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    Exam Review

    1. A nurse is collecting data from an infant who hit her head when she fell off of a dressing table. The nurse should identify which of the following findings as indicating increased intracranial pressure?
      A)
      Brisk pupillary reaction to light
      B)
      Irritability
      C)
      Tachycardia
      D)
      Increased sensory response to painful stimuli
    2. A nurse is caring for a child who has juvenile rheumatoid arthritis. Which of the following actions should the nurse take?
      A)
      Maintain night splints to the affected joint.
      B)
      Encourage the child to take daytime naps.
      C)
      Administer opioids on a schedule.
      D)
      Apply cool compresses for 20 min every hour.
    3. A nurse is caring for an adolescent. The nurse should expect that the adolescent is working on which of the following developmental tasks?
      A)
      Defining a sense of self
      B)
      Learning to perform tasks independently
      C)
      Learning to use creative energies
      D)
      Building a sense of trust
    4. A nurse is collecting data from a 4-year-old child. Which of the following findings should the nurse expect?
      A)
      Heart rate 110/min
      B)
      Capillary refill greater than 3 seconds
      C)
      Weight gain of 0.9 kg (2 lb) in a year
      D)
      Respiratory rate 32/min
    Page 1 of 19

    Exam Review

    1. A nurse is providing teaching about Iron deficiency anemia to the parents of a 14-month-old. Which of the following should the nurse recommend as a method of preventing iron deficiency anemia?
      A)
      Avoid a diet consisting of primarily milk.
      B)
      Include whole grains and legumes in the diet.
      C)
      Administer fat-soluble vitamins daily.
      D)
      Limit intake of high-protein foods.
    2. A nurse is preparing to administer ear drops to a 2-year-old toddler who has an ear infection and a small amount of purulent drainage visible around the ear. Which of the following techniques should the nurse use when instilling the medication?
      A)
      Firmly push a cotton ball into the ear canal after instilling drops.
      B)
      Pull the child's ear auricle upward and outward just before instilling drops.
      C)
      Apply clean gloves and clean the outer ear prior to instilling drops.
      D)
      Warm the medication container for 10 seconds in a microwave oven prior to installation.
    3. A nurse is reinforcing teaching with the parents of an 8-month-old infant who will be admitted for surgery. Which of the following instructions should the nurse include in the teaching?
      A)
      "You should bring the infant's favorite blanket to the hospital."
      B)
      "You should begin to manipulate the infant's bedtime based on the hospitals visiting hours."
      C)
      "You should read the child a story about hospitalization."
      D)
      "You will need to go home when it is not visiting hours."
    4. A nurse is caring for a 7-year-old client who has an upper respiratory infection and a history of type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction?
      A)
      "I will notify the doctor if his temperature is not controlled with acetaminophen."
      B)
      "I will continue to check his blood sugar two times every day."
      C)
      "I will report a change in breathing or signs of confusion."
      D)
      "I will encourage him to drink a half a cup of water or sugar-free fluid every 30 minutes."
    Page 2 of 19

    Exam Review

    1. A nurse is caring for a school-age child who has a fracture to the right femur. Which of the following findings is the nurse's priority?
      A)
      Capillary refill less than 2 seconds
      B)
      Tingling in the right foot
      C)
      2+ right pedal pulse
      D)
      Respiratory rate 24/min
    2. A nurse is reinforcing discharge teaching with the parent of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent requires a clarification of the teaching?
      A)
      "Sweating can occur with hypoglycemia."
      B)
      "My son might have nausea and vomiting with hypoglycemia."
      C)
      "My son might complain of feeling shaky when he has a low blood glucose level."
      D)
      "The onset of low blood glucose usually occurs rapidly."
    3. A nurse is caring for a client who is postoperative immediately following a tonsillectomy. Which of the following snacks should the nurse offer the client?
      A)
      Lime ice pop
      B)
      Cranberry juice
      C)
      Ice cream
      D)
      Hot tea
    4. A nurse is caring for an infant who is dehydrated and requires IV therapy. The nurse should monitor the infant's response to therapy by performing which of the following actions?
      A)
      Taking the infant's vital signs every 2 hr
      B)
      Counting the number of wet diapers every shift
      C)
      Weighing the infant at the same time every day
      D)
      Measuring the infant's head circumference twice per day
    Page 3 of 19

    Exam Review

    1. A nurse is assisting with the admission of a 2-year-old toddler who has acute gastroenteritis. Which of the following actions should the nurse take first?
      A)
      Determine if the toddler is voiding.
      B)
      Request evaluation of the toddler's serum electrolytes.
      C)
      Initiate isotonic fluids with 20 mEq/L potassium chloride.
      D)
      Collect a stool sample from the toddler.
    2. A nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse administer first?
      A)
      Methylprednisolone
      B)
      Montelukast
      C)
      Albuterol
      D)
      Fluticasone
    3. A nurse is caring for an adolescent client who is receiving carbamazepine (Tegretol) for partial seizure disorder. Which of the following statements by the adolescent's parent is the priority for the nurse to address?
      A)
      "He takes his medication between meals with water."
      B)
      "He only sleeps about 5 hours each night."
      C)
      "He seems to be getting a lot more bumps and bruises lately."
      D)
      "He has not been eating as much lately."
    4. A nurse is preparing a 9-year-old child for an IV catheter insertion. Which of the following actions should the nurse take first?
      A)
      Ask the child what he knows about the procedure.
      B)
      Allow the child to see and touch IV tubing and supplies.
      C)
      Describe the procedure using visual aids.
      D)
      Explain to the child's parents what role they will have during the procedure.
    Page 4 of 19

    Exam Review

    1. A nurse is collecting data from a 5-month-old infant who has increased intracranial pressure (ICP) resulting from hydrocephalus. Which of the following manifestations should the nurse expect?
      A)
      Low-pitched cry
      B)
      Positive Babinski reflex
      C)
      Insomnia
      D)
      Bulging fontanel
    2. A nurse is caring for a 4-year-old child who has dehydration. Which of the following findings should the nurse identify as the priority?
      A)
      Sodium 142 mEq/L
      B)
      Urine specific gravity 1.025
      C)
      Potassium 2.5 mEq/L
      D)
      Blood glucose 110 mg/Dl
    3. A nurse is caring for a child following an open reduction and internal fixation of a fractured femur and application of a cast. The cast has a window cut in it for viewing of the incision. Which of the following actions should the nurse take first?
      A)
      Remove the window and view the incision.
      B)
      Medicate the client for pain.
      C)
      Perform neurovascular checks of the affected extremity.
      D)
      Turn the client so the cast will dry on all sides.
    4. A nurse is preparing a 4-year-old child for discharge following a bilateral myringotomy with tympanostomy tube placement. The mother asks what to do if the tubes fall out. The nurse should give the parent which of the following instructions?
      A)
      Gently reinsert the tubes.
      B)
      Call the health care clinic to report that the tubes have fallen out.
      C)
      Reassure the mother that the tubes will not fall out.
      D)
      Take the child to an emergency department.
    Page 5 of 19

    Exam Review

    1. A nurse is assisting with the care of a school-age child who has respiratory failure due to pneumonia. Which of the following positions should the nurse encourage to allow maximal lung expansion?
      A)
      Supine
      B)
      Prone
      C)
      Upright
      D)
      Side-lying
    2. A nurse in a clinic is preparing to administer pre-kindergarten vaccines to a 5-year-old child whose medical record indicates that his Immunizations are up to date. Which of the following vaccines should the nurse plan to administer?
      A)
      Hepatitis B (HBV)
      B)
      Measles, mumps, and rubella (MMR)
      C)
      Haemophilus influenzae type B (Hib)
      D)
      Pneumococcal conjugate vaccine (PCV)
    3. A nurse in a family health clinic is collecting data as part of a routine physical examination of a client who is about to enter high school. The nurse observes an abnormal lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders?
      A)
      Scoliosis
      B)
      Ankylosis
      C)
      Kyphosis
      D)
      Lordosis
    4. A nurse is collecting data from an infant who has a large patent ductus arteriosus. Which of the following is clinical manifestations should the nurse expect?
      A)
      Cyanosis with crying
      B)
      Weak pulses
      C)
      Chronic hypoxemia
      D)
      Machine-like murmur
    Page 6 of 19