What would be the best way for the nurse to teach adolescents regarding health
promotion and health maintenance?
1. Contact the parents and ask what issues they have with their adolescents.
2. Have the adolescents identify a personal health goal.
3. Ask the advice of the counselors at school.
4. Tell the adolescents what you will include in the lecture.
The nurse is measuring an abdominal girth on a child with abdominal distension.
Identify the area on the child’s abdomen where the tape measure should be placed for an
accurate abdominal girth.
1. Below the umbilicus
2. Just below the sternum
3. Just above the pubic bone
4. Just above the umbilicus, around the largest circumference of the abdomen
A nurse is preparing to admit a child with possible obstructive uropathy. What labs
should the nurse expect to draw on this child?
1. Platelet count
2. Blood urea nitrogen (BUN) and creatinine
3. Partial thromboplastin time (PTT)
4. Blood culture
A child is admitted to the hospital unit with a diagnosis of Kawasaki disease. The
physician writes the following orders. Which order would the nurse question?
1. Contact isolation
2. Oral aspirin (dose appropriate for weight) every eight hours
3. Echocardiogram
4. Vital signs every four hours
An adolescent tells the nurse that the new diagnosis of diabetes has him ‘stressed out.”
The nurse will encourage stress reduction activities, including:
Standard Text: Select all that apply.
1. Daily exercise, such as walking.
2. Learning more about his illness.
3. Practicing deep breathing and other relaxation techniques.
4. Not thinking about his diagnosis.
5. Allowing the parents control of his disease.
Following diagnosis of Ewing’s sarcoma, the physician orders chemotherapy for the
12-year-old child. After discussion with the physician, the parents refuse a central line
so the chemotherapy will be administered by peripheral line. The nurse will prevent
extravasation by:
Standard Text: Select all that apply.
1. Ensuring that the intravenous line is a free flowing line.
2. Administering the medication by infusion pump.
3. Checking for blood return before and during chemotherapy administration.
4. Diluting the medication with normal saline.
5. Administering the vesicant drug last.
A teenage girl sees the school nurse to ask about a vaginal discharge that she has had
for a month. The nurse suspects a sexually transmitted disease. What is the nurse’s next
step?
1. Notify the girl’s parents.
2. Determine the girl’s sexual partners.
3. Encourage the girl to go to the free clinic or her private health care provider for an
examination and possible treatment.
4. Notify the health department of the sexually transmitted disease.
Following treatment for iron deficiency anemia, the physician orders lab tests. Which
lab value would indicate an improvement in the child’s condition?
1. Low hemoglobin
2. Normal platelet count
3. High reticulocyte count
4. Low hematocrit
The school nurse is conducting pediculosis capitis (head lice) checks. Which finding
would indicate a “positive” head check?
1. White, flaky particles throughout the entire scalp region
2. Lesions on the scalp that extend to the hairline or neck
3. Maculopapular lesions behind the ears
4. Silver/white sacs attached to the hair shafts in the occipital area
The school nurse is working with an adolescent who reports that he gets six hours or
less of sleep at night. The nurse explains to the adolescent that some of the common
consequences of inadequate sleep include:
Standard Text: Select all that apply.
1. Hyperactivity.
2. Increased nocturnal emissions.
3. Increased risk of automobile accidents when driving.
4. Moodiness.
5. Being unable to perform well at school.
While teaching the parents of a newborn about infant care and feeding, the nurse
instructs the parents to:
1. Delay supplemental foods until the infant is four to six months old.
2. Begin diluted fruit juice at two months of age, but wait three to five days before
trying a new food.
3. Add rice cereal to the nighttime feeding if the infant is having difficulty sleeping after
two months of age.
4. Delay supplemental foods until the infant reaches 15 pounds or greater.
As a component of the family assessment, the family assists the nurse in developing an
ecomap. Prior to beginning the ecomap, the nurse explains that the ecomap:
1. Provides information about the family structure including family life events, health,
and illness.
2. Illustrates family relationships and interactions with community activities including
school, parental jobs, and children’s activities.
3. Is a short questionnaire of five questions that measures family growth, affection, and
resolve.
4. Is a family assessment that consists of three categories of information about the
family’s strengths and problems.
The charge nurse on a hospital unit is developing plans of care related to separation
anxiety. The charge nurse recognizes that the hospitalized child who is at greatest risk
for experiencing separation anxiety when parents cannot stay is the:
1. Six-month-old.
2. 18-month-old.
3. Four-year-old.
4. Six-year-old.
A nurse asks the mother to undress her four-month-old infant. The nurse observes the
mother taking off several layers of clothing, knowing that the outdoor temperature is
70F. Which of these statements should the nurse make to the mother?
1. “When you leave the office, only put one layer of clothing on your baby.”
2. “My, you are dressing your infant warmly today.”
3. “Did you think it was it cold when you left your home this morning?”
4. “I see that you have many layers of clothing on your baby. This could cause your
baby’s temperature to rise.”
The nurse in the long-term care clinic is reviewing the charts of a group of children
being seen for follow-up visits in the pediatric clinic. The nurse recognizes that chronic
limitations might result from which diagnosis?
1. Pneumonia from Haemophilus influenzae virus
2. Respiratory syncytial virus
3. Streptococcus pneumoniae, a gram-positive diplococcus
4. Congenital heart defect
The nurse is reviewing the charts from a multicultural health clinic. The nurse needs to
know that for three cultures, the listed first name is actually the family name, while the
individual’s given name is placed last. The three cultures with this variation are:
1. French, German, and Irish.
2. Cambodian, Filipino, and Korean.
3. Canadian, Egyptian, and Haitian.
4. Brazilian, English, and Jewish.
The home health nurse is visiting a three-month-old who has been diagnosed with
congenital hypothyroidism and is taking daily thyroxine. The baby is on soy formula
and is at the 50th percentile for height and weight. It is important that the mother
understands that:
1. Parents may stop the thyroxine as long as the baby remains in the 50th percentile for
height and weight.
2. Soy-based formula can interfere with the absorption of thyroxine.
3. Dairy-based formula is contraindicated when an infant is taking thyroxine.
4. As long as the baby is growing along the same growth curve, no interventions are
necessary.
A nurse notices a client sitting at the edge of the chair, tapping her fingers, fidgeting,
and blinking her eyes frequently. In planning this client’s care, the nurse should take
into account that this client is most likely displaying nonverbal cues of:
1. Shyness.
2. Anxiety.
3. Anger.
4. Interest.
A high school student calls to ask the nurse for advice on how to care for a new navel
piercing. How should the nurse respond?
1. “Avoid contact with another person’s bodily fluids until the area is well healed.”
2. “Do not move or turn the jewelry for the first three days.”
3. “Apply lotion to the area, rubbing gently, to prevent skin from becoming dry and
irritated.”
4. “Apply warm soaks to the area for the first two days to minimize swelling.”