A six-month-old returns from surgery with elbow restraints in place. What
nursing care should be included when caring for any restrained child?
A. Keep restraints on at all times.
B. Remove restraints one at a time and provide range of motion exercises.
C. Remove all restraints simultaneously and provide play activities.
D. Renew the healthcare provider's prescription for restraints every 72 hours.
- CORRECT ANSWERS-B. Remove restraints one at a time and provide range
of motion exercises.
A 2-year-old child with Down syndrome is brought to the clinic for his regular
physical examination. The nurse knows which problem is frequently
associated with Down syndrome?
A. Congenital heart disease.
B. Fragile X chromosome.
C. Trisomy 13.
D. Pyloric stenosis. - CORRECT ANSWERS-A. Congenital heart disease.
When assessing a child with asthma, the nurse should expect intercostal
retractions during
A. Inspiration.
B. Coughing.
C. Apneic episodes.
D. Expiration. - CORRECT ANSWERS-A. Inspiration.
When planning the care for a child who has had a cleft lip repair, the nurse
knows that crying should be minimized because it
A. Increases salivation.
B. Increases the respiratory rate.
C. Leads to vomiting.
D. Stresses the suture line. - CORRECT ANSWERS-D. Stresses the suture line.
A full-term infant is admitted to the newborn nursery. After careful
assessment, the nurse suspects that the infant may have an esophageal
atresia. Which symptoms is this newborn likely to have exhibited?
A. Choking, coughing, and cyanosis.
B. Projectile vomiting and cyanosis.
C. Apneic spells and grunting.
D. Scaphoid abdomen and anorexia. - CORRECT ANSWERS-A. Choking,
coughing, and cyanosis.
,Which behavior would the nurse expect a two-year-old child to exhibit?
A. Build a house with blocks.
B. Ride a tricycle.
C. Display possessiveness of toys.
D. Look at a picture book for 15 minutes. - CORRECT ANSWERS-C. Display
possessiveness of toys.
The nurse is giving preoperative instructions to a 14-year-old female client
who is scheduled for surgery to correct a spinal curvature. Which statement
by the client best demonstrates that learning has taken place?
A. "I will read all the literature you gave me before surgery."
B. "I have had surgery before when I broke my wrist in a bike accident, so I
know what to expect."
C. "All the things people have told me will help me take care of my back."
D. "I understand that I will be in a body cast and I will show you how you
taught me to turn." - CORRECT ANSWERS-D. "I understand that I will be in a
body cast and I will show you how you taught me to turn."
To take the vital signs of a 4-month-old child, which order will give the most
accurate results?
A. Respiratory rate, heart rate, then rectal temperature.
B. Heart rate, rectal temperature, then respiratory rate.
C. Rectal temperature, heart rate, then respiratory rate.
D. Rectal temperature, respiratory rate, then heart rate. - CORRECT
ANSWERS-A. Respiratory rate, heart rate, then rectal temperature.
During routine screening at a school clinic, an otoscope examination of a
child's ear reveals a tympanic membrane that is pearly gray, slightly bulging,
and not movable. What action should the nurse take next?
A. No action required, as this is an expected finding for a school-aged child.
B. Ask the child if he/she has had a cold, runny nose, or any ear pain lately.
C. Send a note home advising the parents to have the child evaluated by a
healthcare provider as soon as possible.
D. Call the parents and have them take the child home from school for the
rest of the day. - CORRECT ANSWERS-B. Ask the child if he/she has had a
cold, runny nose, or any ear pain lately.
Which restraint should be used for a toddler after a cleft palate repair?
A. Clove hitch.
B. Mummy.
C. Elbow.
D. Jacket. - CORRECT ANSWERS-C. Elbow.
, What preoperative nursing intervention should be included in the plan of
care for an infant with pyloric stenosis?
A. Monitor for signs of metabolic acidosis.
B. Estimate the quantity of diarrhea stools.
C. Place in a supine position after feeding.
D. Observe for projectile vomiting. - CORRECT ANSWERS-D. Observe for
projectile vomiting.
The mother of a preschool-aged child asks the nurse if it is all right to
administer Pepto Bismol to her son when he "has a tummy ache." After
reminding the mother to check the label of all over-the-counter drugs for the
presence of aspirin, which instruction should the nurse include when replying
to this mother's question?
A. If the child's tongue darkens, discontinue the Pepto Bismol immediately.
B. Do not give if the child has chickenpox, the flu, or any other viral illness.
C. Avoid the use of Pepto Bismol until the child is at least 16 years old.
D. Pepto Bismol may cause a rebound hyperacidity, worsening the "tummy
ache." - CORRECT ANSWERS-B. Do not give if the child has chickenpox, the
flu, or any other viral illness.
The nurse observes a 4-year-old boy in a daycare setting. Which behavior
should the nurse consider normal for this child?
A. Has a temper tantrum when told he must share his toys.
B. Plays by himself most of the day.
C. Demonstrates aggressiveness by boasting when telling a story.
D. Begins to cry and is fearful when separated from his parents. - CORRECT
ANSWERS-C. Demonstrates aggressiveness by boasting when telling a story.
A burned child is brought to the emergency room. In estimating the
percentage of the body burned, the nurse uses a modified "Rule of Nines."
Which part of a child's body is calculated as a larger percentage of total body
surface than an adult's?
A. Head and neck.
B. Arms and chest.
C. Legs and abdomen.
D. Back and abdomen. - CORRECT ANSWERS-A. Head and neck.
The nurse receives a lab report stating a child with asthma has a
theophylline level of 15 mcg/dl. What action will the nurse take?
A. Pass the information on in the report.
B. Notify the healthcare provider because the value is high.
C. Repeat the lab study because the value is too high.
D. Hold the next dose of theophylline. - CORRECT ANSWERS-A. Pass the
information on in the report.
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