The school health nurse is evaluating the home environments of several children as they
relate to child safety. Which of these activities places a child at greatest risk for bodily
harm?
1. The parents consume alcohol on a daily basis.
2. The child is permitted to participate, unsupervised, in target practice with a revolver.
3. The child is a latchkey child.
4. The parents are in a methadone program.
A child with hemophilia plans on participating in a bicycling club. Which
recommendation should the nurse give to the child?
1. Wear kneepads, elbow pads, and a helmet while bicycling.
2. Consider a swim club instead of the bicycling club.
3. Do not join the club.
4. Participate only in the social activities of the club.
A child has been diagnosed as having a genetic disorder based on a mosaic trisomy. The
nurse recognizes that the mother understands the significance of this diagnosis when
she states:
1. “Because my child has a mosaic trisomy, he will have some normal cells in his body,
which means his disorder may not be as severe as in other children.”
2. “Children born with mosaic trisomy do not pass the disorder on to their children.”
3. “Mosaic trisomies are inherited from the father’s side of the family.”
4. “Mosaic trisomies occur in an ovum from an older woman.”
Prior to discharge from the birth hospital, the new mother asks the nurse about the use
of a mobile over the crib. The nurse would explain to the mother that the mobile should
be placed about 10 inches above the level of the baby. The nurse would explain that this
placement:
1. Is based on the fact that newborns can focus at a distance of 8 to 12 inches.
2. Will prevent the infant from being injured by the mobile.
3. Is most convenient for the parents.
4. Is for decoration only. The newborn does not have vision sufficient to see the mobile.
A newborn is admitted to the neonatal intensive care unit (NICU). The parents are
concerned because they cannot stay for long hours to visit. Which statement made by
the nurse is most appropriate?
1. “Why can’t you visit after work every day?”
2. “One of you could take a leave of absence to be here more.”
3. “Perhaps the grandparents can make the visits for you.”
4. “Parents often feel this way; you can call any time to see how your baby is doing.”
The nurse works in an oncology clinic. A preschool-age child is being seen in the clinic,
and the nurse anticipates a diagnosis of cancer. The nurse prepares for which of the
common reactions preschool-age children have following illnesses and
hospitalizations?
1. Unawareness of the illness and its severity
2. Acceptance, especially if able to discuss the disease with children their own age
3. Understanding of what cancer is and how it is treated
4. Thoughts that they caused their illness and are being punished
During shift report, the night nurse reports that the child who is terminally ill has
developed tolerance to the morphine that the child has been receiving. The oncoming
nurse realizes that the child:
1. Is physically dependent on morphine.
2. Is addicted to morphine.
3. Is showing physical signs of withdrawal.
4. Will need more medication to achieve the same effect.
A nurse observes the parent-child interaction during the six-year-old well-child checkup
and notes that the parent speaks harshly to the child and uses negative remarks when
speaking with the nurse. Which statement by the nurse would be most beneficial?
1. Addressing the child, the nurse says, “Are you unhappy when Mommy talks to you
like this?”
2. “I am going to refer you for counseling, because your interactions with your child
seem so negative.”
3. “Perhaps you should leave the room so that I can speak with your child privately.”
4. “Let’s talk privately. Let’s discuss ways you can speak to your child in a positive
tone.”
The mother of a two-year-old child becomes very anxious when the child has a temper
tantrum in the medical office. The appropriate nursing response to the mother would be
to say:
1. “Let’s ignore this behavior. It will stop sooner.”
2. “What do you usually do or say during a temper tantrum?”
3. “This is definitely a temper tantrum. I know exactly what you are feeling right now.”
4. “Pick up and cuddle your child now, please.”
While being comforted in the emergency department, the six-year-old sibling of a
pediatric trauma victim blurts out to the nurse, “It’s all my fault! When we were fighting
yesterday, I told him I wished he was dead!” The nurse, realizing that the child is
experiencing magical thinking, should respond by:
1. Asking the child if he would like to sit down and drink some water.
2. Sitting the child down in an empty room with markers and paper so that he can draw
a picture.
3. Reassuring the child that it is normal to get angry and say things that we do not
mean, but that we have no control over whether an accident happens.
4. Calmly discussing the catheters, tubes, and equipment that the patient requires, and
explaining to the sibling why the patient needs them.
A two-month-old infant with a congenital heart defect has been admitted to the pediatric
intensive care unit with congestive heart failure. Nursing care for this child should
include which intervention?
1. Monitor respirations during active periods.
2. Give larger feedings less often to conserve energy.
3. Organize activities to allow for uninterrupted sleep.
4. Force fluids appropriate for age.
A foster mother is caring for an infant who experienced an intrauterine drug exposure to
cocaine. The infant often is irritated and cries for several hours each day. Which of
these interventions will assist the infant in developing self-regulatory behaviors?
1. Encouraging the infant to suck as a comfort measure by placing the infant’s fingers in
the mouth while crying
2. Placing the infant about 15 inches from the TV and turning on an infant show such as
Sesame Street
3. Swaddling the infant
4. Allowing the infant to cry but observing the infant to prevent injury
A child is admitted with acute glomerulonephritis. The nurse would expect the
urinalysis during this acute phase to show which of the following?
1. Bacteriuria and increased specific gravity
2. Hematuria and proteinuria
3. Proteinuria and decreased specific gravity
4. Bacteriuria and hematuria
Prior to her return to school, an individualized health plan (IHP) will be developed for
the child who has:
1. Missed two weeks of school due to mononucleosis.
2. Been newly diagnosed with insulin-dependent diabetes mellitus.
3. Recently developed a penicillin allergy.
4. Been treated for head lice.
A child is being discharged after an extended hospitalization. Prior to discharge from a
hospital, home health care nurses should assess which aspect of the home setting?
1. Parents’ insurance
2. Parents’ income
3. Readiness of the home for the child who is returning home from the hospital
4. Parents’ home location
The nurse is caring for a child on bed rest who has severe edema in a left lower leg due
to blocked lymphatic drainage. Which nursing diagnosis would take priority?
1. Risk for impaired skin integrity
2. Risk for altered body image
3. Risk for imbalanced nutrition: less than body requirements
4. Risk for activity intolerance
The nurse has completed parent education related to treatment for a child with
congenital clubfoot. The nurse knows that parents need further teaching when they
state:
1. “We’re getting a special car seat to accommodate the casts.”
2. “We’ll watch for any swelling of the feet while the casts are on.”
3. “We’ll keep the casts dry.”
4. “We’re happy this is the only cast our baby will need.”