A 14-year-old with cystic fibrosis suddenly becomes noncompliant with the medication
regimen. The intervention by the nurse that would most likely improve compliance
would be to:
1. Give the child a computer-animated game that presents information on the
management of cystic fibrosis.
2. Set up a meeting with some older teens who have cystic fibrosis and have been
managing their disease effectively.
3. Arrange for the physician to sit down and talk to the child about the risks related to
noncompliance with medications.
4. Discuss with the child’s parents that privileges, such as a cell phone, can be taken
away if compliance fails to improve.
Which of the following is a priority nursing diagnosis for the child with idiopathic
thrombocytopenic purpura (ITP)?
1. Ineffective breathing pattern
2. Nausea
3. Fluid-volume deficit
4. Risk for injury
In caring for a hospitalized eight-year-old child with myelodysplasia, the nurse should
remember to:
Standard Text: Select all that apply.
1. Expect the child to have normal intelligence.
2. Use latex precautions.
3. Allow the child to do her own self-catheterization.
4. Ensure that the child has a low-fiber diet.
5. Encourage the child to shift positions hourly when in her wheelchair.
The telephone triage nurse at a pediatric clinic knows that each call is important.
However, recognizing that infant deaths are most frequent in this group, the nurse must
be extra attentive during the call from the parent of an infant who is:
1. Between six and eight months old.
2. Of a Native American family.
3. Of a non-Hispanic black family.
4. Younger than three weeks old.
An important goal for pediatric nurses in the office or healthcare setting is:
1. Develop a positive relationship with the child and family.
2. Develop a plan of care with the physician for the family.
3. Tell the family immediately what’s wrong with the child.
4. Tell the family “Everything will be okay.”
An adolescent comes to the clinic because of a concern with a skin lesion, and he is
accompanied by a parent. When the adolescent is called back to the exam room, the
parent comes with the adolescent. What approach by the nurse would be most
appropriate?
1. Instruct the parent to stay in the waiting room and tell him that the adolescent will
give him a report on the exam.
2. Tell the parent he cannot come into the exam room with the adolescent.
3. Reassure the parent that you will talk with him about any of his concerns and
questions.
4. Allow the parent to come into the exam room with the adolescent.
A child is being discharged from the hospital after a three-week stay following a motor
vehicle collision. The mother expresses concern about caring for the child’s wounds at
home. She has demonstrated appropriate technique with medication administration and
wound care. What is the priority nursing diagnosis?
1. Parental anxiety related to care of the child at home
2. Family processes, altered related to hospitalization
3. Infection, risk for related to presence of healing wounds
4. Knowledge deficient home care
During the assessment, the nurse notices that a Black baby has a darker, slightly
bluish-hued patch about 5 7 cm on the buttocks and lower back. What is the nurse’s next
action?
1. Ask the mother about the cause of the bruise.
2. Call the Department of Social Services (DSS) to report this as a sign of abuse.
3. Confer with the physician the possibility of a bleeding tendency.
4. Chart the presence of a Mongolian spot.
A nurse is taking care of a patient in the ICU who has been on opioids for an extended
period of time. The nurse understands that the child has to slowly wean from the
medication over a period of time. While weaning, the nurse will observe the child for
symptoms of too rapid withdrawal, including:
1. Hyperactive deep tendon reflexes, vomiting, and abdominal cramps.
2. Bradycardia and pallor.
3. Decreased blood pressure and drowsiness.
4. Voracious appetite and hypotonicity.
The nurse is presenting a program on healthy eating habits to the parents of children
attending the clinic. In the discussion period of the program, parents make the following
comments. Which parent needs more information about safe food preparation?
1. “We always wash our hands well before any food preparation.”
2. “We use separate utensils for preparing raw meat and for preparing fruits, vegetables,
and other foods.”
3. “We take the meat out of the freezer and then allow it to thaw on the counter for two
to three hours before cooking it thoroughly.”
4. “If our baby doesn”t drink all the formula in his bottle, we throw the rest out.”
A 12-year-old child is being admitted to the unit for a surgical procedure. The child is
accompanied by two parents and a younger sibling. The level of involvement in
treatment decision making for this child is:
1. That of a mature minor.
2. That of an emancipated minor.
3. That of assent.
4. None.
Prior to accepting an assignment as a home health nurse, the nurse must realize that:
1. The family will adapt their lifestyle to the needs of the nurse.
2. The family is in charge.
3. Independent decisions regarding emergency care of the child will be made by the
nurse.
4. All decisions will be made by the healthcare provider.
The toddler pulled a pot of boiling water off the stove and suffered partial and full
thickness burns to the chest. EMS arrived, stabilized the child, and transported him to
the hospital burn unit. The child is now in the recovery-management phase of burn
treatment. Which is the most common complication seen in this period?
1. Asphyxia
2. Metabolic acidosis
3. Shock
4. Burn-wound infection
A child has been diagnosed with a Wilms’ tumor and is being treated with
chemotherapy. Prior to administering the chemotherapy, what will the nurse monitor to
determine if the child has any capability of fighting infection?
1. Hemoglobin
2. Red blood cell count
3. Platelets
4. Absolute neutrophil count (ANC)
The parents of a school-age child report that they allow their child to eat anything
because the child is a “picky” eater. Which is the best response the nurse should make to
the parent?
1. “Continue to allow this, because he eventually will begin to eat properly.”
2. “Can you try allowing this to continue but only every other day?”
3. “I think you must not be good role models, so let’s talk about your eating habits.”
4. “Let’s talk about what types of food are consumed when your child chooses.”
A toddler has had recurrent respiratory infections. The mother of the child expresses
concern that her infant seems to be at increased risk for complications from respiratory
infections in comparison with her older children. The best response from the nurse
would be:
1. “You are incorrect in your assessment.”
2. “The younger child’s airways are smaller and more easily occluded.”
3. “Air passages are more likely to become blocked with mucus because younger
children make more mucus than older children.”
4. “Toddlers do not breathe as deeply as do older children.”
The nurse working in a multicultural clinic recognizes that when the purpose of
teaching is to promote the health of individual children, this effort should be directed to
the authority responsible for the health care decisions. In certain cultural groups, health
care decisions typically are made by the father. Therefore, the nurse should direct
teaching efforts to the fathers in which cultures?
1. European American
2. African American
3. Native American
4. Appalachian
The school nurse is performing health screenings during the physical education class.
The nurse plans to weigh, measure, and determine body mass index of the adolescents.
The scale has been set up in the open gym to speed the process. What should the nurse
do to maintain confidentiality of the findings?
1. Have a student worker record the screening findings on the appropriate adolescent’s
record.
2. Have a volunteer weigh and measure the adolescents and verbally give the findings
to the nurse to calculate the body mass index and record.
3. Provide a privacy screen and have the health aid record the findings directly on the
record. The nurse will then calculate body mass index.
4. Use a buddy system with the students, having the students measure each other and
record the findings.