An infant returns to the unit following casting of the leg for talipes equinovarus.
Standing orders include monitoring the neurovascular status. In addition to color, for
what will the nurse monitor the infant’s foot?
Standard Text: Select all that apply.
1. Warmth
2. Capillary refill
3. Pedal pulse
4. Sensation
5. Movement of the toes
The parents have requested to be present during their child’s procedure. How should the
nurse plan for this request?
1. Explain in detail, using medical terms, what will occur.
2. Explain to the family that it is not permitted for family members to be present.
3. Prepare family members for what they should anticipate and what is expected of
them.
4. Prepare the family to speak with the physician.
A two-year-old child recently diagnosed with a seizure disorder will be discharged
home on an anticonvulsant. The mother best demonstrates understanding of how to give
the medication when she:
1. Draws up the medication correctly in an oral syringe and administers it to the child.
2. Acknowledges understanding of written instructions.
3. Verbalizes how to give the medication.
4. Observes the nurse drawing up the medication and administering it to the child.
A nurse is working with pediatric clients in a research facility. The nurse recognizes that
federal guidelines are in place to delineate which pediatrics clients must give assent for
participation in research trials. Based upon the client’s age, the nurse would seek assent
from which children?
Standard Text: Select all that apply.
1. The 13-year-old client beginning participation in a research program for ADHD
treatments
2. The precocious four-year-old starting as a cystic fibrosis research study participant
3. The 10-year-old starting in an investigative study for clients with precocious puberty
4. The seven-year-old leukemia client electing to receive a newly developed medication
being researched
Which parental behavior presents a risk for the infant in the home?
1. The father admits smoking cigarettes in the home but says he never smokes around
the baby.
2. The parents have parties once a month in the home and serve alcoholic beverages.
3. The parents allow their other children, ages six and 10, to supervise the infant while
the parents are working in another room.
4. The mother is a diabetic and has insulin and syringes in the household.
A three-year-old is admitted to the hospital unit with cellulitis of the neck. The nurse
will expect medical treatment to include:
1. Topical antibiotics.
2. Intravenous antibiotics.
3. Incision and drainage.
4. Intravenous corticosteroids.
During the visit to the pediatric office, a nurse observes the mother frequently looking
at and massaging her infant. Based on these observations, the nurse’s conclusion should
be:
1. That the mother is displaying positive maternal-infant attachment.
2. That the mother is trying to show the nurse that she can be affectionate to the infant.
3. That there is insufficient data to assess the mother-infant relationship.
4. That the mother might be overwhelmed by the demands of infant care.
The nurse is caring for a child with rheumatoid arthritis. Which is an appropriate
nonpharmacologic measure to reduce the joint pain associated this disease?
1. Elevation of the extremity
2. Immobilization
3. Massage
4. Application of moist heat
The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis)
immunization for a six-month-old infant. To administer this injection safely, the nurse
chooses which of the following needles (size and length), injection type, and injection
site?
1. 25-gauge, 5/8-inch needle; IM (intramuscular); anterolateral thigh
2. 25-gauge, 5/8-inch needle; ID (intradermal); deltoid
3. 22-gauge, 1/2-inch needle; IM (intramuscular); dorsogluteal
4. 25-gauge, 3/4-inch needle; SQ (subcutaneous); anterolateral thigh
Complementary activities that may reduce stress for the child and parents in the
Pediatric Intensive Care Unit include:
Standard Text: Select all that apply.
1. Prayer.
2. Maintaining silence in the PICU.
3. Maintaining a sterile-appearing hospital room.
4. Music playing softly.
5. Encouraging the parents to read age-appropriate books to the child.
The nurse is taking care of a child who had a tonsillectomy. During the postoperative
period, the nurse should observe the child for which clinical manifestation?
1. Arrhythmias
2. Dehydration
3. Increased blood sugar
4. Increased urinary output
Which of the following are major risks during the post-transplant phase of
hematopoietic stem cell transplantation (HSCT)?
Standard Text: Select all that apply.
1. Bleeding
2. Thrombosis
3. Pancytopenia
4. Infection
5. Fluid volume overload
The waiting room of the mental health clinic is full of children with various mental
health issues. The nurse watches the children and notes that which child is displaying
symptoms of autism?
1. Four-year-old girl who doesn”t make eye contact with mother and resists the mother’s
touch
2. Three-year-old boy who joins one group of children then moves to another group of
children without joining their activities
3. 18-month-old child who walks around the area using the furniture to provide balance
4. Six-year-old boy who chatters constantly to anyone who will listen
The nurse is taking care of a school-age child with 50% burns to the head and upper
part of the body. The nurse recognizes that the most significant stressors for school-age
children with life-threatening illness are:
Standard Text: Select all that apply.
1. Painful and invasive procedures.
2. Fear of the medical team.
3. Disfigurement.
4. Separation from family.
5. Loss of self-control.
A child has sustained a minor burn. Which of the following should be included in
increased amounts in the child’s diet?
1. Protein
2. Minerals
3. Carbohydrates
4. Fats
An adolescent is visiting the clinic for the first time. What should the nurse keep in
mind when attending to this patient?
1. The nurse should explain procedures and introduce personnel to adolescents.
2. Adolescents usually are quiet and will offer no opinions.
3. The nurse should attend to and discharge adolescents quickly.
4. Adolescents are comfortable with their surroundings.
While assessing the development of a nine-month-old infant, the nurse asks the mother
if the child actively looks for toys when they are placed out of sight. The nurse is trying
to determine whether the infant has developed:
1. Transductive reasoning
2. Conservation
3. Centration
4. Object permanence
Which of these developmental milestones should the nurse expect to find in children
who are between two and three years old?
Standard Text: Select all that apply.
1. Always feeds self
2. Throws ball overhand
3. Kicks a ball
4. Goes up and down stairs
5. Scribbles and draws on paper