PEDS NRS-Exam II

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Toddler,preschool, and school-age children development and health promotion. GI disorders in children.

Which of the following conditions is often associated with severe diarrhea?
a.Metabolic acidosis
b.Metabolic alkalosis
c.Respiratory acidosis
d.Respiratory alkalosis

ANS: A
Metabolic acidosis results from the increased absorption of short-chain fatty acids produced in the colon. There is an increase in lactic acid from tissue hypoxia secondary to hypovolemia. Bicarbonate is lost through the stool. Ketosis results from fat metabolism when glycogen stores are depleted. Metabolic alkalosis and respiratory alkalosis do not occur from severe diarrhea.

Which of the following is a parasite that causes acute diarrhea?
a.Shigella organisms
b.Salmonella organisms
c.Giardia lamblia
d.Escherichia coli

ANS: C
G. lamblia is a parasite that represents 10% of nondysenteric illness in the United States. Shigella, Salmonella, and E. coli are bacterial pathogens.

A school-age child with diarrhea has been rehydrated. The nurse is discussing the child's diet with the family. Which of the following may be tolerated the best?
a.Clear fluids
b.Carbonated drinks
c.Applesauce and milk
d.Easily digested foods

ANS: D
Easily digested foods such as cereals, cooked vegetables, and meats should be provided for the child. Early reintroduction of nutrients is desirable. Continued feeding or reintroduction of a regular diet has no adverse effects and actually lessens the severity and duration of the illness. Clear fluids (such as fruit juices and gelatin) and carbonated drinks have high carbohydrate content and few electrolytes. Caffeinated beverages should be avoided because caffeine is a mild diuretic. In some children, lactose intolerance will develop with diarrhea, and cow's milk should be avoided in the recovery stage.

A school-age child with acute diarrhea and mild dehydration is being given oral rehydration solutions (ORS). The child's mother calls the clinic nurse because he is also occasionally vomiting. The nurse should recommend which of the following?
a.Bring the child to the hospital for intravenous fluids.
b.Alternate giving ORS and carbonated drinks.
c.Continue to give ORS frequently in small amounts.
d.Keep child NPO (nothing by mouth) for 8 hours and resume ORS if vomiting has subsided.

ANS: C
Children who are vomiting should be given ORS at frequent intervals and in small amounts. Intravenous fluids are not indicated for mild dehydration. Carbonated beverages are high in carbohydrates and are not recommended for the treatment of diarrhea and vomiting. The child is not kept NPO, since this would cause additional fluid losses.

A 7-year-old child with acute diarrhea has been rehydrated with oral rehydration solution (ORS). The nurse should recommend that the child's diet be advanced to include which of the following?
a.Regular diet
b.Clear liquids
c.High carbohydrate diet
d.BRAT diet (bananas, rice, applesauce, and toast or tea)

ANS: A
It is appropriate to advance to a regular diet after ORS has been used to rehydrate the child. Clear liquids are not appropriate for hydration or afterward. A high carbohydrate diet may contribute to loose stools because of the low electrolyte content and high osmolality. The BRAT diet has little nutritional value and is high in carbohydrates.

The psychosocial developmental tasks of toddlerhood include which of the following?

a.Development of a conscience
b.Recognition of sex differences
c.Ability to get along with age-mates
d.Ability to delay gratification

ANS: D
If the need for basic trust has been satisfied, then toddlers can give up dependence for control, independence, and autonomy. One of the tasks that the toddler is concerned with is the ability to delay gratification. Development of a conscience and recognition of sex differences occur during the preschool years. The ability to get along with age-mates develops during the preschool and school-age years.

The developmental task with which the child of 15 to 30 months is likely to be struggling is a sense of what?

a.Trust
b.Initiative
c.Intimacy
d.Autonomy

ANS: D
Autonomy versus shame and doubt is the developmental task of toddlers. Trust versus mistrust is the developmental stage of infancy. Initiative versus guilt is the developmental stage of early childhood. Intimacy and solidarity versus isolation is the developmental stage of early adulthood.

A parent of an 18-month-old boy tells the nurse that he says "no" to everything and has rapid mood swings. If he is scolded, he shows anger and then immediately wants to be held. The nurse's best interpretation of this behavior is which of the following?

a.This is normal behavior for his age.
b.This is unusual behavior for his age.
c.He is not effectively coping with stress.
d.He is showing he needs more attention.

ANS: A
Toddlers use distinct behaviors in the quest for autonomy. They express their will with continued negativity and use of the word "no." Children at this age also have rapid mood swings. The nurse should reassure the parents that their child is engaged in expected behavior for an 18-month-old.

Although a 14-month-old girl received a shock from an electrical outlet recently, her parent finds her about to place a paper clip in another outlet. Which of the following is the best interpretation of this behavior?

a.Her cognitive development is delayed.
b.This is typical behavior because toddlers are not very developed.
c.This is typical behavior because of inability to transfer knowledge to new situations.
d.This is not typical behavior because toddlers should know better than to repeat an act that caused pain.

ANS: C
During the tertiary circular reactions stage, children have only a rudimentary sense of the classification of objects. The appearance of an object denotes its function for these children. The slot of an outlet is for putting things into. This is typical behavior for a toddler, who is only somewhat aware of a causal relation between events. Her cognitive development is appropriate for her age.

A toddler, age 16 months, falls down a few stairs. He gets up and "scolds" the stairs as if they caused him to fall. This is an example of which of the following?

a.Animism
b.Ritualism
c.Irreversibility
d.Delayed cognitive development

ANS: A
Animism is the attribution of lifelike qualities to inanimate objects. By scolding the stairs, the toddler is attributing human characteristics to them. Ritualism is the need to maintain the sameness and reliability. It provides a sense of comfort to the toddler. Irreversibility is the inability to reverse or undo actions initiated physically. He is acting in an age-appropriate manner.

Which of the following is a characteristic of a toddler's language development at age 18 months?

a.Vocabulary of 25 words
b.Use of holophrases
c.Increasing level of comprehension
d.Approximately one third of speech understandable

ANS: C
During the second year of life the comprehension and understanding of speech increase to a level far greater than the child's vocabulary. This is also true for bilingual children, who are able to achieve this linguistic milestone in both languages. The 18-month-old has a vocabulary of approximately 10 words. At this age the child does not use the one-word sentences that are characteristic of 1-year-olds. The child has a very limited vocabulary of single words that are comprehensible.

Which of the following characteristics best describes the gross motor skills of a 24-month-old child?

a.Skips
b.Broad jumps
c.Rides tricycle
d.Walks up and down stairs

ANS: D
The 24-month-old child can go up and down stairs alone with two feet on each step. Skipping and broad jumping are skills acquired at age 3. Tricycle riding is achieved at age 4.

Which of the following developmental characteristics does not occur until a child reaches age 2 1/2 years?

a.Birth weight has doubled.
b.Anterior fontanel is open.
c.Primary dentition is complete.
d.Binocularity may be established.

ANS: C
Usually by age 30 months the primary dentition of 20 teeth is complete. Birth weight doubles at approximately ages 5 to 6 months. The anterior fontanel closes at ages 12 to 18 months. Binocularity is established by age 15 months.

When assessing a 2-year-old child brought by his mother to the clinic for a routine checkup, which of the following would the nurse expect the child to be able to do?

A.Ride a tricycle.
B.Tie his shoelaces.
C.Kick a ball forward.
D.Use blunt scissors

Ans: C
A 2-year-old child usually can kick a ball forward. Riding a tricycle is characteristic of a 3-year-old child. Tying shoelaces is a behavior to be expected of a 5-year-old child. Using blunt scissors is characteristic of a 3-year-old child.

A 2½-year-old child brought to the clinic by her parents is uncooperative when the nurse tries to look in her ears. Which of the following would the nurse try first?

A.Ask another nurse to assist.
B.Allow a parent to assist.
C. Wait until the child calms down.
D.Restrain the child's arms.

Ans: B.
Parents can be asked to assist when their child becomes uncooperative during a procedure. Most commonly, the child's difficulty in cooperating is caused by fear. In most situations, the child will feel more secure with a parent present. Other methods may be necessary, but obtaining a parent's assistance is the recommended first action. Restraints should be used only as a last resort, after all other attempts have been made to encourage cooperation.

The mother asks the nurse for advice about discipline for her 18-month-old. Which of the following would the nurse suggest that the mother use first?

A.Structured interactions.
B.Spanking.
C.Reasoning.
D.Time out.

Ans: D.
Time out is the most appropriate discipline for toddlers. It helps to remove them from the situation and allows them to regain control. Structuring interactions with 3-year-olds helps minimize unacceptable behavior. This approach involves setting clear and reasonable rules and calling attention to unacceptable behavior as soon as it occurs. Physical punishment, such as spanking, does cause a dramatic decrease in a behavior but has serious negative effects. However, slapping a child's hand is effective when the child refuses to listen to verbal commands. Reasoning is more appropriate for older children, such as preschoolers and those older, especially when moral issues are involved. Unfortunately, reasoning combined with scolding often takes the form of shame or criticism and children take such remarks seriously, believing that they are "bad."

Which of the following statements is correct about toilet training?

a.Bladder training is usually accomplished before bowel training.
b.Wanting to please the parent helps motivate the child to use the toilet.
c.Watching older siblings use the toilet confuses the child.
d.Children must be forced to sit on the toilet when first learning.

ANS: B
Voluntary control of the anal and urethral sphincters is achieved sometime after the child is walking. The child must be able to recognize the urge to let go and to hold on. The child must want to please parent by holding on rather than pleasing self by letting go. Bowel training precedes bladder training. Watching older siblings provides role modeling and facilitates imitation for the toddler. The child should be introduced to the potty chair or toilet in a nonthreatening manner.

The parents of a newborn say that their toddler "hates the baby. . . . He suggested that we put him in the trash can so the trash truck could take him away." The nurse's best reply is which of the following?

a."Let's see if we can figure out why he hates the new baby."
b."That's a strong statement to come from such a small boy."
c."Let's refer him to counseling to work this hatred out. It's not a normal response."
d."That is a normal response to the birth of a sibling. Let's look at ways to deal with this."

ANS: D
The arrival of a new infant represents a crisis for even the best-prepared toddler. Toddlers have their entire schedule and routines disrupted because of the new family member. The nurse should work with parents on ways to involve the toddler in the newborn's care and to help focus attention on the toddler. The toddler does not hate the infant. This is an expected, normal response to the changes in routines and attention that affect the toddler. The toddler can be provided with a doll to imitate parents' behaviors. The child can care for the doll's needs at the same time the parent is performing similar care for the newborn.

A toddler's parent asks the nurse for suggestions on dealing with temper tantrums. Which of the following is the most appropriate recommendation?

a.Punish the child.
b.Explain to child that this is wrong.
c.Leave the child alone until the tantrum is over.
d.Remain close by the child but without eye contact.

ANS: D
The best way to deal with temper tantrums is to ignore the behaviors, provided that the actions are not dangerous to the child. Tantrums are common during this age-group as the child becomes more independent and overwhelmed by increasingly complex tasks. The parents and caregivers need to have consistent and developmentally appropriate expectations. Punishment and explanations will not be beneficial. The presence of the parent is necessary both for safety and to provide a feeling of control and security to the child when the tantrum is over.

A parent asks the nurse about negativism in toddlers. The most appropriate recommendation is which of the following?

a.Punish the child.
b.Provide more attention.
c.Ask child not to always say "no."
d.Reduce the opportunities for a "no" answer.

ANS: D
The nurse should suggest to the parent that questions should be phrased with realistic choices rather than yes or no answers. This provides a sense of control for the toddler and reduces the opportunity for negativism. Negativism is not an indication of stubbornness or insolence and should not be punished. The negativism is not a function of attention; the child is testing limits to gain an understanding of the world. The toddler is too young to comply with requests not to say "no."

The parents of a 2-year-old tell the nurse they are concerned because the toddler has started to use "baby talk" since the arrival of their new baby. The nurse should recommend which of the following?

a.Ignore the baby talk.
b.Tell the toddler frequently, "You are a big kid now."
c.Explain to the toddler that baby talk is for babies.
d.Encourage the toddler to practice more advanced patterns of speech.

ANS: A
The baby talk is a sign of regression in the toddler. Often toddlers attempt to cope with a stressful situation by reverting to patterns of behavior that were successful in earlier stages of development. It should be ignored, while praising the child for developmentally appropriate behaviors. Regression is children's way of expressing stress. The parents should not introduce new expectations and allow the child to master the developmental tasks without criticism.

Parents tell the nurse that their toddler eats little at mealtime, only sits at the table with the family briefly, and wants snacks "all the time." Which of the following should the nurse recommend?

a.Give her nutritious snacks.
b.Offer rewards for eating at mealtimes.
c.Avoid snacks so she is hungry at mealtimes.
d.Explain to her in a firm manner what is expected of her.

ANS: A
Most toddlers exhibit a physiologic anorexia in response to the decreased nutritional requirement associated with the slower growth rate. Parents should assist the child in developing healthy eating habits. The toddler is often unable to sit through a meal. Frequent nutritious snacks are a good way to ensure proper nutrition. To help with developing healthy eating habits, food should be not be used as positive or negative reinforcement for behavior. The child may develop habits of overeating or eat nonnutritious foods in response. A toddler is not able to understand explanations of what is expected of her and comply with the expectations.

A father tells the nurse that his daughter wants the same plate and cup used at every meal, even if they go to a restaurant. The nurse should explain that this is which of the following?

a.A sign the child is spoiled
b.An attempt to exert unhealthy control
c.Regression, which is common at this age
d.Ritualism, an expected behavior at this age

ANS: D
The child is exhibiting the ritualism that is characteristic at this age. Ritualism is the need to maintain the sameness and reliability. It provides a sense of structure and comfort to the toddler. It will dictate certain principles in feeding practices, including rejecting a favorite food because it is served in a different container. This does not indicate the child has unreasonable expectations, but rather is part of normal development. Ritualism is not regression, which is a retreat from a present pattern of functioning.

What is the leading cause of death during the toddler period?

a.Injuries
b.Infectious diseases
c.Childhood diseases
d.Congenital disorders

ANS: A
Injuries are the most common cause of death in children ages 1 through 4 years. It is the highest rate of death from injuries of any childhood age-group except adolescence. Congenital disorders are the second leading cause of death in this age-group. Infectious and childhood diseases are less common causes of death in this age-group.

The parent of 16-month-old Brian asks, "What is the best way to keep Brian from getting into our medicines at home?" The nurse should advise which of the following?

a."All medicines should be locked securely away."
b."The medicines should be placed in high cabinets."
c."Brian just needs to be taught not to touch medicines."
d."Medicines should not be kept in the homes of small children."

ANS: A
The major reason for poisoning in the home is improper storage. Toddlers can climb, unlatch cabinets, and obtain access to high-security places. For medications, only a locked cabinet is safe. Toddlers can climb using furniture. High places are not a deterrent to an exploring toddler. Toddlers are not able to generalize that all the different forms of medications in the home may be dangerous. Keeping medicines out of the homes of small children is not feasible. Many parents require medications for chronic or acute illnesses. Parents must be taught safe storage for their home and when they visit other homes.

A toddler's parents have been using a rear-facing convertible car seat since she was born. The seat can be safely switched to the forward-facing position when she weighs how many pounds?

a.10
b.20
c.30
d.40

ANS: B
Although the transition point for switching to the forward-facing position is defined by the manufacturer, it is generally at 9 kg (20 lb); 4.5 kg (10 lb) is too small to be safe. Because of the relatively large head, this size child should be in the rear-facing position. It is usually safe to put children who weigh more than 20 lb in forward-facing convertible safety seats.

The most common type of burn in the toddler age-group is:

a.electric burn from electrical outlets.
b.flame burn from playing with matches.
c.hot object burn from cigarettes or irons.
d.scald burn from high-temperature tap water.

ANS: D
Scald burns are the most common type of thermal injury in children, especially 1- and 2-year-olds. Temperature should be reduced on the hot water in the house and hot liquids placed out of the child's reach. Electric burns from electrical outlets and hot object burns from cigarettes or irons are both significant causes of burn injury. The child should be protected by reducing the temperature on the hot water heater in the home, keeping objects such as cigarettes and irons away from children, and placing protective guards over electrical outlets when not in use. Flame burns from matches and lighters represent one of the most fatal types of burns in the toddler age-group, but not one of the most common types of burn.

The nurse is assessing a 20-month-old toddler during a well-child visit and notices tooth decay. The nurse should understand that early childhood caries are caused by which of the following?

a.Allowing the child to eat citrus foods at bedtime
b.A hereditary factor that cannot be prevented
c.Poor fluoride supply in the drinking water
d.Giving the child a bottle of juice or milk at naptime

ANS: D
One cause of early childhood caries is allowing the child to go to sleep with a bottle of milk or juice; as the sweet liquid pools in the mouth, the teeth are bathed for several hours in this cariogenic environment. Eating citrus fruit at bedtime and poor fluoride supply in drinking water do not cause early childhood caries. The problem is not hereditary and can be prevented with proper education.

The nurse is providing guidance strategies to a group of parents with toddlers at a community outreach program. Which of the following statements by a parent would indicate a correct understanding of the teaching?

a."I should expect my 24-month-old child to express some signs of readiness for toilet training."
b."I should be firm and structured when disciplining my 18-month-old child."
c."I should expect my 12-month-old child to start to develop a fear of darkness and to need a security blanket."
d."I should expect my 36-month-old child to understand time and proximity of events."

ANS: A
A 24-month-old toddler starts to show readiness for toilet training; it is important for the parent to be aware of this and be ready to start the process. At 18 months of age, a child needs consistent but gentle discipline, since the child cannot yet understand firmness and structure with discipline. Development of fears and need for security items usually occurs at the end of the 18- to 24-month stage. A 36-month-old child does not yet understand time and proximity of events, so the parent needs to understand that the toddler cannot "hurry up or we will be late."

SELECT ALL THAT APPLY
The nurse is preparing a staff education program about growth and development of an 18-month-old toddler. Which of the following characteristics should the nurse include in the staff education program?

a.Eats well with a spoon and cup
b.Runs clumsily and can walk up stairs
c.Points to common objects
d.Builds a tower of three or four blocks
e.Has a vocabulary of 300 words
f.Dresses self in simple clothes

ANS: A, B, C, D
Tasks accomplished by an 18-month-old toddler include eating well with a spoon and cup, running clumsily, walking up stairs, pointing to common objects such as shoes, and building a tower with three or four blocks. An 18-month-old toddler has a vocabulary of only 10 words, not 300. Toddlers cannot dress themselves in simple clothing until 24 months of age.

In terms of fine motor development, what could the 3-year-old child be expected to do?

a.Tie shoelaces.
b.Copy (draw) a circle.
c.Use scissors or a pencil very well.
d.Draw a person with seven to nine parts.

ANS: B
Three-year-olds are able to accomplish this fine motor skill of copying (drawing) a circle. The ability to tie shoelaces, to use scissors or a pencil very well, and to draw a person with seven to nine parts are fine motor skills of 5-year-olds.

According to Piaget, magical thinking is the belief that:

a.thoughts are all-powerful.
b.God is an imaginary friend.
c.events have cause and effect.
d.if the skin is broken, the insides will come out.

ANS: A
Because of their egocentrism and transductive reasoning, preschoolers believe that thoughts are all-powerful. Believing God is an imaginary friend is an example of concrete thinking in a preschooler's spiritual development. Cause-and-effect implies logical thought, not magical thinking. Believing that, if the skin is broken, the insides will come out is an example of concrete thinking in development of body image.

In terms of cognitive development, the 5-year-old child would be expected to do which of the following?

a.Think abstractly.
b.Use magical thinking.
c.Understand conservation of matter.
d.Understand another person's perspective.

ANS: B
Magical thinking is believing that thoughts can cause events. An example would be that thinking of the death of a parent might cause it to happen. Abstract thought does not develop until school-age years. The concept of conservation is the cognitive task of school-age children, ages 5 to 7 years. A five-year-old child cannot understand another's perspective.

The nurse is caring for a hospitalized 4-year-old boy. His parents tell the nurse they will be back to visit at 6 PM. When he asks the nurse when his parents are coming, the nurse's best response would be which of the following?

a."They will be here soon."
b."They will come after dinner."
c."Let me show you on the clock when 6 PM is."
d."I will tell you every time I see you how much longer it will be."

ANS: B
A 4-year-old understands time in relation to events such as meals. Children perceive "soon" as a very short time. The nurse may lose the child's trust if his parents do not return in the time he perceives as "soon." Children cannot read or use a clock for practical purposes until age 7 years. "I will tell you every time I see you how much longer it will be" assumes the child understands the concepts of hours and minutes, which does not occur until age 5 or 6 years.

A 4-year-old boy is hospitalized with a serious bacterial infection. He tells the nurse that he is sick because he was "bad." Which of the following is the nurse's best interpretation of this comment?

a.Sign of stress
b.Common at this age
c.Suggestive of maladaptation
d.Suggestive of excessive discipline at home

ANS: B
Preschoolers cannot understand the cause and effect of illness. Their egocentrism makes them think they are directly responsible for events, making them feel guilt for things outside of their control. Children of this age react to stress by regressing developmentally or acting out. Maladaptation is unlikely. This comment does not imply excessive discipline at home.

A 4-year-old child tells the nurse that she doesn't want another blood sample drawn because "I need all of my insides and I don't want anyone taking them out." Which of the following is the nurse's best interpretation of this?

a.Child is being overly dramatic.
b.Child has a disturbed body image.
c.Preschoolers have poorly defined body boundaries.
d.Preschoolers normally have a good understanding of their bodies.

ANS: C
Preschoolers have little understanding of body boundaries, which leads to fears of mutilation. The child is not capable of being dramatic at this age. She truly has fear. Body image is just developing in the school-age child. Preschoolers do not have good understanding of their bodies.

Which of the following types of play is most typical of the preschool period?

a.Team
b.Parallel
c.Solitary
d.Associative

ANS: D
Associative play is group play in similar or identical activities but without rigid organization or rules. School-age children play in teams. Parallel play is that of toddlers. Solitary play is that of infants.

Which of the following characteristics best describes the language skills of a 3-year-old child?

a.Asks meanings of words
b.Follows directional commands
c.Can describe an object according to its composition
d.Talks incessantly regardless of whether anyone is listening

ANS: D
Because of the dramatic vocabulary increase at this age, 3-year-olds are known to talk incessantly regardless of whether anyone is listening. A 4- to 5-year-old asks lots of questions and can follow simple directional commands. A 6-year-old can describe an object according to its composition.

During a well-child visit the father of a 4-year-old boy tells the nurse that he is not sure if his son is ready for kindergarten. The boy's birthday is close to the cut-off date, and he has not attended preschool. Which of the following is the nurse's best recommendation?

a.Start kindergarten.
b.Observe a kindergarten class.
c.Perform developmental screening.
d.Postpone kindergarten and go to preschool.

ANS: C
A developmental assessment with a screening tool that addresses cognitive, social, and physical milestones can help identify children who may need further assessment. A readiness assessment involves an evaluation of skill acquisition. Stating the child should start kindergarten or go to preschool and postpone kindergarten does not address the father's concerns about readiness for school. Observation of a class will provide information about what happens during the day. The father can use this to help determine if his son is ready.

Parents tell the nurse they found their 3-year-old daughter and a male cousin of the same age inspecting each other closely as they used the bathroom. Which of the following is the most appropriate recommendation for the nurse to make?

a.Punish children so this behavior stops.
b.Neither condone nor condemn the curiosity.
c.Get counseling for this unusual and dangerous behavior.
d.Allow children unrestricted permission to satisfy this curiosity.

ANS: B
Three-year-olds become aware of anatomic differences and are concerned about how the other sex "works." Such exploration should not be condoned or condemned. Children should not be punished for this normal exploration. This is age appropriate and not dangerous behavior. Encouraging the children to ask their parents questions and redirecting their activity is more appropriate than giving permission.

Which one of the following dysfunctional speech patterns is a normal characteristic of the language development of a preschool child?

a.Lisp
b.Echolalia
c.Stammering
d.Repetition without meaning

ANS: C
Stammering and stuttering are normal dysfluency in preschool-age children. Lisps are not a normal characteristic of language development. Echolalia and repetition are traits of toddlers' language.

The parent of a 4-year-old boy tells the nurse that the child believes "monsters and bogeymen" are in his bedroom at night. The nurse's best suggestion for coping with this problem is which of the following?

a.Let the child sleep with his parents.
b.Keep a night light on in the child's bedroom.
c.Help the child understand that these fears are illogical.
d.Tell the child that monsters and bogeymen do not exist.

ANS: B
Involve the child in problem solving. A night light shows a child that imaginary creatures do not lurk in the darkness. Letting the child sleep with parents will not get rid of the fears. A 4-year-old is in the preconceptual stage and cannot understand logical thought.

Which of the following is descriptive of the nutritional requirements of preschool children?

a.Quality of the food consumed is more important than the quantity.
b.Average daily intake of preschoolers should be about 3000 calories.
c.Nutritional requirements for preschoolers are very different from requirements for toddlers.
d.Requirements for calories per unit of body weight increase slightly during the preschool period.

ANS: A
Parents need to be reassured that the quality of food eaten is more important than the quantity. Children are able to self-regulate their intake when offered foods high in nutritional value. The average daily caloric intake should be approximately 1800 calories. Toddlers and preschoolers have similar nutritional requirements. There is an overall slight decrease in needed calories and fluids during the preschool period.

A child age 4 1/2 years sometimes wakes her parents up at night screaming, thrashing, sweating, and apparently frightened. Yet she is not aware of her parents' presence when they check on her. She lies down and sleeps without any parental intervention. This is most likely which of the following?

a.Nightmare
b.Sleep terror
c.Sleep apnea
d.Seizure activity

ANS: B
This is a description of a sleep terror. The child is observed during the episode and not disturbed unless there is a possibility of injury. A child who awakes from a nightmare is distressed. She is aware of and reassured by the parent's presence. This is not the case with sleep apnea. This behavior is not indicative of seizure activity.

During the preschool period the emphasis of injury prevention should be placed on which of the following?

a.Limitation of physical activities
b.Punishment for unsafe behaviors
c.Constant vigilance and protection
d.Teaching about safety and potential hazards

ANS: D
Education about safety and potential hazards is appropriate for preschoolers because they can begin to understand dangers. Limitation of physical activities is not appropriate. Punishment may make children scared of trying new things. Constant vigilance and protection is not practical at this age, since preschoolers are becoming more independent.

The nurse is talking to the parent of a 5-year-old child who refuses to go to sleep at night. Which of the following interventions should the nurse suggest in helping the parent to cope with this sleep disturbance?

a.Establish a consistent punishment if the child does not go to bed when told.
b.Allow child to fall asleep in a different room, then gently move the child to his or her bed.
c.Establish limited rituals that signal readiness for bedtime.
d.Allow the child to watch television until almost asleep.

ANS: C
An appropriate intervention for a child who resists going to bed is to establish limited rituals such as a bath or story that signal readiness for bed and consistently follow through with the ritual. Punishing the child will not alleviate the resistance problem and may only add to the frustration. Allowing the child to fall asleep in a different room or to watch television to fall asleep is not a recommended approach to sleep resistance.

At a seminar for parents with preschool-age children the nurse has discussed anticipatory tasks during the preschool years. Which of the following statements by a parent would indicate a correct understanding of the teaching?

a."I should be worried if my 4-year-old child has an increase in sexual curiosity, since this is a sign of sexual abuse."
b."I should expect my 5-year-old to change from a tranquil child to an aggressive child when school starts."
c."I should be concerned if my 4-year-old child starts telling exaggerated stories and has an imaginary playmate, since these could be signs of stress."
d."I should expect my 3-year-old child to have a more stable appetite and an increase in food selections."

ANS: D
A 3-year-old exhibits a more stable appetite than during the toddler years and is more willing to try different foods. A 4-year-old child is imaginative and indulges in telling "tall tales" and may have an imaginary playmate; these are normal findings, not signs of stress. Also a 4-year-old has an increasing curiosity in sexuality, which is not a sign of child abuse. A 5-year-old child is usually tranquil, not aggressive like the 4-year-old child.

Which if the following developmental achievements are demonstrated by a 4-year-old child? Select all that apply.

a.Cares for self totally
b.Throws a ball overhead
c.Has a vocabulary of 1500 words
d.Can skip and hop on alternate feet
e.Tends to be selfish and impatient
f.Commonly has an imaginary playmate

ANS: B, C, E, F
Developmental achievements for a 4-year-old include throwing a ball overhead, having a vocabulary of 1500 words, tending to be selfish and impatient, and perhaps having an imaginary playmate. Caring for self totally and skipping and hopping on alternate feet are achievements normally seen in the 5-year-old age-group.

Which of the following is a high-fiber food that the nurse could recommend for a child with chronic constipation?

a. White rice
b. Popcorn
c. Fruit juice
d. Ripe bananas

ANS: B
Popcorn is a high-fiber food. Refined rice is not a significant source of fiber. Unrefined brown rice is a fiber source. Fruit juices are not a significant source of fiber. Raw fruits, especially those with skins and seeds, other than ripe bananas, have high fiber.

Which of the following statements best describes Hirschsprung disease?

a. The colon has an aganglionic segment.
b. It results in frequent evacuation of solids, liquid, and gas.
c. The neonate passes excessive amounts of meconium.
d. It results in excessive peristaltic movements within the gastrointestinal tract.

ANS: A
Mechanical obstruction in the colon results from a lack of innervation. In most cases the aganglionic segment includes the rectum and some portion of the distal colon. There is decreased evacuation of the large intestine secondary to the aganglionic segment. Liquid stool may ooze around the blockage. The obstruction does not affect meconium production. The infant may not be able to pass the meconium stool. There is decreased movement in the colon.

Abdominal circumferences are monitored on a child with progressive abdominal distention secondary to a bowel obstruction. The appropriate procedure for assessment includes:

a. measuring abdomen after feedings.
b. marking the point of measurement with a pen.
c. measuring circumference at the symphysis pubis.
d. using a new tape measure with each assessment to ensure accuracy.

ANS: B
Pen marks on either side of the tape measure allow the nurse to measure the same spot on the child's abdomen at each assessment. The child most likely will be kept NPO (nothing by mouth) if a bowel obstruction is present. If the child is being fed, the assessment should be done before feedings. The symphysis pubis is too low. Usually the largest part of the abdomen is at the umbilicus. Leaving the tape measure in place reduces the trauma to the child.

A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. The nurse should recognize that preparing this child is which of the following?

a. Unnecessary because of child's age
b. Essential because it will be an adjustment
c. Not needed, since the colostomy is temporary
d. Important because the child needs to deal with negative body image

ANS: B
The child's age dictates the type and extent of psychologic preparation. When a colostomy is performed, it is necessary to prepare the child who is at least preschool age by telling him or her about the procedure and what to expect in concrete terms, with the use of visual aids. The preschooler is not yet concerned with body image.

A child has a nasogastric (NG) tube after surgery for Hirschsprung disease. The purpose of the NG tube is which of the following?

a. Prevent spread of infection
b. Monitor electrolyte balance
c. Prevent abdominal distention
d. Maintain accurate record of output

ANS: C
The NG tube is placed to suction out gastrointestinal secretions and prevent abdominal distention. The NG tube would not affect infection. Electrolyte content of the NG drainage can be monitored. Without the NG tube, there would be no drainage. Once the NG tube is placed, it is important to maintain an accurate record of intake and output. This is not the reason for placement of the tube.

The nurse is assessing an infant with Hirschsprung's disease. The nurse can expect the infant to:

a. Weigh less than expected for height and age
b. Have a scaphoid-shaped abdomen
c. Exhibit clubbing of the fingers and toes
d. Have hyperactive deep tendon reflexes

Ans: B

The child with Hirschsprung's disease will have a scaphoid or hollowed abdomen. Answers A, C, and D do not apply to the condition; therefore, they are incorrect.

Which antibiotic is contraindicated for the treatment of infections in infants and young children?

a. Tetracyn (tetracycline)
b. Amoxil (amoxicillin)
c. Cefotan (cefotetan)
d. E-Mycin (erythromycin)

Ans: A.

Tetracycline is contraindicated for use in infants and young children because it stains the teeth and arrests bone development. Answers B, C, and D are incorrect because they can be used to treat infections in infants and children.

Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and watery explosive diarrhea?

a. Notify the physician immediately
b. Administer antidiarrheal medications
c. Monitor child ever 30 minutes
d. Nothing, this is characteristic of Hirschsprung disease

Answer A.

For the child with Hirschsprung disease, fever andexplosive diarrhea indicate enterocolitis, a life-threatening situation. Therefore, the physicianshould be notified immediately. Generally, becauseof the intestinal obstruction and inadequatepropulsive intestinal movement, antidiarrheals arenot used to treat Hirschsprung disease. The child isacutely ill and requires intervention, with monitoringmore frequently than every 30 minutes.Hirschsprung disease typically presents withchronic constipation.

A newborn's failure to pass meconium within the first 24 hours after birth may indicate which of the following?

a.Hirschsprung disease
b. Celiac disease
c. Intussusception
d. Abdominal wall defect

Answer A

Failure to pass meconium within the first 24 hoursafter birth may be an indication of Hirschsprungdisease, a congenital anomaly resulting in mechanicalobstruction due to inadequate motility in anintestinal segment. Failure to pass meconium is notassociated with celiac disease, intussusception, orabdominal wall defect.

Which of the following clinical manifestations would be the most suggestive of acute appendicitis?

a. Rebound tenderness
b. Bright red or dark red rectal bleeding
c. Abdominal pain that is relieved by eating
d. Colicky, cramping, abdominal pain around the umbilicus

ANS: D
Pain is the cardinal feature. It is initially generalized, usually periumbilical. The pain becomes constant and may shift to the right lower quadrant. Rebound tenderness is not a reliable sign and is extremely painful to the child. Bright or dark red rectal bleeding and abdominal pain that is relieved by eating are not signs of acute appendicitis.

When caring for a child with probable appendicitis, the nurse should be alert to recognize which of the following as a sign of perforation?

a. Anorexia
b. Bradycardia
c. Sudden relief from pain
d. Decreased abdominal distention

ANS: C
Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation. Anorexia is already a clinical manifestation of appendicitis. Tachycardia, not bradycardia, is a manifestation of peritonitis. Abdominal distention usually increases in addition to an increase in pain (usually diffuse and accompanied by rigid guarding of the abdomen).

The nurse is caring for a child admitted with acute abdominal pain and possible appendicitis. Which of the following is appropriate to relieve the abdominal discomfort during the evaluation?

a. Place in Trendelenburg position.
b. Apply moist heat to the abdomen.
c. Allow child to assume position of comfort.
d. Administer a saline enema to cleanse the bowel.

ANS: C
The child should be allowed to take a position of comfort, usually with the legs flexed. The Trendelenburg position will not help with the discomfort. If appendicitis is a possibility, administering laxative or enemas or applying heat to the area is dangerous. Such measures stimulate bowel motility and increase the risk of perforation.

When assessing a child for possible intussusception, which of the following would be least likely to provide valuable information?

a.Stool inspection
b. Pain pattern
c. Family history
d. Abdominal palpation

Answer C

Because intussusception is not believed to have a familial tendency, obtaining a family history would provide the least amount of information. Stool inspection, pain pattern, and abdominal palpation would reveal possible indicators of intussusception.Current, jelly-like stools containing blood and mucus are an indication of intussusception. Acute,episodic abdominal pain is characteristics of intussusception. A sausage-shaped mass may be palpated in the right upper quadrant.

Which of the following nursing diagnoses would be inappropriate for the infant with gastroesophageal reflux(GER)?

a.Fluid volume deficit
b. Risk for aspiration
c. Altered nutrition: less than bodyrequirements
d. Altered oral mucous membranes

Answer D

GER is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal (cardiac)sphincter. No alteration in the oral mucous membranes occurs with this disorder. Fluid volume deficit, risk for aspiration, and altered nutrition are appropriate nursing diagnoses.

Which of the following parameters would the nurse monitor to evaluate the effectiveness of thickened feedings for an infant with gastroesophageal reflux (GER)?

a.Vomiting
b. Stools
c. Urine
d. Weight

Answer A

Thickened feedings are used with GER to stop the vomiting. Therefore, the nurse would monitor the child's vomiting to evaluate the effectiveness of using the thickened feedings.No relationship exists between feedings and characteristics of stools and urine. If feedings are ineffective, this should be noted
before there is any change in the child's weight.

A newborn's failure to pass meconium within 24 hours after birth may indicate which of the following?

a. Aganglionic Mega colon
b. Celiac disease
c. Intussusception
d. Abdominal wall defect

Answer A

Failure to pass meconium of newborn during the first 24 hours of life may indicate Hirschsprung disease or Congenital Aganglionic Megacolon, an anomaly resulting in mechanical obstruction due to inadequate motility in an intestinal segment. B, C,and D are not associated in the failure to pass meconium of the newborn.

Among the following pediatric clients, who should be assessed first by the nurse?

a)the child with 2 episodes of soft stools during theshift
b) the child who had cough for the past three days, with clear nasal discharge and is irritable
c) the child with 2 episodes of inconsolable crying while the knees are drawn over the abdomen and plays between the episodes
d) the child with skin rashes on his face and trunk

Answer C

- this indicates appendicitis. The pattern of abdominal pain in appendicitis is as follows: pain occurs for 2 to 3hours, pain is relieved in 2 to 3 hours, then pain recurs and persists. During the time that pain subsides, it is when rupture of appendicitis may occur unnoticed.

While assessing a child with pyloric stenosis, the nurse is likely to note which of the following?

a.Regurgitation
b. Steatorrhea
c. Projectile vomiting
d. "Currant jelly" stools

Answer C.

Projectile vomiting is a key symptom of pyloric stenosis. Regurgitation is seen more commonly withGER. Steatorrhea occurs in malabsorption disorders such as celiac disease. "Currant jelly"stools are characteristic of intussusception.

Which of the following suggestions should the nurse offer the parents of a 4-year-old boy who resists going to bed at night?

a."Allow him to fall asleep in your room, then move him to his own bed."
b. "Tell him that you will lock him in his room if he gets out of bed one more time."
c. "Encourage active play at bedtime to tire him out so he will fall asleep faster."
d. "Read him a story and allow him to play quietly in his bed until he falls asleep."

Answer D.

Preschoolers commonly have fears of the dark,being left alone especially at bedtime, and ghosts,which may affect the child's going to bed at night. Quiet play and time with parents is a positive bedtime routine that provides security and also readies the child for sleep. The child should sleep in his own bed. Telling the child about locking him in his room will viewed by the child as a threat. Additionally, a locked door is frightening and potentially hazardous. Vigorous activity at bedtime stirs up the child and makes more difficult to fall asleep.

A 2-year old is hospitalized with suspected intussusception. Which finding is associated with intussusception?

a. "currant jelly" stools
b. Projectile vomiting
c. "ribbonlike" stools
d. Palpable mass over the flank

Answer A

A child with intussusception has stools that contain blood and mucus, which are described as"currant jelly" stools.

A child with pyloric stenosis is having excessive vomiting. Which of the following is a potential complication?

a. Hyperkalemia
b. Hyperchloremia
c. Metabolic acidosis
d. Metabolic alkalosis

ANS: D
Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions. Potassium and chloride ions are lost with vomiting. Metabolic alkalosis, not acidosis, is likely.

Invagination of one segment of bowel within another is called which of the following?

a. Atresia
b. Stenosis
c. Herniation
d. Intussusception

ANS: D
Intussusception occurs when a proximal section of the bowel telescopes into a more distal segment, pulling the mesentery with it. The mesentery is compressed and angled, resulting in lymphatic and venous obstruction. Atresia is the absence or closure of a natural opening in the body. Stenosis is a narrowing or constriction of the diameter of a bodily passage or orifice. Herniation is the protrusion of an organ or part through connective tissue or through a wall of the cavity in which it is normally enclosed.

SELECT ALL THAT APPLY
The nurse is teaching a parent of a 6-month-old infant with gastroesophageal reflux (GER) before discharge. Which of the following instructions should the nurse include?

a. Elevate the head of the bed in the crib to a 90-degree angle while the infant is sleeping.
b. Hold the infant in the prone position after a feeding.
c. Discontinue breast-feeding so that a formula and rice cereal mixture can be used.
d. The infant will require the Nissen fundoplication after 1 year of age.
e. Prescribed cimetidine (Tagamet) should be given 30 minutes before feedings.

ANS: B, E
Discharge instructions for an infant with GER should include the prone position (up on the shoulder or across the lap) after a feeding. Use of the prone position while the infant is sleeping is still controversial. The American Academy of Pediatrics recommends the supine position to decrease the risk of sudden infant death syndrome, even in infants with GER. Prescribed cimetidine or another proton pump inhibitor should be given 30 minutes before the morning and evening feeding so that peak plasma concentrations occur with mealtime. The head of the bed in the crib does not need to be elevated. The mother may continue to breast-feed or express breast milk to add rice cereal if recommended by the health care provider; thickening breast milk or formula with cereal is not recommended by all practitioners. The Nissen fundoplication is only done on infants with GER in severe cases with complications.

SELECT ALL THAT APPLY
The nurse is preparing to admit a 3-year-old with intussusception. Which of the following clinical manifestations would the nurse expect to observe?

a. Absent bowel sounds
b. Passage of red, currant jelly-like stools
c. Anorexia
d. Tender, distended abdomen
e. Hematemesis
f. Sudden acute abdominal pain

ANS: B, D, F
Intussusception occurs when a proximal segment of the bowel telescopes into a more distal segment, pulling the mesentery with it and leading to obstruction. Clinical manifestations of intussusception include the passage of red, currant jelly-like stools; a tender, distended abdomen; and sudden acute abdominal pain. Absent bowel sounds, anorexia, and hematemesis are clinical manifestations observed in other types of gastrointestinal dysfunction.

A toddler's mother calls the nurse because she thinks her son has swallowed a button type of battery. He has no signs of respiratory distress. The nurse's response should be based on which of the following?

a. An emergency laparotomy is very likely.
b. The location needs to be confirmed by x-ray examination.
c. Surgery will be necessary if the battery has not passed in the stool in 48 hours.
d. Careful observation is essential because an ingested battery cannot be accurately detected.

ANS: B
Button batteries can cause severe damage if lodged in the esophagus. If both poles of the battery come in contact with the wall of the esophagus, acid burns, necrosis, and perforation can occur. If the battery is in the stomach, it will most likely be passed without incident. Surgery is not indicated. The battery is metallic and is readily seen on radiologic examination.

The mother of a child with cognitive impairment calls the nurse because her son has been gagging and drooling all morning. The nurse suspects foreign body ingestion because of which of the following?

a. Gastrointestinal perforation may have occurred.
b. Object may have been aspirated.
c. Object may be lodged in esophagus.
d. Object may be embedded in stomach wall.

ANS: C
Gagging and drooling may be signs of esophageal obstruction. The child is unable to swallow saliva, which contributes to the drooling. Signs of gastrointestinal (GI) perforation include chest or abdominal pain and evidence of bleeding in the GI tract. If the object was aspirated, the child would most likely have coughing, choking, inability to speak, or difficulty breathing. If the object was embedded in the stomach wall, it would not result in symptoms of gagging and drooling.

Which of the following statements accurately describes physical development during the school-age years?

a. Child's weight almost triples.
b. Muscles become functionally mature.
c. Boys and girls double strength and physical capabilities.
d. Fat gradually increases, which contributes to child's heavier appearance.

ANS: C
Boys and girls double both strength and physical capabilities. Their consistent refinement in coordination increases their poise and skill. In middle childhood, growth in height and weight occurs at a slower pace. Between the ages of 6 and 12 years, children grow 5 cm/yr and gain 3 kg/yr. Their weight will almost double. Although the strength increases, muscles are still functionally immature when compared with those of adolescents. This age-group is more easily injured by overuse. Children take on a slimmer look with longer legs in middle childhood.

The parents of 9-year-old twin children tell the nurse, "They have filled up their bedroom with collections of rocks, shells, stamps, and bird nests." The nurse should recognize that this is which of the following?

a. Indicative of giftedness
b. Indicative of typical twin behavior
c. Characteristic of cognitive development at this age
d. Characteristic of psychosocial development at this age

ANS: C
Classification skills involve the ability to group objects according to the attributes they have in common. School-age children can place things in a sensible and logical order, group and sort, and hold a concept in their mind while they make decisions based on that concept. Individuals who are not twins engage in classification at this age. Psychosocial behavior at this age is described according to Erikson's stage of industry versus inferiority.

Which of the following statements characterizes moral development in the older school-age child?

a. Rule violations are viewed in an isolated context.
b. Judgments and rules become more absolute and authoritarian.
c. The child has knowledge of the rules, but cannot understand the reasons behind them.
d. The child is able to judge an act by the intentions that prompted it rather than just by the consequences.

ANS: D
Older school-age children are able to judge an act by the intentions that prompted the behavior rather than just by the consequences. Rule violation is likely to be viewed in relation to the total context in which it appears. Rules and judgments become less absolute and authoritarian. The situation and the morality of the rule itself influence reactions.

An 8-year-old girl tells the nurse that she has cancer because God is punishing her for "being bad." The nurse should interpret this as being which of the following?

a. A common belief at this age
b. Indicative of excessive family pressure
c. Faith that forms the basis for most religions
d. Suggestive of a failure to develop a conscience

ANS: A
Children at this age may view illness or injury as a punishment for a real or imagined misbehavior. School-age children expect to be punished and tend to choose a punishment that they think "fits the crime." This is a common belief and not related to excessive family pressure. Many faiths do not include a God that causes cancer in response for "bad" behavior. This statement reflects the child's belief in what is right and wrong.

What is the role of the peer group in the life of school-age children?

a. Decreases their need to learn appropriate sex roles
b. Gives them an opportunity to learn dominance and hostility
c. Allows them to remain dependent on their parents for a longer time
d. Provides them with security as they gain independence from their parents

ANS: D
Peer-group identification is an important factor in gaining independence from parents. Through peer relationships, children learn ways to deal with dominance and hostility. They also learn how to relate to people in positions of leadership and authority and how to explore ideas and the physical environment. A child's concept of appropriate sex roles is influenced by relationship with peers.

Which of the following is descriptive of the social development of school-age children?

a. Identification with peers is minimum.
b. Children frequently have "best friends."
c. Boys and girls play equally with each other.
d. Peer approval is not yet an influence for the child to conform.

ANS: B
Identification with peers is a strong influence in children's gaining independence from parents. Interaction among peers leads to the formation of close friendships with same-sex peers—"best friends." Daily relationships with age-mates in the school setting provide important social interaction for school-age children. During later school years, groups are composed predominantly of children of the same sex. Conforming to the rules of the peer group provides children with a sense of security and relieves them of the responsibility of making decisions.

Which of the following statements best describes the relationship school-age children have with their families?

a. Ready to reject parental controls
b. Desire to spend equal time with family and peers
c. Need and want restrictions placed on their behavior by the family
d. Peer group replaces the family as the primary influence in setting standards of behavior and rules

ANS: C
School-age children need and want restrictions placed on their behavior, and they are not prepared to cope with all the problems of their expanding environment. Although increased independence is the goal of middle childhood, they feel more secure knowing that an authority figure can implement controls and restriction. In the middle-school years, children prefer peer-group activities to family activities and want to spend more time in the company of peers. Family values usually take precedence over peer value systems.

A parent asks about whether a 7-year-old is able to care for a dog. Based on the child's age, the nurse suggests:

a. caring for an animal requires more maturity than the average 7-year-old possesses.
b. this will help the parent identify the child's weaknesses.
c. a dog can help the child develop confidence and emotional health.
d. cats are better pets for school-age children.

ANS: C
Pets have been observed to influence a child's self-esteem. They can have a positive effect on physical and emotional health and can teach children the importance of nurturing and nonverbal communication. Most 7-year-olds are capable of caring for a pet with supervision. Caring for a pet should be a positive experience. It should not be used to identify weaknesses. The pet chosen does not matter as much as the child's being responsible for a pet.

Which of the following is descriptive of the play of school-age children?

a. They like to invent games, making up the rules as they go.
b. Individuality in play is better tolerated than at earlier ages.
c. Knowing the rules of a game gives an important sense of belonging.
d. Team play helps children learn the universal importance of competition and winning.

ANS: C
Play involves increased physical skill, intellectual ability, and fantasy. Children form groups and cliques and develop a sense of belonging to a team or club. At this age, children begin to see the need for rules. Conformity and ritual permeate their play. Their games have fixed and unvarying rules, which may be bizarre and extraordinarily rigid. With team play, children learn about competition and the importance of winning, an attribute highly valued in the United States but not in all cultures.

Which of the following is characteristic of dishonest behavior in children ages 8 to 10 years?

a. Cheating during games is now more common.
b. Stealing can occur because their sense of property rights is limited.
c. Lying is used to meet expectations set by others that they have been unable to attain.
d. Dishonesty results from the inability to distinguish between fact and fantasy.

ANS: C
Older school-age children may lie to meet expectations set by others to which they have been unable to measure up. Cheating usually becomes less frequent as the child matures. Young children may lack a sense of property rights; older children may steal to supplement an inadequate allowance, or it may be an indication of serious problems. In this age-group, children are able to distinguish between fact and fantasy.

A 9-year-old girl often comes to the school nurse complaining of stomach pains. Her teacher says she is completing her school work satisfactorily, but lately has been somewhat aggressive and stubborn in the classroom. The school nurse should recognize this as which of the following?

a. Signs of stress
b. Developmental delay
c. Lack of adjustment to school environment
d. Physical problem that needs medical intervention

ANS: A
Signs of stress include stomach pains or headache, sleep problems, bed-wetting, changes in eating habits, aggressive or stubborn behavior, reluctance to participate, or regression to earlier behaviors. The child is completing school work satisfactorily; any developmental delay would have been diagnosed earlier. The teacher reports that this is a departure from the child's normal behavior. Adjustment issues would most likely be evident soon after a change. Medical intervention is not immediately required. Recognizing that this constellation of symptoms can indicate stress, the nurse should help the child identify sources of stress and how to use stress reduction techniques. The parents are involved in the evaluation process.

Which one of the following statements best describes fear in the school-age child?

a. Increasing concerns about bodily safety overwhelm them.
b. They should be encouraged to hide their fears to prevent ridicule by peers.
c. Most of the new fears that trouble them are related to school and family.
d. Children with numerous fears need continuous protective behavior by parents to eliminate these fears.

ANS: C
During the school-age years, children experience a wide variety of fears, but new fears related predominantly to school and family bother children during this time. Parents and other persons involved with children should discuss children's fear with them individually or as a group activity. Sometimes school-age children hide their fears to avoid being teased. Hiding the fears does not end them and may lead to phobias.

Which of the following is an important consideration in preventing injuries during middle childhood?

a. Achieving social acceptance is a primary objective.
b. Incidence of injuries in girls is significantly higher than it is in boys.
c. Injuries from burns are the highest at this age because of fascination with fire.
d. Lack of muscular coordination and control results in an increased incidence of injuries.

ANS: A
School-age children often participate in dangerous activities in an attempt to prove themselves worthy of acceptance. The incidence of injury during middle childhood is significantly higher in boys compared with girls. Motor vehicle collisions are the most common cause of severe injuries in children. The child has increasing muscular coordination. Those children who are risk takers may have inadequate self-regulatory behavior.

When teaching injury prevention during the school-age years, the nurse should include which of the following?

a. Teach child about need to fear strangers.
b. Teach basic rules of water safety.
c. Avoid letting child cook in microwave ovens.
d. Caution child against engaging in competitive sports.

ANS: B
Water safety instruction is an important component of injury prevention at this age. The child should be taught to swim, select safe and supervised places to swim, swim with a companion, check sufficient water depth for diving, and use an approved flotation device. Teach stranger safety, not fear of strangers. This includes telling the child not to go with strangers, not to wear personalized clothing in public places, to tell parents if anyone makes child feel uncomfortable, and to say no in uncomfortable situations. Teach the child safe cooking. Caution against engaging in dangerous sports such as jumping on trampolines.

Which of the following is an important consideration for the school nurse who is planning a class on bicycle safety?

a. Most bicycle injuries involve collision with an automobile.
b. Head injuries are the major causes of bicycle-related fatalities.
c. Children should wear a bicycle helmet if they ride on paved streets.
d. Children should not ride double unless the bicycle has an extra large seat.

ANS: B
The most important aspect of bicycle safety is to encourage the rider to use a protective helmet. Head injuries are the major cause of bicycle-related fatalities. Although motor vehicle collisions do cause injuries to bicyclists, most injuries result from falls. The child should always wear a properly fitted helmet approved by the U.S. Consumer Product Safety Commission. Children should not ride double unless it is a tandem bike (built for two).

When reviewing the allergy history of a patient, the nurse notes that the patient is allergic to penicillin. Based on this finding, the nurse would question an order for which class of antibiotics?

A. Tetracyclines
B. Sulfonamides
C. Cephalosporins
D. Imipenem-cilastatin

ANS: C
Allergy to penicillin may also result in hypersensitivity to cephalosporins. The other options are not correct.

When teaching a patient who will be taking tetracycline, which of the following instructions should the nurse share?

A. "Avoid direct sunlight and tanning beds while on this medication."
B. "Milk and cheese products result in increased levels of tetracycline."
C. "Antacids taken with the medication help to reduce gastrointestinal distress."
D. "Take the medication until you are feeling better."

ANS: A
Drug-related photosensitivity occurs when patients take tetracyclines, and it may continue for several days after therapy. Milk and cheese products result in decreased levels of tetracycline when the two are taken together. Antacids also interfere with absorption and should not be taken with tetracycline.

When reviewing the medication orders for a patient who is taking penicillin, the nurse notes that the patient is also taking the oral anticoagulant warfarin (Coumadin). What possible effect may occur as the result of an interaction between these drugs?

A. The penicillin will cause an enhanced anticoagulant effect of the warfarin.
B. The penicillin will cause the anticoagulant effect of the warfarin to decrease.
C. The warfarin will reduce the antiinfective action of the penicillin.
D. The warfarin will increase the effectiveness of the penicillin.

ANS: A
Administering penicillin reduces the vitamin K in the gut (intestines); therefore, enhanced anticoagulant effect of warfarin may occur.

A patient is receiving his third intravenous dose of a penicillin drug. He calls the nurse to report that he is feeling "anxious" and is having trouble breathing. What will the nurse do first?

A. Notify the physician.
B. Take the patient's vital signs.
C. Stop the antibiotic infusion.
D. Check for allergies.

ANS: C
Hypersensitivity reactions are characterized by wheezing; shortness of breath; swelling of the face, tongue, or hands; itching; or rash. The nurse should immediately stop the antibiotic infusion, have someone notify the physician, and stay with the patient to monitor the patient's vital signs and condition. Checking for allergies should have been done before the infusion.

A patient is admitted with a fever of 102.8 F (39.3 ° C), origin unknown. Assessment reveals cloudy, foul-smelling urine that is dark amber in color. Orders have just been written to obtain urine and blood cultures and to administer an antibiotic intravenously stat (now). The nurse will complete these orders in which sequence?

A. Blood culture, ampicillin dose, urine culture
B. Urine culture, ampicillin dose, blood culture
C. Ampicillin dose, blood and urine cultures
D. Blood and urine cultures, ampicillin dose

ANS: D
Culture specimens should be obtained before initiating drug therapy; otherwise, the presence of antibiotics in the tissues may result in misleading culture and sensitivity results.

During drug therapy with a tetracycline antibiotic, a patient complains of some nausea and anorexia. The nurse's best advice to the patient would be which of the following?

A. "Take it with cheese and crackers or yogurt."
B. "Take each dose with a glass of milk."
C. "Take an antacid with each dose as needed."
D. "Drink a full glass of water with each dose."

ANS: D
Oral doses should be given with at least 8 ounces of fluids and food to minimize gastrointestinal upset; however, antacids and dairy products will bind with the tetracycline and make it inactive.

The nurse is reviewing the sputum culture results of a patient with pneumonia and notes that the patient has a gram-positive infection. Which type of cephalosporin is most appropriate for this infection?

A. First generation
B. Second generation
C. Third generation
D. Fourth generation

ANS: A
First-generation cephalosporins provide excellent coverage against gram-positive bacteria but limited coverage against gram-negative bacteria.

A patient has a urinary tract infection. The nurse knows that which class of drugs is especially useful for such infections?

A. Sulfonamides
B. Carbapenems
C. Macrolides
D. Tetracyclines

ANS: A
These antibiotics achieve very high concentrations in the kidneys, through which they are eliminated. Therefore, sulfonamides are often used in the treatment of urinary tract infections.

SELECT ALL THAT APPLY.
During antibiotic therapy, the nurse should monitor closely for signs and symptoms of a hypersensitivity reaction. Which of the following may be an indication of a hypersensitivity reaction?

A. Wheezing
B. Diarrhea
C. Shortness of breath
D. Swelling of the tongue
E. Itching
F. Black, hairy tongue

ANS: A, C, D, E
Hypersensitivity reactions may be manifested by wheezing; shortness of breath; swelling of the face, tongue, or hands; itching; or rash.

When a patient is on aminoglycoside therapy, the nurse will monitor the patient for which indicators of potential toxicity?

A. Fever
B. White blood cell count of 7000 mm3
C. Tinnitus and hearing loss
D. Decreased creatinine levels

ANS: C
Tinnitus and hearing loss could indicate ototoxicity, a potentially serious toxicity in a patient. Nephrotoxicity is indicated by rising blood urea nitrogen and creatinine levels. Fever may be indicative of the patient's infection; a white blood count of 7000 mm3 is within the normal range of 5000 to 10,000.

The nurse is administering a vancomycin (Vancocin) infusion. Which measure is appropriate for the nurse to implement in order to reduce complications that may occur with this drug's administration?

A. Monitoring blood pressure for hypertension during the infusions
B. Infusing the drug rapidly
C. Restricting fluids during vancomycin therapy
D. Infusing the drug over at least 1 hour

ANS: D
Adequate hydration (at least 2 liters of fluid in 24 hours) during vancomycin therapy is important for the prevention of nephrotoxicity. The medication should be infused during at least 60 minutes to reduce red man syndrome. Hypotension may occur during the infusion, especially if it is given too rapidly.

Which of the following nursing diagnoses is appropriate for a patient who has started aminoglycoside therapy?

A. Constipation
B. Risk for injury (hearing loss)
C. Disturbed body image related to gynecomastia
D. Imbalanced nutrition, less than body requirements, related to nausea

ANS: B
Patients on aminoglycoside therapy have an increased risk for injury caused by ototoxicity. The other options are incorrect.

A patient who has been hospitalized for 2 weeks has developed a pressure ulcer that contains multidrug-resistant Staphylococcus aureus (MRSA). Which drug would the nurse expect to be chosen for his therapy?

A. metronidazole (Flagyl)
B. tobramycin (Nebcin)
C. vancomycin (Vancocin)
D. ciprofloxacin (Cipro)

ANS: C
Vancomycin is the drug of choice for the treatment of MRSA. The other drugs and drug classes are not used for MRSA.

A patient is receiving aminoglycoside therapy and will be receiving a beta-lactam antibiotic as well. The patient asks why two antibiotics have been ordered. What is the nurse's best response?

A. "The combined effect of both antibiotics is greater than each of them alone."
B. "The first antibiotic was not strong enough to work."
C. "We have not yet isolated the bacteria, so the two antibiotics are given to cover a wide range of microorganisms."
D. "We can give a reduced amount of each one if we give them together."

ANS: A
Aminoglycosides are often used in combination with other antibiotics, such as beta-lactams or vancomycin, in the treatment of various infections because the combined effect of the two antibiotics is greater than that of either drug alone.

The nurse is about to give a dose of vancomycin (Vancocin), but before doing so checks the patient's lab work and finds that the trough vancomycin level is 24 mcg/mL. What will the nurse do next?

A. Administer the vancomycin as ordered and draw a peak level.
B. Hold the drug and administer 4 hours later.
C. Hold the drug and notify the physician.
D. Repeat the test to verify results.

ANS: C
Optimal blood levels of vancomycin are a trough level of 10 to 20 mcg/mL. Measurement of peak levels is no longer routinely recommended, and only trough levels are commonly monitored. Blood samples for measurement of trough levels should be drawn immediately before administration of the next dose. Because of the increase in resistant organisms, many clinicians use a trough level of 15 to 20 mcg/mL as their goal. These trough levels mean that even just before the next dose is due, when drug levels should be low, the drug levels are actually too high.

SELECT ALL THAT APPLY.
The nurse who is administering aminoglycoside therapy must monitor the patient closely for signs of toxicity as manifested by which of the following?

A. Electrocardiogram changes
B. Hearing loss
C. Dizziness
D. Blood dyscrasias
E. Decreasing serum creatinine level
F. Rising serum creatinine level

ANS: B, C, F
Patients on aminoglycoside therapy must be monitored for signs of nephrotoxicity (rising serum creatinine level) and ototoxicity (hearing loss, dizziness). The other options are not signs of toxicity.

A patient is taking intravenous aminophylline for a severe exacerbation of chronic obstructive pulmonary disease. Which finding would the nurse expect when evaluating for a therapeutic response to the medication?

A. Increased work of breathing
B. Increased heart rate
C. Increased respiratory rate
D. Increased ease of breathing

ANS: D
The therapeutic effects of bronchodilating drugs such as xanthine derivatives include increased ease of breathing.

A patient is taking a xanthine derivative as part of treatment for chronic obstructive pulmonary disease. The nurse will monitor for adverse effects associated with the use of xanthine derivatives, including

A. diarrhea.
B. palpitations.
C. bradycardia.
D. drowsiness.

ANS: B
The common adverse effects of the xanthine derivatives include nausea, vomiting, and anorexia. In addition, gastroesophageal reflux has been observed to occur during sleep in patients taking these drugs. Cardiac adverse effects include sinus tachycardia, extrasystole, palpitations, and ventricular dysrhythmias. Transient increased urination and hyperglycemia are other possible adverse effects.

A patient is in an urgent-care center with an acute asthma attack. The nurse expects that which medication will be used for initial treatment?

A. An anticholinergic such as ipratropium (Atrovent)
B. A leukotriene receptor antagonist such as montelukast (Singulair)
C. A beta2 agonist such as albuterol (Proventil)
D. A corticosteroid such as fluticasone (Flovent)

ANS: C
The beta-agonists are commonly used during the acute phase of an asthmatic attack to reduce airway constriction quickly and to restore airflow to normal levels. The other drugs listed are not appropriate for acute asthma attacks. Anticholinergic drugs are used to prevent attacks; leukotriene receptor antagonists and corticosteroids are used to reduce airway inflammation.

The physician has changed a patient's medication regimen to include the leukotriene receptor antagonist zileuton (Zyflo) to treat her asthma. The nurse should emphasize which point about this medication?

A. The proper technique for inhalation must be followed.
B. The patient should keep it close by at all times to treat acute asthma attacks.
C. It should be taken every day on a continuous schedule, even if symptoms improve.
D. When the asthma symptoms improve, the dosage schedule can be tapered and eventually discontinued.

ANS: C
These drugs are indicated for chronic, not acute, asthma and should be taken every day on a continuous schedule, even if symptoms improve. These drugs are taken orally.

After receiving a nebulizer treatment with a beta-agonist, a patient complains of feeling slightly nervous and wonders if her asthma is getting worse. What is the nurse's best response?

A. "This is an expected adverse effect. Let me take your pulse."
B. "The next scheduled nebulizer treatment should be skipped."
C. "I will notify the physician about this adverse effect."
D. "We will hold the treatment for 24 hours."

ANS: A
Nervousness, tremors, and cardiac stimulation are possible and expected adverse effects of beta-agonists. The other options are not correct responses.

A patient has prescriptions for two inhalers. One inhaler is a bronchodilator, and the other is a corticosteroid. Which instruction regarding these inhalers should the nurse give to the patient?

A. "The corticosteroid should be taken first."
B. "The bronchodilator should be taken first."
C. "The two drugs should be taken at least 2 hours apart."
D. "The order of administration does not matter with these two drugs."

ANS: B
An inhaled beta2-agonist may be used before the inhaled corticosteroid to provide bronchodilation before administration of the antiinflammatory drug.

When educating a patient recently placed on inhaled corticosteroids, the nurse will discuss which potential adverse effects?

A. Fatigue and depression
B. Anxiety and peripheral vasoconstriction
C. Headache and rapid heart rate
D. Oral candidiasis and dry mouth

ANS: D
Oral candidiasis and dry mouth are two possible adverse effects of inhaled corticosteroids.

The nurse is monitoring the drug levels for a patient who is receiving theophylline. Which drug level is considered within therapeutic limits?

A. 14 mcg/mL
B. 18 mcg/mL
C. 24 mcg/mL
D. 30 mcg/mL

ANS: A
Although the optimal level may vary from patient to patient, most standard references have suggested that the therapeutic range for theophylline blood level is 10 to 20 mcg/mL. However, most clinicians now advise levels between 5 and 15 mcg/mL.

SELECT ALL THAT APPLY.
The nurse is reviewing medications for the treatment of asthma. Which drugs are used for acute asthma attacks?

A. Zafirlukast (Accolate) tablet
B. Albuterol (Proventil) nebulizer solution
C. Epinephrine
D. Montelukast (Singulair)
E. Fluticasone (Flovent) Rotadisk inhaler
F. Aminophylline IV infusion

ANS: B, C, F
Fluticasone is an inhaled corticosteroid; zafirlukast and montelukast are antileukotriene drugs. These types of medications are used for asthma prophylaxis. Albuterol (a beta2-agonist) and epinephrine (a beta1- and beta2-agonist) are used for acute bronchospasms. Aminophylline can be used for mild to moderate asthma attacks.

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