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    Exam Review

    1. A nurse is caring for an infant in the emergency department. Exhibits Which of the following actions should the nurse take? (Select all that apply.)
      (SATA)
      A)
      Stabilize the infant's spine.
      B)
      Palpate fontanel level.
      C)
      Assess pupillary reaction to light.
      D)
      Encourage the guardian to feed the infant.
      E)
      Measure the infant's head circumference.
      F)
      Evaluate for the presence of a Babinski reflex
    2. Exhibits The client is at risk for developing▾ Stevens-Johnson syndrome due to ▾ Skin rash.
      Dropdown 1:
      Option 1: Pneumonia
      Option 2: liver failure
      Option 3: Stevens-Johnson syndrome
      Option 4: Pneumothorax
      Dropdown 2:
      Option 1: breath sounds
      Option 2: Phenytoin level
      Option 3: Cough
      Option 4: Skin rash
      Option 5: Liver enzymes
    3. The nurse is teaching a group of parents about signs of depression in adolescents. Which statement by a parent indicates the need for further education?
      A)
      The child prefers being with their friends rather than family
      B)
      Child has gained or lost weight more than expected
      C)
      Child sleeps more than usual
      D)
      Child is not doing well in school
    4. A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care?
      A)
      Modify the environment.
      B)
      Foster self-care activities.
      C)
      Improve the client's communication skills.
      D)
      Provide respite services for the parents.
    Page 1 of 13

    Exam Review

    1. A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?
      A)
      “I do wheelchair exercises while watching TV."
      B)
      "I only need to catheterize myself twice every day."
      C)
      "I carry a water bottle with me because I drink a lot of water."
      D)
      "I use a suppository every night to have a bowel movement."
    2. A nurse is teaching a school-age child who has type 1 diabetes mellitus and their parents about management during an illness. Which of the following instructions should the nurse include? (Select All that Apply.)
      (SATA)
      A)
      "If child is not able to eat solid foods, you can offer fluids with some carbohydrates"
      B)
      “Test urine for protein twice a day.”
      C)
      "Encourage fluid without sugar during illness"
      D)
      “Limit carbohydrates during illness"
      E)
      Test the blood/urine for ketones."
      F)
      “Withhold insulin dose if feeling nauseous."
    3. A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?
      A)
      Perform a neurovascular assessment.
      B)
      Apply an ice pack to the casted leg.
      C)
      Provide reassurance to the client and parents.
      D)
      Explain the discharge instructions to the client and parents.
    4. An adolescent client has just been diagnosed with systemic lupus erythematosus (SLE). Following client education about the disease, which statement by the client demonstrates understanding of SLE?
      A)
      SLE only affects my skin. It seldom causes problems in any other organs.
      B)
      If my SLE has been found early enough in the disease process, there is a good chance that medication can cure it.
      C)
      SLE is an autoimmune disorder that I will always have, with times of flare-ups and times of minimal to no symptoms.
      D)
      SLE is a rheumatic disease that mostly affects my joints
    Page 2 of 13

    Exam Review

    1. A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?
      A)
      Administer an intravenous antibiotic.
      B)
      Obtain blood cultures.
      C)
      Place the child in isolation.
      D)
      Prepare the child for a lumbar puncture.
    2. A nurse in the emergency department is caring for a 10-year old child who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?
      A)
      Paralytic ileus
      B)
      Fluid imbalance
      C)
      Airway obstruction
      D)
      Infection
    3. A nurse is assessing a child and notes several bruises. Which of the following actions should the nurse take first?
      A)
      Obtain a detailed history.
      B)
      Ask a psychiatrist to talk with the parents.
      C)
      Report the suspected abuse to the authorities.
      D)
      Separate the child from the parents.
    4. A new graduate nurse is caring for an infant with myelomeningocele before surgical intervention. Which action will demonstrate the need for further education by their preceptor?
      A)
      Keeping the mass uncovered and dry.
      B)
      Preventing cold stress using an isolette or radiant warmer
      C)
      Placing the infant in prone/semi-sidelying position and repositioning every 2 hrs.
      D)
      Encouraging parents to touch and interact with their infant
    Page 3 of 13

    Exam Review

    1. Which finding will cause the nurse to refer a 12-month-old child for further neuromuscular testing?
      A)
      Feeds self with a sippy cup
      B)
      Takes steps independently
      C)
      Able to sit when supported
      D)
      Uses pincer grasp
    2. A nurse is monitoring a 14 year old adolescent who was admitted with a severe burn injury and shock and is receiving IV fluid resuscitation therapy. Assessment findings: Temperature 36.5C, HR 122, Respirations 22, BP 108/68. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
      A)
      BP
      B)
      Heart rate
      C)
      Weight
      D)
      Urine output
    3. A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 44 pounds. The amount available is acetaminophen 120 mg/5 mL. How many ml should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
    4. When planning the discharge of a child with juvenile idiopathic arthritis, which intervention should the nurse include in the plan of care to promote joint mobility and reduce pain?
      A)
      Administering corticosteroid injections
      B)
      Providing hot compresses to affected joints
      C)
      Encouraging regular physical activity and exercise
      D)
      Limiting movement and activity to prevent joint damage
    Page 4 of 13

    Exam Review

    1. A nurse is caring for a school-age child who has full-thickness burns to 30% of the total body surface area (TBSA). Exhibits A nurse is initiating the client's plan of care. Complete the following sentence by using the list of options. The client is at highest risk for developing ___ as evidenced by the client's ___
    2. A nurse is caring for a child who ingested laundry detergent pods (Tide pods). Which of the following assessments is the nurse's priority?
      A)
      Respiratory status
      B)
      Bowel sounds
      C)
      Burns of the mouth
      D)
      Visual acuity
    3. A child has been diagnosed with medical abuse by his mother who is suspected of Munchausen syndrome by proxy. When setting goals, which is of the highest priority?
      A)
      Psychotherapy for the unaffected children in the family
      B)
      Therapy for the child
      C)
      Establishing safety of the child
      D)
      Obtaining treatment for the mother
    4. The nurse is providing support to a family who is experiencing anticipatory grief related to their child's imminent death. Which of the following is an appropriate nursing intervention?
      A)
      Attempt to "lighten the mood."
      B)
      Discourage crying until actual time of death.
      C)
      Suggest activities to cheer up the family
      D)
      Be available to family
    Page 5 of 13

    Exam Review

    1. A nurse is caring for a school-age child who was involved in a motor- vehicle crash. Exhibits Complete the following sentence by using the list of options. The child is at highest risk for developing ___ evidenced by the client's ___ ​​​​​​
    2. Which of the following actions should the nurse take when caring for a child in skeletal traction? (Select All that Apply)
      A)
      Encourage the child to bear weight on the affected limb
      B)
      Remove the traction periodically to allow the child to take a break
      C)
      Encourage the child to move the affected limb frequently
      D)
      Encourage the child to participate in physical activities to promote mobility
      E)
      Assess the child's neurovascular status regularly
      F)
      Monitor for signs of infection at the traction site
      G)
      Administer pain medication as needed
      H)
      Apply ice packs to the traction site to reduce swelling
    3. The physician of a child with juvenile idiopathic arthritis asks the nurse to telephone the school to arrange a new activity program for her. A change the nurse would anticipate arranging for the child is to:
      A)
      be excused from all extracurricular activities.
      B)
      modify her physical exercise program.
      C)
      begin school earlier in the day than other children.
      D)
      be excused from all swimming classes.
    4. A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)
      A)
      Assess the client's airway patency.
      B)
      Restrain the client.
      C)
      Place a tongue depressor in the client's mouth.
      D)
      Place the client in a side-lying position.
      E)
      Remove objects from the client's bed.
    Page 6 of 13