問題一覧
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1. The nurse is caring for a child who has leukemia with a white blood cell (WBC) count of < 1000 mm. Which of the following should the nurse include in the child’s plan of care?
a. Administer prescribed influenza vaccination
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2. The nurse is providing a teaching session to the health care staff regarding osteosarcoma. Which of the following statements by an attendee indicates a need for additional teaching?
d. “In the early stage, the symptoms of this disease are usually attributed to normal growing pains.” bone cancer antibiotics
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3. The nurse is caring for a child who is suspected of having a Wilm’s tumor. Which of the following actions by the nurse indicates the need for additional training?
d. Palpating the child’s abdomen.
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4. The nurse is caring for a 5-year-old child who has sickle cell disease (SCD). An assessment of the child includes the following: respirations 10 and unarousable. The child is currently on intravenous (IV) fluids and continuous IV morphine sulfate Based on the assessment information, which of the following actions should the nurse take first?
d. Administer naloxone to reverse the effect of the morphine.
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5. The nurse is admitting a child who has a vaso-occlusive sickle cell crisis. Which of the following interventions should the nurse anticipate to be prescribed for the child?
c. Hydration and pain management.
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6. The nurse working in the emergency department (ED) is caring for a child who has hemophilia and developed a swollen knee after falling off a bicycle. The nurse is teaching the child’s parents about care when similar incidents occur at home in the future. Which of the following actions should the nurse teach the parents?
c. Apply an ice pack and compression dressings to the knee.
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7. The newly hired nurse is talking with the nurse preceptor about the prevention of iron- deficiency anemia in infants. Which of the following statements by the newly hired nurse is correct regarding prevention of this condition?
c. “Iron-fortified commercial formula should be given for the first 6 months of life.”
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8. The nurse is assessing a child who has severe iron deficiency anemia. Which of the following assessment finds should the nurse expect to observe?
a. Pallor.
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9. The nurse is caring for 4-year-old child who is 36 hours postoperative following a removal of a Wilm’s tumor. Which of the following requires immediate follow up by the nurse?
d. Incision site is pink at the edges.
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10. The nurse is providing discharge instructions to the parents of a child who had surgical resection of a neuroblastoma 4 days ago. Which of the following statements by the parents indicates teaching has been effective?
b. “We will provide pain relief using pain medication and rest.”
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11. The nurse is caring for a child who has increased intracranial pressure (ICP) and is in stable condition. Which of the following interventions should the nurse implement to decrease ICP in the child?
a. Limit number of visitors inside the child’s room.
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12. The nurse is caring for a child who has Reye’s syndrome. Which of the following should the nurse include in the child’s plan of care?
b. Provide the child a quiet atmosphere with dimmed lighting.
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13. The nurse is caring for a child who is suspected of having bacterial meningitis. The results of the lumbar puncture are still pending. Which of the following actions by the nurse is the priority?
c. Assessing neurological status every 2-4 hours. antibiotics increased ICP
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14. The nurse is screening infants for early warning signs of cerebral palsy. Which of the following should the nurse recognize as 1 of the early warning signs of cerebral palsy?
c. Poor head control.
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15. The nurse is assessing a 6-year-old for manifestations of autism spectrum disorder. Which of the following manifestations should the nurse expect to observe in this child?
c. Monotone speech.
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16. The nurse is developing a plan of care for a child diagnosed with attention-deficit hyperactivity disorder (ADHD). Which of the following information should the nurse include in the plan of care?
b. Psychostimulant medications and behavior modification.
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17. The nurse preceptor is observing a newly hired nurse care for a child who has Down syndrome. Which of the following manifestations, if documented by the newly hired nurse, requires follow up by the nurse preceptor?
large stature for chronological age correct: short stature Protruding tongue hyper flexibility hypotonicity low birth weight
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18. The nurse is caring for a child who had a ventricular shunt placement 24 hours ago. The child is sitting up in bed crying and has vomited a small amount on the bed linens. Which of the following actions should the nurse take first?
d. Complete a neurological assessment.
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19. The nurse working in the emergency department (ED) is caring for a 2-month-old child who presents with intraocular bleeding, bradycardia, and bulging fontanels, but no trauma to the head, face, or neck. Health history and physical examination is incongruent, and abuse is suspected. Which of the following actions should the nurse perform?
b. Notify child protective services (CPS).
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20. The nurse is caring for a child who is hospitalized for 24-hour observation following a head injury. Which of the following actions by the nurse is the priority?
b. Checking pupil reaction every 4 hours.
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21. The nurse is assessing a child in a coma and notes that the child has decorticate posturing. Which of the following findings should the nurse expect the child to demonstrate?
c. Rigid flexion with elbows, wrists and fingers flexed, and legs extended and rotated inward.
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22. The nurse is admitting a toddler who is being hospitalized following a near-drowning accident/submersion injury. The child’s mother states to the nurse, “This is unnecessary. My child seems perfectly fine.” What is an appropriate response for the nurse to provide to the mother?
a. “Complications can still occur with your child.” monitor for 6-8 hrs
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23. The nurse is caring for an infant who is having an active seizure. Which of the following actions should the nurse perform when caring for the infant during a seizure?
d. Remove any items out of the crib that can harm the infant.
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24. The nurse is caring for an infant with a myelomeningocele sac. Which of the following interventions demonstrates appropriate care for the infant?
b. Use latex-free medical products. prone position keep moist no diaper
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25. The school nurse is instructing a school-age child who has diabetes mellitus (type 1). The child participates in soccer practice 3 afternoons a week. Which of the following statements by the child indicates a correct understanding of how to prevent hypoglycemia during practice?
d. “I will eat a small box of raisins or a cup of juice before soccer practice.”
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26. The nurse is preparing discharge instructions for a child who has precocious puberty. Which of the following should the nurse include in the teaching?
a. Explain the importance for the child to have peers of the same age.
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27. The nurse is teaching a 10-year-old child and the parents about scoliosis and treatment options. Which of the following should the nurse include when teaching about scoliosis?
a. Use of a brace will slow the progression of scoliosis for most clients.
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28. The nurse is caring of a 12-year-old child who has acute osteomyelitis in the right foot. The child’s parents ask the nurse if the child can go to the activity room. Which of the following responses should the nurse reply to the parents?
b. “Let me get wheelchair for your child to help keep the foot supported.” bone infection
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29. The nurse working in a community clinic is teaching the mother of an infant who was recently diagnosed with congenital hypothyroidism. Which of the following instructions should the nurse give the mother about the administration of prescribed levothyroxine?
c. “Give the medication one hour after a feeding.” take on empty stomach
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30. The nurse is preparing to teach a parent about how to care for a child who has impetigo contagiosa. Which of the following should the nurse include in the teaching plan?
a. Apply bactericidal ointment to lesions. remove yellow stuff first
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31. The nurse working in a clinic is instructing the parent of a child who has atopic dermatitis (eczema) about the administration of a prescribed topical corticosteroid. When instructing the parent about how to apply the cream, it is appropriate for the nurse to instruct the parent to apply
b. The cream to the affected area after cleansing with water.
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32. The school nurse is teaching parents about pediculosis capitis (lace). Which of the following should the nurse include in the teaching plan?
d. Children should be instructed to refrain from sharing headbands with others.
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33. A nurse is admitting an infant diagnosed with phenylketonuria (PKU). Which of the following should the nurse consider when planning care for this infant?
b. Providing teaching about a low-phenylalanine diet.
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34. The nurse is caring for a 5-year-old child who has been bitten on the leg by a dog. After cleansing the area with soap and water, which of the following actions should the nurse take next?
c. Report the bite to the local health department.
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35. The nurse is teaching the parent of a toddler about insect bites. Which of the following statements by the parents indicates an understanding of the teaching? “If my child ever gets stung by a bee, I will
d. Remove the stinger immediately.”
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36. The nurse is caring for the following assigned clients. Which client should the nurse follow up with first?
c. The client who is in skeletal traction and has warmth, redness, and pain in the affected leg.
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37. A nurse is caring for a child who has a new cast and is at risk for compartment syndrome. Which of the following manifestations should the nurse monitor with this child?
c. Paresthesia.
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38. The nurse is caring for an infant who is undergoing serial casting for the correction of clubfoot and has had the initial cast applies. Which of the following actions should the nurse teach the parents?
d. Perform neurovascular checks every 2 hours. pain, poikilothermia, paresthesia, paralysis, pulselessness, and pallor.
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39. The nurse is caring for a child who is diagnosed with severe scoliosis. Which of the following prescriptions should the nurse expect to be ordered?
b. A referral to an orthopedic surgeon for surgery.
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40. The nurse manager is providing an in-service to nursing staff about juvenile idiopathic arthritis (JIA). Which of the following statements by a staff member indicates a need for additional teaching?
b. “JIA tends to disappear after age 15.”
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41. The nurse is giving discharge instructions to the parents of an infant in a Pavlik harness. Which of the following statements by a parent indicates the need for further instructions?
d. “I will loosen the straps when bathing my infant so all areas of the skin can be cleansed.”
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42. The nurse is teaching parents of a 2-year-old child who has a hip Spica cast about care management when discharged home. Which of the following statements by the parents indicates a need for further teaching?
a. “Our child can stand in the cast while we support them.”
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43. The nurse is caring for an adolescent with a fracture. Which of the following nursing interventions is a priority?
d. Encourage peer visitation.
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44. The nurse is caring for a client who has a fracture of the right femur with a newly applied cast. Which of the following assessment findings should the nurse report to the primary health care provider (PHCP) immediately?
a. An unrelenting pain that is unrelieved by pain medication.