The nurse is caring for a child with a terminal illness. Physical care for the dying child
would include which interventions?
Standard Text: Select all that apply.
1. Providing oral care to moisten a dry mouth
2. Administering ordered laxatives to counter the effects of opioids
3. Encouraging a favorite food
4. Keeping the child pain-free
5. Taking vital signs and blood pressure every two hours
The nurse is assessing a 15-year-old female. The girl’s menses began when she was 12
years old. The girl’s body mass index (BMI) is 27.5 and her height is 5 feet, 2 inches.
She weighs 160 pounds. Her school performance has been spotty. The priority client
teaching would be related to:
1. Menstrual cycle.
2. Nutritional intake.
3. School performance.
4. Adolescent mini mental health status examination.
Following diagnosis of osteosarcoma, a 14-year-old girl has a below-the-knee
amputation. The girl has had trouble accepting the reality of her amputation. Which
behavior, when observed by the nurse, indicates she is beginning to accept the
amputation?
1. The girl complains of pain in the missing leg.
2. When physical therapy comes, she is willing to have her temporary prosthetic applied
and attempts crutch training.
3. Prior to visiting hours, she asks to be helped to a wheelchair with a blanket over her
legs.
4. When the nurses change the dressing on the stump, she watches the dressing change.
Which would be the priority nursing diagnosis during the acute phase of burn injury for
a child who has a third-degree circumferential burn of the right arm?
1. Altered tissue perfusion, risk for
2. Infection, risk for
3. Impaired physical mobility
4. Altered nutrition: less than body requirements, risk for
A hospitalized child has been diagnosed with SIADH (syndrome of inappropriate
antidiuretic hormone), a complication of his meningitis. What would the nurse expect to
see on this child’s lab results?
1. Hyponatremia
2. Hypocalcemia
3. Hyperglycemia
4. Hypernatremia
A term infant is found to have a congenital heart defect. During a cardiac
catheterization, a stent is inserted to maintain the ductus arteriosus. The parents ask the
nurse to explain the purpose of this procedure. The nurse’s response would include the
information that the stent:
1. Will keep the ductus arteriosus open and oxygenated and unoxygenated blood mixed.
2. Is used to close the ductus arteriosus to prevent mixing of arterial and venous blood.
3. Will redirect the blood so that blood bypasses the right ventricle.
4. Connects the ventricle to the atrium.
The nurse has admitted a child with a ventricular septal defect (VSD) to the unit. Which
nursing diagnosis is appropriate for this child?
1. Hypothermia related to decreased metabolic state
2. Acute pain related to the effects of a congenital heart defect
3. Ineffective tissue perfusion (peripheral) related to cyanosis secondary to congenital
heart defect
4. Impaired gas exchange related to pulmonary congestion secondary to the increased
pulmonary blood flow
The teacher has referred a 10-year-old boy to the school nurse. The school nurse knows
that the child is an only child with a single mother who works full time and is going to
school. Which additional finding would the nurse identify as putting the child at risk for
mental health issues?
1. The child is well nourished, wears glasses, and wears clothing styles that matches the
other boys in his class.
2. The boy has a grandmother, aunts, and several cousins living nearby.
3. The family attends church on a regular basis.
4. The child is not involved in community social activities and does not play sports. The
child states he plays video games at home after school.
A toddler is admitted to the surgical unit for planned closure of the temporary
colostomy. The nurse completes the admission assessment and reviews the medical
orders. Which order should the nurse question?
1. Clear liquids today. NPO tomorrow
2. Type and cross-match for one unit of packed red blood cells.
3. Rectal temperatures every four hours
4. Start an intravenous line with D5NS at 20 ml per hour.
The nurse is assessing a new admission to the newborn nursery. Which physical
findings suggest the infant was preterm?
Standard Text: Select all that apply.
1. The ear pinna quickly returns to original position after being bent manually.
2. The infant’s resting position is tightly flexed.
3. Labia widely separated with clitoris prominent.
4. Breast area barely perceptible with flat areola, no bud.
5. Sole creases do not extend the length of the foot.
A child is on rifampin (Rimactane) for treatment of tuberculosis. The parents call the
clinic and report that the child’s urine is orange. The nurse should advise the parents to:
1. Encourage the child to drink cranberry juice.
2. Expect orange-colored urine while the child is on rifampin.
3. Bring the child to the clinic for a urinalysis.
4. Bring the child to the clinic for a radiograph of the kidneys.
During a four-month-old infant’s well-child checkup, the nurse discusses introduction of
solid foods into the infant’s diet. Although the nurse recommends delaying the
introduction of many foods into the diet, which food(s) will the nurse discuss delaying
because they increase the risk for food allergy?
1. Honey
2. Carrots, beets, and spinach
3. Pork
4. Cow’s milk, eggs, and peanuts
Which athletic activity could the nurse recommend for a school-age child with
pulmonary-artery hypertension?
1. Golf
2. Basketball
3. Cross-country running
4. Soccer
Which nursing assessment activities should be included for the child and family at each
health supervision visit?
Standard Text: Select all that apply.
1. Performing an age-appropriate developmental assessment
2. Performing age-appropriate screening examinations
3. Monitoring parents’ ability to pay for services
4. Assessing for genetic abnormalities
5. Obtaining an updated health history
Manifestations of cancer in the pediatric patient vary by type and location but typically
include which of the following general manifestations?
Standard Text: Select all that apply.
1. Infection
2. Weight gain
3. Polycythemia
4. Neurologic symptoms
5. Pain
6. Cachexia