Multiple Choice
Identify the
choice that best completes the statement or answers the question.
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1.
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A nursing student caring for a 6-month-old infant
is asked to collect a urine specimen from the infant. The student collects the specimen
by:
a. | Attaching a urinary collection device to the
infant’s perineum for collection | b. | Obtaining the
specimen from the diaper by squeezing the diaper after the infant voids | c. | Catheterizing the infant using the smallest available French Foley
catheter | d. | Noting the time of the next expected voiding and
preparing to collect the specimen into a cup when the infant
voids |
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2.
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A nurse is collecting data on a child recently
diagnosed with glomerulonephritis. Which of the following questions to the mother would elicit
information about the cause of this disease?
a. | “Did your child sustain any injuries to the kidney
area?” | b. | “Did your
child recently complain of a sore throat?” | c. | “Has your child had any diarrhea?” | d. | “Have you noticed any rashes on your
child?” |
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3.
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A nurse caring for a child with nephrotic syndrome
reviews the medication record. The nurse notes that prazosin hydrochloride (Minipress) is prescribed
for the child. The nurse determines that this medication has been prescribed to:
a. | Reduce proteinuria | b. | Decrease inflammation | c. | Suppress the
autoimmune response | d. | Control
hypertension |
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4.
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A nurse is assisting in planning discharge
instructions to the mother of a child following orchiopexy, which was performed on an outpatient
basis. Which of the following is the priority in the plan of care?
a. | Pain control measures | b. | Measurement of intake | c. | Wound
care | d. | Cold and heat
applications |
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5.
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A nurse has provided discharge instructions to the
mother of an 18-month-old child following surgical repair of hypospadias. Which statement by the
mother indicates a need for further instruction?
a. | “I should carry my child by straddling the child
on my hip.” | b. | “I should
use double diapers to hold the surgery site in place.” | c. | “I should avoid toilet training right
now.” | d. | “I should
encourage fluid intake.” |
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6.
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A nursing instructor is observing a nursing student
caring for an infant with a diagnosis of bladder exstrophy. The nursing student provides appropriate
care to the infant by:
a. | Covering the bladder with a dry sterile
dressing | b. | Covering the bladder with a wet-to-dry
dressing | c. | Applying sterile water soaks to the bladder
mucosa | d. | Covering the bladder with a nonadhering plastic
wrap |
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7.
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A nurse is assisting in developing a plan of care
for a 10-year-old child diagnosed with acute glomerulonephritis. Following review of the plan of
care, the nurse determines that which of the following is the priority for the child?
a. | Restricting oral fluids | b. | Allowing the child to play with the other children in the
playroom | c. | Promoting bedrest | d. | Encouraging visits from friends |
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8.
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A nurse is providing information to the mother of a
child with nephrotic syndrome regarding the edematous appearance of the child. Which of the following
statements should the nurse make to the mother?
a. | “Dress the child in loose-fitting clothing to hide
the extra weight.” | b. | “Children
always look a little bit fat, so don’t be concerned.” | c. | “The fluid retention should be controlled by medication and
diet.” | d. | “The child
will always have this appearance, and preparing the child for the body image change is
important.” |
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9.
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A nurse is providing instructions to a mother of a
child with atopic dermatitis (eczema) regarding the application of topical cortisone cream to the
affected skin sites. Which of the following statements, if made by the mother, indicates an
understanding of the use of this medication?
a. | “I need to wash the sites gently before I apply
the medication.” | b. | “The
medication is applied everywhere except the face.” | c. | “I need to apply the medication generously and allow it to
absorb.” | d. | “I
shouldn’t rub the medication into the skin.” |
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10.
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A nurse in a physician’s office receives a
telephone call from the mother of a child who tells the nurse that the child was just stung by a bee.
The mother asks the nurse for instructions regarding removal of the stinger. Which of the following
instructions should the nurse provide to the mother?
a. | Leave the stinger alone because it will
dissolve. | b. | Squeeze the stinger out of the
skin. | c. | Remove the stinger by carefully scraping it out
horizontally. | d. | Wash the area with
soap and water and apply heat to help the stinger move out of the
skin. |
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11.
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A camp nurse is providing instructions to the
parents of the children who are attending a daytime camp for the summer. The nurse instructs the
parents to check their child daily for the presence of tick bites and tells the parents if a tick is
found to first:
a. | Remove the tick with a sterilized sewing
needle. | b. | Bring the child to the emergency department at the
nearest hospital. | c. | Suffocate the tick
with a substance such as nail polish. | d. | Remove the tick
with tweezers immediately. |
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12.
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A 5-week-old infant is brought to the well-baby
clinic by the mother because the mother has noted white patches in the infant’s mouth.
Following assessment, the infant is diagnosed with oral candidiasis (thrush). Nystatin oral
suspension is prescribed. The mother is concerned because she is breast-feeding the infant and asks
the nurse if breast-feeding can be continued. Which of the following responses is
appropriate?
a. | “Breast-feeding must be stopped
immediately.” | b. | “Breast-feeding can continue, but your breasts should also be treated
with nystatin.” | c. | “You should
bottle-feed the infant for 1 week and then resume breast-feeding.” | d. | “You will need to take the oral nystatin also because the infant
probably contracted the infection from you.” |
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13.
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A mother brings her child to the health care clinic
because the child has developed lesions located around the mouth and nose, and mild impetigo is
diagnosed. The nurse provides instructions to the mother regarding care of the child. Which statement
by the mother indicates the need for further instructions?
a. | “The impetigo is extremely
contagious.” | b. | “The lesions
should be washed gently three times a day with a warm, soapy
washcloth.” | c. | “The crusts
on the lesions need to be soaked and carefully removed.” | d. | “My child will need to be treated with oral
antibiotics.” |
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14.
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A child is diagnosed with tinea capitis of the
scalp. Oral griseofulvin (Gris-PEG) has been prescribed for the child, and the nurse provides
instructions regarding the administration of the medication. Which of the following instructions
would the nurse provide to the mother?
a. | Administer the medication with
water. | b. | Administer the medication on an empty
stomach. | c. | Administer the medication at
bedtime. | d. | Administer the medication with
milk. |
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15.
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A nurse is caring for a child who was burned in a
house fire. The nurse assists in developing a plan of care for monitoring the child during the
treatment for burn shock. The nurse identifies which of the following assessments as providing the
most accurate guide to determine the adequacy of fluid resuscitation?
a. | Level of consciousness | b. | Amount of edema at the site of the burn injury | c. | Heart rate | d. | Lung
sounds |
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16.
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A 4-year-old child is being transported to the
trauma center from a local community hospital for treatment of a burn injury that is estimated as
covering over 40% of the body. The burns are both partial- and full-thickness burns. The nurse is
asked to prepare for the arrival of the child and gathers supplies anticipating that which of the
following will be prescribed initially?
a. | Insertion of a nasogastric
tube | b. | Insertion of a Foley catheter | c. | Administration of an anesthetic agent for sedation | d. | Application of an antimicrobial agent to the
burns |
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17.
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A nurse provides instructions to the mother of a
child diagnosed with pediculosis (head lice). Permethrin (Nix) has been prescribed. Which statement
by the mother regarding the use of the medication indicates a need for further
instructions?
a. | “After rinsing out the medication, I need to avoid
washing my child’s hair for 24 hours.” | b. | “I need to shampoo my child’s hair, apply the medication, leave it
on for 10 minutes, and then rinse it out.” | c. | “I need to shampoo my child’s hair, apply the medication, and
leave the medication on for 24 hours.” | d. | “I need to
purchase the medication from the pharmacy.” |
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18.
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A nurse is reviewing the health care record of an
infant suspected of having unilateral hip dysplasia. Which assessment finding would the nurse expect
to note documented in the infant’s record regarding this condition?
a. | Asymmetric adduction of the affected hip when placed
supine with the knees and hips flexed | b. | Asymmetry of the
gluteal skin folds when the infant is placed prone and the legs are extended against the examining
table | c. | An apparent short femur on the unaffected
side | d. | Full range of motion in the affected
hip |
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19.
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A child is brought to the emergency department, and
a fracture of the left lower arm is suspected. The mother states that the child was Rollerblading and
attempted to break a fall with an outstretched arm. The child receives diagnostic x-rays, from which
it has been determined that a fracture is present. A plaster of paris cast is applied to the arm, and
the nurse provides instructions to the mother regarding cast care at home. Which of the following
instructions would the nurse provide to the mother?
a. | The cast should be dry in about 6
hours. | b. | The cast is water resistant, so the child is able to
take a bath or a shower. | c. | The cast will not
mold to the body and should heal the fracture in no time at all. | d. | The cast needs to be kept dry, because when wet it will begin to
disintegrate. |
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20.
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A nurse is monitoring the child with a cast on the
forearm for signs of compartment syndrome. The nurse understands that which data collection technique
is unlikely to provide information about this complication?
a. | Checking the quality of the radial
pulse | b. | Checking the child’s ability to extend the
fingers | c. | Checking for effectiveness of analgesics administered
for pain | d. | Checking the child’s ability to perform range of
motion to the shoulder area of the affected extremity |
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21.
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An adolescent is seen in the emergency department
following an athletic injury, and it is suspected that the child sprained an ankle. X-rays are taken,
and a fracture has been ruled out. The nurse provides instructions to the adolescent regarding home
care for treatment of the sprain and tells the adolescent which of the following?
a. | Apply ice to the injured area for a period of 30 minutes
every 4 to 6 hours for the first 24 hours. | b. | Apply heat to the
injured area every 4 hours for the first 48 hours, then begin to apply
ice. | c. | Immobilize the extremity and maintain the extremity in a
dependent position. | d. | Elevate the
extremity and maintain strict bedrest for a period of 7 days. |
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22.
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A nurse provides instructions to the parents of an
infant with hip dysplasia regarding care of the Pavlik harness. Which statement, if made by one of
the parents, indicates an understanding of the use of the harness?
a. | “I need to remove the harness to feed my
infant.” | b. | “I need to
remove the harness to change the diaper.” | c. | “My infant
needs to remain in the harness at all times.” | d. | “I can remove the harness to bathe my
infant.” |
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23.
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A nurse is providing instructions to the mother of
a child with juvenile idiopathic arthritis regarding measures to take if a painful exacerbation of
the disease occurs. Which statement by the mother indicates the need for further
instructions?
a. | “The full range-of-motion [ROM]
exercises must be performed every day, even during the
exacerbations.” | b. | “Hot or cold
packs will assist in reducing discomfort.” | c. | “The painful joint should be splinted and positioned in a neutral
position.” | d. | “I should
have my child perform simple isometric exercises during
exacerbations.” |
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24.
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A nurse is caring for a child with a fracture who
is placed in skeletal traction. The nurse monitors for the most serious complication associated with
this type of traction by checking for:
a. | An increase in the blood
pressure | b. | A decrease in the urinary
output | c. | A lack of appetite | d. | An elevated temperature |
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25.
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A 4-year-old child sustains a fall at home and is
brought to the emergency department by the mother. Following x-ray examination, it has been
determined that the child has a fractured arm, and a plaster cast is applied. The nurse provides
instructions to the mother regarding cast care for the child. Which statement by the mother indicates
a need for further instructions?
a. | “The cast will feel warm when it is
dried.” | b. | “If the cast
becomes wet, a fan may be used to dry the cast.” | c. | “I need to call the physician if any blood or drainage appears on the
cast.” | d. | “I can apply
ice to the casted area to prevent swelling.” |
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26.
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A nurse is collecting data on a 12-month-old child
with iron deficiency anemia. Which of the following findings would the nurse expect to note in this
child?
a. | Bradycardia | b. | Tachycardia | c. | Hyperactivity | d. | A reddened
appearance to the cheeks |
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27.
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Oral iron is prescribed for a child with an iron
deficiency anemia, and the nurse provides instructions to the mother regarding the administration of
the iron. The nurse instructs the mother to administer the iron:
a. | Just before a meal | b. | Just after a meal | c. | Between
meals | d. | With a fruit low in vitamin
C |
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28.
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A nurse is reviewing the laboratory results of a
child with aplastic anemia and notes that the white blood cell (WBC) count is 2000/mL and the platelet count is 150,000/mm3. Which of the following
nursing interventions will the nurse incorporate into the plan of care?
a. | Maintain strict isolation
precautions. | b. | Encourage the
child to use a soft toothbrush. | c. | Avoid unnecessary
injections. | d. | Encourage quiet
play activities. |
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29.
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A nursing student is assigned to care for a child
with hemophilia. The nursing instructor reviews the plan of care with the student and asks the
student to describe the characteristics of this disorder. Which statement by the student indicates a
need for further research?
a. | Hemophilia is inherited in a recessive manner via a
genetic defect on the X chromosome. | b. | Males inherit
hemophilia from their fathers. | c. | Females inherit
the carrier status from their fathers. | d. | Hemophilia A
results from deficiency of factor VIII. |
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30.
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A nurse is caring for a child following surgical
removal of a brain tumor. The nurse is monitoring the child and notes that the pulse rate has
increased and the blood pressure has dropped significantly. Bloody drainage is also noted on the
posterior dressing. The initial nursing action is to:
a. | Notify the registered nurse
(RN). | b. | Document the findings. | c. | Recheck the vital signs in 1 hour. | d. | Place the child in Trendelenburg’s
position. |
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31.
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A nurse is assisting in preparing to care for a
child with a brain tumor who will be returning from the recovery room following debulking of the
tumor. Which of the following items will the nurse place at the bedside in preparation for the
child’s return from surgery?
a. | A suction machine | b. | A cooling blanket | c. | Protective
isolation equipment | d. | Skeletal traction
equipment |
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32.
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A nurse has reviewed the physician’s orders
for a child suspected of a diagnosis of neuroblastoma and is preparing to implement diagnostic
procedures that will confirm the diagnosis. The nurse prepares to:
a. | Collect a 24-hour urine
sample. | b. | Perform a neurological
assessment. | c. | Send the child to
the radiology department for a chest x-ray. | d. | Assist with a bone
marrow aspiration. |
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33.
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A nurse is asked to prepare for the admission of a
child to the pediatric unit with a diagnosis of Wilms’ tumor. The nurse assists in developing a
plan of care for the child and suggests including which of the following in the plan of
care?
a. | Palpate the abdomen for an increase in the size of the
tumor every 8 hours. | b. | Inspect the urine
for the presence of hematuria at each voiding. | c. | Monitor the
temperature for hypothermia. | d. | Monitor the blood
pressure for hypotension. |
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34.
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A nurse is monitoring the laboratory values of a
child with leukemia who is receiving chemotherapy. The nurse prepares to implement bleeding
precautions if the child becomes thrombocytopenic and the platelet count is less than:
a. | 20,000/mm3 | b. | 100,000/mm3 | c. | 120,000/mm3 | d. | 150,000/mm3 |
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35.
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A nurse is preparing to care for a child who
received an allogenic bone marrow transplant (BMT). The nurse understands that which of the following
is the priority concern?
a. | Bleeding | b. | Infection | c. | Sensory
alterations | d. | Social
isolation |
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36.
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A nurse is caring for a child with osteosarcoma
following amputation of the left lower limb. The child is continually complaining of aching and
cramping in the missing limb. The initial nursing action is which of the following?
a. | Request a referral for a psychiatric
consultation. | b. | Ask the physician
for an order for a placebo. | c. | Reassure the child
that this is a temporary condition. | d. | Tell the child
that the prosthesis will relieve this sensation. |
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37.
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A child is seen in the health care clinic and
received an immunization of DPT (diphtheria, pertussis, tetanus vaccine). One hour later, the mother
calls the clinic and tells the nurse that the injection site is painful and red. Which of the
following instructions would the nurse provide to the mother?
a. | To return to the health care clinic
immediately | b. | To call the
physician | c. | To apply warm compresses on the
site | d. | To apply cold compresses for 24 hours following the
injection |
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38.
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A nurse is preparing to administer a measles,
mumps, rubella (MMR) vaccine to a 15-month-old child. Before administering the vaccine, which of the
following questions would the nurse ask the mother of the child?
a. | “Is the child allergic to any
antibiotics?” | b. | “Has the
child had any sore throats?” | c. | “Has the
child been eating properly?” | d. | “Has the
child been exposed to any infections?” |
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39.
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A nurse of a well-baby clinic prepares to
administer an immunization to a child. The mother of the child tells the nurse that the child has had
a fever and is taking antibiotics. The nurse takes the child’s temperature and notes that it is
101.5° F rectally. The nurse plans to implement which of the following?
a. | Administer the immunization. | b. | Delay the immunization. | c. | Administer one
half of the prescribed dose of each scheduled immunization. | d. | Administer one of the three scheduled
immunizations. |
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40.
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A nursing student is assisting the clinic nurse
with the administration of immunizations in the well-baby clinic. The student is asked to administer
a measles, mumps, and rubella (MMR) vaccine to a child and prepares to administer the
vaccine:
a. | Subcutaneously in the gluteal
muscle | b. | Subcutaneously in the upper
arm | c. | Intramuscularly in the deltoid
muscle | d. | Intramuscularly in the
thigh |
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41.
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An adolescent is seen in the health care clinic
with complaints of chronic fatigue. On physical examination, the nurse notes that the adolescent has
swollen lymph nodes. A laboratory test is performed, and the results indicate the presence of
Epstein-Barr virus (mononucleosis). The nurse calls the mother of the adolescent to inform the mother
of the test results and provides instructions regarding the care of the adolescent. Which statement
by the mother indicates an understanding of the care measures?
a. | “I need to keep my child on bedrest for 3
weeks.” | b. | “I will call
the physician if my child is still feeling tired in 1 week.” | c. | “I need to call the physician if my child complains of abdominal pain or
left shoulder pain.” | d. | “I need to
isolate my child so that the respiratory infection is not spread to
others.” |
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42.
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In preparing to care for a hospitalized child with
a diagnosis of measles (rubeola), which supplies would the nurse bring to the child’s room to
prevent the transmission of the virus?
a. | Mask and gloves | b. | Gown and gloves | c. | Goggles and
gloves | d. | Gown, gloves, and
goggles |
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43.
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A nurse is caring for a child with a diagnosis of
roseola. The nurse provides instructions to the mother regarding preventing the transmission of the
infection to the other children in the family and the other household members and tells the mother
which of the following?
a. | Isolate the child from others because the virus is
transmitted by breathing and coughing. | b. | Wash sheets and
towels used by the child separately in bleach to prevent the spread of the infection to the
others. | c. | Have the child use a separate bathroom for urination and
bowel movements to prevent the spread of infection through the urine and
feces. | d. | Avoid allowing the children to share drinking glasses or
eating utensils because the disease is transmitted through the
saliva. |
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44.
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A nurse is reviewing the immunization schedule for
a child with human immunodeficiency virus (HIV) infection with the mother. Which of the following
will be a component of the instructions that the nurse provides to the mother?
a. | The immunization schedule needs to altered because of
the HIV infection. | b. | No live virus
vaccines should be administered to the child. | c. | Immunizations will
not be given to the child with HIV infection. | d. | Immunizations will
be given to the child with HIV infection but will not be initiated until the child is 3 years
old. |
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45.
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A nurse is providing instructions to the mother of
a child who has been exposed to human immunodeficiency virus (HIV) infection. The nurse instructs the
mother to notify the physician if which of the following symptoms occur in the child?
a. | Lethargy or fatigue | b. | Hyperactivity | c. | Coughing or chest
congestion | d. | Irritability and
fussiness |
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Multiple Response
Identify one
or more choices that best complete the statement or answer the question.
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46.
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A nurse is collecting data from a child suspected
of having juvenile idiopathic arthritis (JIA). Which findings would the nurse expect to note if JIA
were present? Select all that apply.
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47.
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A 6-year-old child with leukemia is hospitalized
and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic,
and the nurse prepares to implement protective isolation procedures. Which interventions would the
nurse initiate? Select all that apply.
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48.
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A CD4+ count has been ordered for a child with
human immunodeficiency virus (HIV) infection. The mother asks the nurse about the purpose of the test
and why the test needs to be done if it is already known that the child has HIV. The nurse should
provide which information to the mother? Select all that apply.
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