Multiple Choice
Identify the
choice that best completes the statement or answers the question.
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1.
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A nurse in the pediatric unit is admitting a
2-year-old child. The nurse plans care, knowing that the child is in which stage of Erikson’s
psychosocial stages of development?
a. | Trust vs. mistrust | b. | Autonomy vs. shame and doubt | c. | Initiative vs. guilt | d. | Industry vs.
inferiority |
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2.
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A nurse is admitting a 10-month-old infant who is
being hospitalized for a respiratory infection. The nurse develops a plan of care for the infant and
includes which of the following?
a. | Keeping the infant as quiet as
possible | b. | Placing small toys in the crib to provide stimulation
for the infant | c. | Restraining the
infant to prevent tubes from being dislodged | d. | Providing a
consistent routine such as touching, rocking, and cuddling throughout the
hospitalization |
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3.
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A nurse is performing a safety assessment in the
home of a mother with two children. The ages of the children are 1 and 3 years. Which of the
following, if noted during the assessment, would present the greatest hazard to the
children?
a. | The water heater set above 120°
F | b. | A small dog as a house pet | c. | A gate placed at the stairs of the second floor | d. | Toys with small loose parts in the
playroom |
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4.
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A nurse is providing instructions to the mother of
a 2-year-old child regarding dental care. Which statement by the mother indicates the need for
further instructions?
a. | “Proper dental care is not necessary for toddlers
until their permanent teeth erupt.” | b. | “It is best
to substitute sweets or snacks with food items such as cheese.” | c. | “I should schedule my child’s first dental examination when his
first primary tooth erupts.” | d. | “I do not
need to be concerned if my child swallows some toothpaste while he is brushing his
teeth.” |
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5.
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A nurse is providing instructions to the mother of
a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement
by the mother indicates a need for further instruction?
a. | “I need to remain in the kitchen when I prepare
meals.” | b. | “I need to
be sure to place my cup of coffee on the counter.” | c. | “I need to use the back burners for
cooking.” | d. | “I need to
turn pot handles inward and to the middle of the stove.” |
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6.
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A nursing student is assigned to care for a
hospitalized 2-year-old child. The nursing instructor reviews the plan of care with the student and
asks the student to identify the expected behavior of the child in regard to separation anxiety.
Which statement by the student indicates an understanding of separation anxiety that can occur in a
2-year-old?
a. | “The child will
withdraw.” | b. | “Separation
anxiety is not an issue in a 2-year-old.” | c. | “The child
may ignore the parents when they visit.” | d. | “Two-year-olds usually adjust well to
hospitalization.” |
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7.
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The mother of a 4-year-old who was recently
hospitalized brings the child to the clinic for a follow-up visit. The mother tells the nurse that
the child has begun to wet the bed and that it started when the child was brought home from the
hospital. The mother is concerned and asks the nurse what to do. The appropriate nursing response is
which of the following?
a. | “You need to discipline the
child.” | b. | “This is a
normal occurrence following hospitalization.” | c. | “We will need to discuss this behavior with the
physician.” | d. | “The child
probably has developed a urinary tract infection.” |
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8.
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A 6-year-old is hospitalized with a fracture of the
femur and is placed in traction. In meeting the psychosocial needs of the child, the nurse most
appropriately selects which of the following play activities for the child?
a. | A coloring book with crayons | b. | A finger-painting set | c. | A large
puzzle | d. | A board game |
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9.
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A nurse has provided information to the mother of a
toddler regarding toilet training. Which statement by the mother would indicate a need for further
instructions?
a. | “I should wait until my child is at least 24
months old.” | b. | “I know that
my child will develop bowel control before bladder control.” | c. | “I should have my child sit on the potty until my child
urinates.” | d. | “I know my
child is ready to begin toilet training if my child can walk
well.” |
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10.
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A nurse is providing instructions to a 16-year-old
female adolescent regarding dietary patterns. The nurse instructs the adolescent that the recommended
amount of daily calories is approximately:
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11.
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The mother of a 2-year-old child asks the nurse if
it is all right to give the child a bottle at naptime. The appropriate response by the nurse is which
of the following?
a. | “At this age, the child may have a bottle at any
time.” | b. | “The child
may have a bottle at naptime, but it is best not to give a bottle at
bedtime.” | c. | “A bottle
may be given if the child isn’t taking fluids well during the
day.” | d. | “You may
give the child a bottle if necessary, but if you do, it should contain
water.” |
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12.
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A 4-year-old child is hospitalized for severe
gastroenteritis. The child is crying and clinging to the mother. The mother becomes very upset and is
afraid to leave the child. Which of the following nursing interventions would be most appropriate to
alleviate the child’s fears and the mother’s anxiety?
a. | Reassure the mother that the child will be fine after
she leaves. | b. | Give the mother
the telephone number of the pediatric unit, and tell the mother to call at any
time. | c. | Ask the mother if she would like to stay overnight with
the child. | d. | Tell the mother to
bring the child’s favorite toys the next time she comes to the hospital to
visit. |
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13.
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A licensed practical nurse (LPN) is collecting data
on a child and notes the presence of old and new bruises on the child’s back and legs. The LPN
suspects physical abuse and reports the findings to the registered nurse, knowing that which of the
following is necessary?
a. | Filing charges against the mother and father of the
child | b. | Reporting the case to legal
authorities | c. | Asking the mother
to identify the person who is physically abusing the child | d. | Telling the child that he or she will need to go to a foster home until the
situation is straightened out |
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14.
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A nurse is speaking with a client with a hearing
impairment. The nurse refrains from doing which of the following, which is least helpful when
communicating with this client?
a. | Standing directly in front of the client while
speaking | b. | Speaking slowly and clearly | c. | Turning down the volume on the radio or TV | d. | Using many exaggerated hand gestures while
talking |
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15.
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A long-term care nurse notes that an older female
client has leaking of urine when sneezing, coughing, or laughing. The nurse reports that this client
has which of the following types of incontinence?
a. | Urge incontinence | b. | Stress incontinence | c. | Reflex
incontinence | d. | Functional
incontinence |
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16.
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A nurse is gathering data from a client with a
history of untreated cataracts. The nurse asks the client about the presence of which of the
following signs of a cataract?
a. | Difficulty with driving at night and blurred
vision | b. | Pain in the eyes when in dim
light | c. | Either excessive itching or tearing of the
eyes | d. | A blank spot in the field of
vision |
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17.
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A long-term care nurse is caring for an older
client taking cimetidine (Tagamet). The nurse observes this client frequently for which most frequent
central nervous system (CNS) side effect of this medication?
a. | Tremors | b. | Hallucinations | c. | Confusion | d. | Dizziness |
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18.
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A nurse is assisting a client who has just been
given a hearing aid to wear for the first time. The nurse provides teaching about the device,
including that:
a. | “The hearing aid contains a lifelong battery, so
there is no need to be concerned about changing batteries.” | b. | “The hearing aid should not be worn if an ear infection is
present.” | c. | “The ear
mold should be washed with mild soap and water once a month.” | d. | “The hearing aid should be removed at the end of the day and then turned
off after removal.” |
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19.
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A nurse is caring for a hospitalized infant and is
monitoring for increased intracranial pressure (ICP). The nurse notes that the anterior fontanel
bulges when the infant cries. Based on this finding, which of the following actions would the nurse
take?
a. | Lower the head of the bed. | b. | Document the findings. | c. | Place the infant
on nothing-per-mouth (NPO) status. | d. | Ask the registered
nurse to notify the physician immediately. |
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20.
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A child is admitted to the hospital, and a
diagnosis of bacterial meningitis is suspected. A lumbar puncture is performed, and the results
reveal cloudy cerebrospinal fluid (CSF) with high protein and low glucose levels. The nurse
determines that these results are indicative of:
a. | The need to repeat the test | b. | Possible contamination of the specimen | c. | Confirmation of the diagnosis | d. | A negative test |
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21.
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A nurse is caring for a child who sustained a head
injury in an automobile accident and is monitoring the child for signs of increased intracranial
pressure (ICP). The nurse plans to monitor for the earliest sign of increased ICP by assessing
for:
a. | Tachycardia | b. | Changes in level of consciousness (LOC) | c. | Posturing | d. | Apnea |
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22.
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A nurse is providing instructions to the parents of
an infant with a ventricular-peritoneal shunt. The nurse plans to include which of the following
instructions?
a. | Call the physician if the infant is
fussy. | b. | Position the infant on the side of the shunt when the
infant is put to bed. | c. | Expect an
increased urine output from the shunt. | d. | Call the physician
if the infant has a high-pitched cry. |
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23.
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A nurse in a newborn nursery is told that a newborn
with spina bifida (myelomeningocele type) will be transported from the delivery room. The nurse is
asked to prepare for the arrival of the newborn. The nurse places which of the following priority
items at the newborn’s bedside?
a. | A blood pressure cuff | b. | A rectal thermometer | c. | A specific gravity
urinometer | d. | A bottle of
sterile normal saline |
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24.
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A nurse reviews the plan of care for a child with
Reye’s syndrome. The nurse prioritizes the nursing interventions included in the plan and
prepares to monitor for:
a. | Signs of increased intracranial
pressure | b. | The presence of protein in the
urine | c. | Signs of a bacterial
infection | d. | Signs of
hyperglycemia |
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25.
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A nurse employed in the emergency department is
collecting data on a 7-year-old child with a fractured arm. The child is hesitant to answer questions
that the nurse is asking and consistently looks at the parents in a fearful manner. The nurse
suspects physical abuse and continues with the data collection procedures. Which of the following
findings would most likely assist in verifying the suspicion?
a. | Poor hygiene | b. | Bald spots on the scalp | c. | Lacerations in the
anal area | d. | Swelling of the
genitals |
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26.
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A nurse working in the day care center is told that
a child with autism will be attending the center. The nurse collaborates with the staff of the day
care center and assists in planning activities that will meet the child’s needs. The nurse
understands that the priority consideration in planning activities for the child is to
ensure:
a. | Social interactions with other children in the same age
group | b. | Safety with activities | c. | Familiarity with all activities and providing orientation throughout the
activities | d. | Activities
providing verbal stimulation |
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27.
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A nurse is providing instructions to an adolescent
who is taking phenytoin (Dilantin) for the control of seizures. Which statement by the adolescent
indicates a need for further teaching regarding the medication?
a. | “The medication may cause oily
skin.” | b. | “Drinking
alcohol may affect the medication.” | c. | “If my gums
become sore, I need to stop the medication.” | d. | “Birth control pills may not be effective when I take this
medication.” |
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28.
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A nurse is providing instructions to a child with
cystic fibrosis regarding how to perform the “huff” maneuver. The child asks the nurse
about the purpose of this type of breathing. The appropriate nursing response is which of the
following?
a. | “This type of breathing is used to mobilize
secretions so that they can be easily coughed out.” | b. | “This type of breathing prolongs inspiration
time.” | c. | “This type
of breathing moves air out of the lower lungs.” | d. | “This type of breathing moves air through the
lungs.” |
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29.
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A nurse is providing home care instructions to the
mother of a child diagnosed with pneumonia. Which statement by the mother indicates the need for
further instructions?
a. | “I can administer acetaminophen
[Tylenol] for a fever.” | b. | “I can use a
warm mist humidifier to keep the secretions loose.” | c. | “I should administer the antibiotics until the prescribed amount is
completed.” | d. | “I can give
my child warm liquids to loosen secretions.” |
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30.
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A child with a tracheal obstruction is brought to
the emergency department by emergency medical services. The child aspirated a grape, and the foreign
body was removed by direct laryngoscopy. Following the procedure, the nurse plans to inform the
mother of the child that:
a. | The child will need to be hospitalized for
observation. | b. | The child may go
home with a prescription for antibiotics. | c. | The child will
need to return to the hospital for a chest x-ray in 1 week. | d. | The child will require a bronchoscopy for follow-up evaluation in 1
month. |
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31.
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A nurse is caring for a hospitalized infant with a
diagnosis of bronchiolitis. The nurse positions the infant:
a. | With the head at a 60-degree angle with the neck
slightly flexed | b. | In a supine,
side-lying position | c. | With the head and
chest at a 30-degree angle, with the neck slightly extended | d. | Prone, with the head of the bed elevated 15
degrees |
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32.
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A nurse employed in an emergency department is
instructed to monitor a child diagnosed with epiglottitis. The nurse notes that the child is leaning
forward with the chin thrust out. The nurse interprets this finding as indicating:
a. | The presence of dehydration | b. | The presence of pain | c. | Extreme
fatigue | d. | An airway
obstruction |
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33.
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A nurse is preparing for the administration of
ribavirin (Virazole) to a child with respiratory syncytial virus. Which of the following supplies
will the nurse obtain for the administration of this medication?
a. | An intravenous (IV) pole | b. | An intramuscular (IM) syringe | c. | A pair of goggles | d. | A protective
isolation gown |
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34.
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A nurse is assisting in developing a plan of care
for a child who will be returning from the operating room following a tonsillectomy. The nurse plans
to place the child in which position on return from the operating room?
a. | Side-lying | b. | Trendelenburg’s and on the right side | c. | Supine | d. | High
Fowler’s and on the left side |
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35.
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A nurse is providing discharge instructions to the
mother of a child who had a myringotomy with insertion of tympanostomy tubes. The nurse instructs the
mother that if the tubes should fall out, she should:
a. | Contact the physician. | b. | Bring the child to the emergency department
immediately. | c. | Replace them
immediately. | d. | Immediately
immerse the tubes in half-strength hydrogen peroxide. |
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36.
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A 9-year-old child is diagnosed with chlamydial
conjunctivitis. The nurse consults with the primary health care provider regarding necessary
follow-up because this infection can be associated with:
a. | The presence of systemic
allergies | b. | The cleanliness of the home
environment | c. | The presence of
otitis media | d. | Possible sexual
abuse |
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37.
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A nurse is assigned to care for a child admitted to
the hospital with a diagnosis of suspected bacterial endocarditis. The nurse prepares the child for
which of the following diagnostic tests that will confirm the diagnosis?
a. | Blood cultures | b. | Chest x-ray | c. | Echocardiogram | d. | Transesophageal
echocardiography |
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38.
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A nurse is assisting in developing a plan of care
for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care,
the nurse suggests that the child should be monitored for signs of:
a. | Failure to thrive | b. | Bleeding | c. | Congestive heart
failure (CHF) | d. | Decreased
tolerance to stimulation |
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39.
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A nurse is reviewing the physician’s orders
for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that
acetylsalicylic acid (aspirin) is prescribed for the child. Which of the following nursing actions is
appropriate?
a. | Administer the aspirin if the child’s temperature
is elevated. | b. | Administer the
aspirin if the child experiences any joint pain. | c. | Consult with the registered nurse to verify the
prescription. | d. | Administer
acetaminophen (Tylenol) instead of the aspirin for temperature
elevation. |
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40.
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A nurse is assigned to care for an infant with
tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly
seems to be having difficulty breathing. The nurse enters the room and notes that the infant is
experiencing a hypercyanotic episode. The initial nursing action is to:
a. | Call a code. | b. | Contact the respiratory therapy department. | c. | Place the infant in a prone position. | d. | Place the infant in a knee-chest
position. |
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41.
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A nurse is caring for an infant with congenital
heart disease. Which of the following signs, if noted in the infant, would alert the nurse to the
early development of congestive heart failure (CHF)?
a. | Strong sucking reflex | b. | Slow and shallow breathing | c. | Pallor | d. | Diaphoresis during
feeding |
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42.
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A nursing student is assigned to care for an infant
with a diagnosis of congestive heart failure (CHF). The student develops a plan of care for the child
that is focused on monitoring for fluid overload. The student plans to best assess the urine output
of the infant by:
a. | Asking the physician for permission to insert a Foley
catheter | b. | Monitoring the intake closely | c. | Comparing the intake with the output | d. | Weighing the diapers |
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43.
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A nurse is caring for a child with congestive heart
failure and provides instructions to the mother regarding the procedure for administration of the
prescribed lanoxin (Digoxin). Which statement by the mother indicates a need for further
instruction?
a. | “If the child vomits after the medication is
given, I should not repeat the dose.” | b. | “I need to
take the child’s pulse before administering the medication.” | c. | “I can mix the medication with food.” | d. | “If more than one dose is missed, I need to call the
physician.” |
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44.
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A child with a right-to-left cardiac shunt is
receiving propranolol (Inderal). The physician visits the child and writes orders in the
child’s record. The licensed practical nurse (LPN) reviews the orders and notes that the child
is placed on a nothing-by-mouth (NPO) status. The LPN consults with the registered nurse and prepares
to monitor which of the following most closely?
a. | Blood urea nitrogen | b. | White blood cell count | c. | Sodium
level | d. | Glucose level |
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45.
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A nurse is collecting data on a child with a
diagnosis of rheumatic fever. Which of the following questions would the nurse initially ask the
mother of the child?
a. | “Has the child had any
diarrhea?” | b. | “Has the
child been vomiting?” | c. | “Does the
child complain of chest pain?” | d. | “Has the
child complained of a sore throat within the past few
months?” |
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46.
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A nurse is assisting in admitting to the hospital a
4-month-old infant with a diagnosis of vomiting and dehydration. The nurse assists in developing a
plan of care for the infant and suggests including in the plan to position the infant in
a(n):
a. | Prone position | b. | Side-lying position | c. | Modified
Trendelenburg’s position | d. | Infant car seat
with the head of the seat in a flat position |
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47.
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A nursing student is asked to administer a tepid
bath to a child with a fever. The student avoids which of the following when performing this
procedure?
a. | Squeezes water over the child’s body, using a
washcloth | b. | Applies alcohol-soaked cloths over the child’s
body | c. | Uses a water toy to distract the child during the
bath | d. | Places lightweight pajamas on the child after the
bath |
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48.
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A licensed practical nurse (LPN) is assigned to
assist in caring for a hospitalized child who is receiving a continuous infusion of intravenous (IV)
potassium for the treatment of dehydration. The LPN monitors the child closely and notifies the
registered nurse if which of the following is noted?
a. | Temperature of 100.8° F
rectally | b. | Weight increase of 0.5 kg | c. | A decrease in urine output to 0.5 mL/kg/hr | d. | Blood pressure (BP) unchanged from
baseline |
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49.
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A nursing instructor asks the nursing student to
plan and conduct a clinical conference on phenylketonuria (PKU). The student researches the topic and
plans to include which of the following in the conference?
a. | PKU is an autosomal dominant
disorder. | b. | PKU results in central nervous system (CNS)
damage. | c. | Some state laws require routine screening of all newborn
infants for PKU. | d. | Treatment includes
dietary restriction of sodium. |
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50.
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A female adolescent with type 1 diabetes mellitus
will become a member of the school’s football cheerleader team. The adolescent excitedly
reports to the school nurse to obtain information regarding adjustments needed in the treatment plan
for the diabetes. The school nurse would instruct the adolescent to:
a. | Eat six graham crackers or drink a cup of orange juice
before practice or game time. | b. | Eat half the
amount of food normally eaten at lunchtime. | c. | Take the
prescribed insulin one half hour before practice or game time rather than in the
morning. | d. | Take two times the amount of prescribed insulin on
practice and game days. |
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51.
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An adolescent with diabetes mellitus is attending
gym class and suddenly becomes flushed and complains of dizziness and a headache. The gym teacher
quickly takes the adolescent to the school nurse’s office. The nurse obtains a blood glucose
level, and the results indicate a level of 65 mg/dL. The appropriate initial nursing intervention is
to:
a. | Call the child’s mother for permission to treat
the child. | b. | Call the school
physician immediately. | c. | Let the child rest
until the blood glucose has an opportunity to rise. | d. | Give the child 6 oz of a regular cola
drink. |
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52.
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A nurse is caring for an infant who has been
diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests and
would expect to note which of the following?
a. | An elevated T4
level | b. | An elevated thyroid-stimulating hormone (TSH)
level | c. | A decreased TSH level | d. | A normal T4 level |
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53.
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A nurse is assisting in admitting a child who
arrived from the emergency department after treatment for acetaminophen (Tylenol) overdose. The nurse
reviews the child’s record and expects to note that the child received which of the following
for the acetaminophen overdose?
a. | Calcium disodium edetate
(EDTA) | b. | Protamine sulfate | c. | Epoetin alfa (Epogen) | d. | Acetylcysteine
(Mucomyst) |
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54.
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A nurse is monitoring a child who is receiving
calcium disodium edetate (EDTA) for the treatment of lead poisoning. The nurse reviews the laboratory
results of the child during treatment with this medication and is particularly concerned with
monitoring which laboratory test result?
a. | Blood urea nitrogen | b. | Hemoglobin and hematocrit (H&H) level | c. | Complete blood cell (CBC) count | d. | Cholesterol level |
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55.
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A nurse is collecting data on an infant with a
diagnosis of suspected Hirschsprung’s disease. Which of the following questions to the mother
will most specifically elicit information regarding this disorder?
a. | “Does your infant have foul-smelling, ribbon-like
stools?” | b. | “Is your
infant constantly vomiting?” | c. | “Does your
infant constantly spit up feedings?” | d. | “Does your
infant have diarrhea?” |
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Multiple Response
Identify one
or more choices that best complete the statement or answer the question.
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56.
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A nurse is assisting in preparing a plan of care
for a child who is being admitted to the pediatric unit with a diagnosis of seizures. Which of the
following would be a component of the plan of care? Select all that apply.
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57.
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A nursing student is preparing a clinical
conference, and the topic of the discussion is caring for the child with cystic fibrosis (CF). The
student prepares a handout for the group and lists which of the following on the handout? Select all
that apply.
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