The nurse is caring for a child who experiences an anaphylactic shock reaction. In
which position will the nurse place the child?
1. In Trendelenburg position
2. Flat, with legs slightly elevated
3. In high Fowler’s position
4. In reverse Trendelenburg position
A seven-year-old with a head injury is hospitalized after losing consciousness when he
was hit in the head with a bat at baseball practice. The child was not wearing a helmet.
The last set of vital signs showed heart rate 48, BP 148/74, respiratory rate 28 and
irregular. The nurse suspects that these vital signs are:
1. A sign that this child has a spinal cord injury.
2. A sign of increased intracranial pressure.
3. Typical for a sleeping child at this age.
4. A sign that the child’s condition is improving.
A child is receiving chemotherapy induction for acute lymphocytic leukemia (ALL).
Taking common side effects into consideration, which nursing diagnoses would be
appropriate during the induction chemotherapy?
Standard Text: Select all that apply.
1. Risk for injury: hemorrhagic cystitis
2. Skin integrity: impaired mucous membrane
3. Fluid and electrolyte impairment: nausea and vomiting
4. Risk for infection
5. Impaired sleep pattern
6. Diarrhea
A child diagnosed with congestive heart failure is started on digoxin (Lanoxin) and
spironolactone (Aldactone). The mother questions why the child was placed on
spironolactone (Aldactone) instead of furosemide (Lasix), which her elderly
grandmother uses. The nurse explains that spironolactone (Aldactone) is a diuretic that:
1. Produces rapid diuresis.
2. Blocks reabsorption of sodium and water in renal tubules.
3. Spares potassium.
4. Promotes vascular relaxation.
The nurse is preparing to ambulate an 11-year-old child who has had an appendectomy.
In addition to pharmacological pain management, which of the following
nonpharmacologic, independent nursing pain management strategies would be
appropriate for this child?
1. A warm, moist pack
2. EMLA cream to the incision site
3. An ice pack
4. A splint pillow against the abdomen when moving or coughing
A child must wear a brace for correction of scoliosis. Which nursing diagnosis takes
priority at this time?
1. Impaired gas exchange, risk for
2. Altered growth and development, risk for
3. Impaired skin integrity, risk for
4. Impaired mobility, risk for
A non-Spanish-speaking nurse is working with a seven-year-old client who is able to
speak English but whose family speaks only Spanish. The nurse needs to give discharge
instructions regarding the client’s oral antibiotics. There are no Spanish-speaking
interpreters available presently, but one will be able to come in about one hour. The
nurse’s most appropriate intervention would be:
1. To give the discharge instructions to the parents, with the child acting as interpreter.
2. To give the discharge instructions to the child.
3. To obtain an English/Spanish translation book and use this to aid in giving discharge
instructions to the parents.
4. To have the parents wait until an interpreter can be found to translate the discharge
instructions.
The nurse is working with a 14-year-old adolescent with an intellectual disability. The
adolescent’s mental age is four. In explaining an X-ray to the adolescent, the nurse
should explain:
1. To the adolescent in terms appropriate to a teenager.
2. To the parents and have them explain to their child.
3. As little as possible because the child will not understand anyway.
4. Using words that are in the vocabulary of a four-year-old without talking down to the
adolescent.
Prior to discharging the child from the hospital, what routine discharge instructions
should the nurse discuss with the family?
1. Monitoring signs and symptoms specific to condition
2. Instruction on performing a medical exam on the child
3. No instructions are needed; the family is familiar with the child.
4. A list of all diagnostic tests obtained during the hospitalization and their results
An infant has a severe case of oral thrush (Candida albicans). Which is the priority
nursing diagnosis for this infant?
1. Ineffective infant feeding pattern related to discomfort
2. Ineffective breathing pattern related to oral thrush
3. Activity intolerance related to oral thrush
4. Ineffective airway clearance related to mucus
A majority of pediatric health care occurs in community-based settings.
Community-based health care settings include:
Standard Text: Select all that apply.
1. The local community hospital.
2. Outpatient surgical facilities.
3. The public health clinic.
4. An inpatient mental health center.
5. A pediatrician’s office
The nurse is caring for an eight-year-old child who has been in a car accident, has a
head injury, and is in the ICU. The nurse sees the child pulling on the IV line. What
action should the nurse take?
1. Sedate the child as needed.
2. Place soft wrist restraints on the child.
3. Ask the parents to watch the child closely at all times.
4. Tell the child not to pull on the IV line.
A child with inflammatory bowel disease is taking prednisone daily. The family should
be taught to administer the prednisone at what time?
1. Between meals
2. At bedtime
3. One hour before meals
4. With meals
While in the pediatrician’s office for their child’s 12-month well-child exam, the parents
ask the nurse for advice on age-appropriate toys for their child. Based on the child’s
developmental level, the nurse should suggest which types of toys?
Standard Text: Select all that apply.
1. Soft toys that can be manipulated and mouthed
2. Toys with black-and-white patterns
3. Toys that can pop apart and go back together
4. Jack-in-the-box toys
5. Push-and-pull toys
While preparing for the day in the integument clinic, the nurse notices that a number of
the patients being seen that day have conditions with a genetic component. Which skin
conditions have a genetic or inherited component?
Standard Text: Select all that apply.
1. Atopic dermatitis
2. Seborrheic dermatitis
3. Epidermolysis bullosa
4. Molluscum contagiosum
5. Psoriasis
The nurse is speaking with a group of adolescents about what can happen when having
unprotected sex. The nurse understands that to communicate effectively with teens, the
nurse must:
1. Offer personal opinions on the topic and cite examples of what can happen if they
don’t listen.
2. Allow for discussion, and bring peers who have had experience related to the topic
being discussed.
3. Lecture on the topic for the allotted time without any discussion.
4. Discuss sex education related to religious belief.