
A) Discussing the events with the adolescent and his mother upon arrival the
morning of the procedure
B) Providing detailed explanations of the procedurerat least a week in advance
of the procedure
C) Encouraging the parent to stay with the adolescent as much as possible
before the procedure
D) Answering the adolescent’s questions with simple answers, encouraging
him to ask the surgeon
B
The nurse is providing developmentally appropriate care for a toddler hospitalized for observation following a fall down the steps. Which measurest might the nurse consider when caring for this child? Select all that apply.
A) Use the en face position when holding the toddler. m/test
B) Use a bed for toddlers who have an adult present.
C) Avoid leaving small objects that can be swallowed in the bed.
D) Explain activities in concrete, simple terms.
E) Allow the child to select meals and activities.
F) Encourage parents to stay to prevent separation anxiety.
C F
.The nurse isordered to apply restraints to a toddler who keepspulling at the tubes in his arm. Which criteria must occur to ensure proper use of these restraints? Select all that apply.
A) The nurse must check the restraints every 15 minutest while they are in
place.
B) Secure the restraints with ties to the side rails, not the bed or crib frame.
C) Assess the temperature of the affected extremities, pulses, and capillary refill every 15 minutes after placement.
D) Use a clove-hitch type of knot to secure the restraints with ties.
E) Remove the restraint every 2 hours to allow for range of motion and
repositioning.
F) Encourage parent participation, providing continuous explanations about
the reasons and time frame for restraints.
D E F
