1. The nurse is discussing growth and development with the parents of a four-year-old child. The nurse should identify which of the following as the type of play characteristic of this age group?
1. Solitary play.
2. Parallel play.
3. Associative play.
4. Aggressive play.
2. The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which of the following is the BEST response by the nurse?
1. 11 months of age.
2. 14 months of age.
3. 17 months of age.
4. 20 months of age.
. The school nurse observes a group of preschool children in the playroom. The nurse recognizes which of the following activities as appropriate behavior for a five-year-old boy?
1. The boy plays with a large truck with another child.
2. The boy talks on a toy telephone and imitates his father.
3. The boy works on a puzzle with several other children.
4. The boy holds and cuddles a large stuffed animal.
4. A mother brings her nine-month-old child to the pediatrician's office for complaints of a fever of 102.2ºF (39ºC) and frequent vomiting. The nurse would expect which of the following reflexes to still be present?
1. Babinski's reflex.
2. Moro's reflex.
3. Tonic neck reflex.
4. Grasp reflex.
5. The nurse in the pediatrician's office observes a child in the waiting room. The nurse notes the child can walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet. The nurse identifies the child's chronological age to be:
1. 1 year-old.
2. 2-years-old.
3. 3-years-old.
4. 5-years-old.
RESPI 5 items
1. An 18-month-old is admitted to the unit with a diagnosis of laryngotracheobronchitis (LTB). During the initial assessment, the nurse should expect to find which of the following early symptoms?
1. Kussmaul respirations and bradycardia.
2. Elevated temperature and slow respiratory rate.
3. Expiratory wheezing and substernal retractions.
4. Inspiratory stridor and restlessness.
2. The nurse is planning a diet for an eight-year-old with cystic fibrosis (CF). Which of the following dietary requirements should be considered?
1. High protein, high fat, and high calories.
2. High protein, low fat, and high calories.
3. Low protein, low fat, and low carbohydrate.
4. High protein, high fat, and low carbohydrate.
3. The nurse in the outpatient clinic teaches the mother of a 10-year-old boy with asthma how to prevent future asthmatic attacks. The nurse would be MOST concerned if the mother made which of the following statements?
"My son plays the tuba in the grade school band."
"My son loves to help his dad rake leaves."
"My son participates in after-school activities three days a week."
"My son walks one mile to school every day with his friends."
4. The nurse is assessing a child with cystic fibrosis. The nurse would be MOST concerned if which of the following was observed?
1. The child is expectorating thick yellow mucus.
2. There is increased mucus production with postural drainage.
3. Exertional dyspnea increases during the day.
4. The child complains about difficulty breathing.
5. The nurse is caring for an eight-year-old child after a tonsillectomy. The nurse would be MOST concerned if which of the following was observed?
1. Heart rate of 88 beats per minute.
2. Expectorating bright red secretions.
2. 30 ml of dark brown secretions.
4. Infrequent swallowing.
GASTRO 5 items
1. The nurse is preparing discharge teaching for the parents of a newborn. Which of the following information should the nurse provide to the parents regarding the accuracy of a PKU (phenylketonuria) test?
1. Breastfed babies need to be a week old for the test, and infants on formula can be tested in three days.
2. The infant can have water but should not have formula for six hours before the test.
3. The test will need to be repeated at six weeks and at the three-month check-up.
4. Blood will be drawn at three one-hour intervals; there is no specific preparation.
2. The nurse is caring for a two-month-old infant. A pH probe test indicates that the infant has reflux. Which nursing action is MOST appropriate?
1. Hold the next feeding.
2. Teach the mother CPR.
3. Maintain a normal feeding schedule.
4. Elevate the head of the bed.
3. The nurse is assessing an infant who had a repair of a cleft lip and palate. The respiratory assessment reveals that the infant has upper airway congestion and slightly labored respirations. Which of the following nursing actions would be MOST appropriate?
1. Elevate the head of the bed.
2. Suction the infant's mouth and nose.
3. Position the infant on one side.
4. Administer oxygen until breathing is easier.
4. The nurse knows that which of the following plans would be a priority for an infant with a positive PKU blood test?
1. Place the infant on Lofenlac formula.
2. Administer medium-chain triglyceride (MCT) oil with each feeding.
3. Provide genetic counseling for the family.
4. Place the infant on Lorenzo's Oil treatments.
5. The nurse is instructing the parents of a child with celiac disease. The nurse knows that teaching has been effective when the parents make which of the following statements?
1. "My child's diet should include raw vegetables, fruits, and crackers."
2. "My child's diet should be high in carbohydrates, high in calories, and high in proteins."
3. "The only restriction in my child's diet should be breads and cereals."
4. "My child's diet should be high in calories, high in protein, and restrict from pasta, hotdogs & meat extenders.
NEURO 5 items
1. The nurse obtains a history from the father of a six-year-old boy with a history of epilepsy admitted with uncontrolled seizures. It is MOST important for the nurse to ask which of the following questions?
1. "What part of the body was affected by the seizure?"
2. "What is the family history of seizure disorders?"
3. "What was your son doing before the seizure?"
4. "How long has it been since his last episode of seizures?"
2. The home care nurse is visiting an infant who had a myelomeningocele repair. The home care nurse determines that the parents are accepting of their infant if which of the following is observed?
1. The parents state that the infant will outgrow this problem in time.
2. The parents ask a neighbor to perform bladder expression.
3. The parents measure the head circumference daily.
4. The parents relate that they believe the child will walk in one year.
3. The nurse is caring for a four-year-old child with a closed head injury. The nurse would be reassured by which of the following observations?
1. The child is able to state his name when asked who he is.
2. The child reaches for a stuffed animal brought from home.
3. The child maintains himself in opisthotonos.
4. The child withdraws from mildly painful stimuli.
4. The nurse is performing teaching on a client with Bell's palsy. It is MOST important for the nurse to include which of the following instructions?
1. Use artificial tears 4 times per day.
2. Wear sunglasses at all times.
3. Avoid sudden movements of the head.
4. Change the pillowcase daily.
5. An 8-year-old boy is brought to the physician's office by his mother. The mother is concerned because the boy has a fever, vomited twice, and slept all day yesterday with the curtains closed. The boy complains of headache, nausea, and has a temperature of 103°F (39.3°C). The nurse observes the boy has a petechial rash on the trunk of his body.
Which of the following assessments would be MOST important for the nurse to perform?
1. Grasp the child's hands and ask him to squeeze the nurse's hands.
2. Stroke the plantar surface of the child's foot with a reflex hammer.
3. Gently flex the child's head and neck onto the chest.
Cardio 5 items
1. Cerebrovascular accident associated with congenital heart disease results mainly from:
A. Altered pulmonary blood flow
B. Cardiomegaly
C. Decreased exercise tolerance
D. Polycythemia
RATIONALE:
Polycythemia is stimulated by chronic hypoxia associated w/ congestive heart disease. Overabundance of RBCs makes the blood more viscous, increasing the risk of CVA. Children w/ congenital heart disease have altered pulmonary blood flow caused by anatomic deviations; most have decreased exercise tolerance from insufficient nutritional intake & increased metabolic demands. However, altered pulmonary blood flow does not cause CVA. Cardiomegaly may result from heart failure or congenital heart disease; it’s not associated w/ CVA.
2. Blood pressure that varies among extremities is a common finding in children with:
A. Aortic stenosis
B. Coarctation of the aorta
C. Patent ductus arteriosus
D. Atrial septal defect
RATIONALE:
>> A child w/ coarcation of the aorta has bounding pulses & high blood pressure in aread of the body receving blood from vessels proximal to the defect. A child w/ PDA typically has a wide pulse pressure caused by a low diastolic pressure from the shunting of blood. A child w/ aortic stenosis typically shows no symptoms except for a possible systolic heart murmur. A child w/ atrial sepatl defect typically has a harsh systolic murmur.
3. In a child with TOF, cyanosis results from:
A. a left-to-right shunt through a ventricular septal defect
B. A right-to-left shunt through a ventricular septal defect
C. An increase in pulmonary blood flow
D. A left-to-right shunt through a Blalock-Taussig shunt
RATIONALE:
>> A R-L shunt thru a ventricular septal defect forces desaturated blood to enter the systemic circulation, decreasing arterial oxygen tension & causing cyanosis (bluish skin discoloration). IN TOF, decreased pulmonary blood flowcombined with a R-L shunt causes cyanosis. The Blalock-Taussig procedure is a temporary surgical procedure used to treat hypoxic episodes; it is not the cause of cyanosis, but rather a temporary measure to correct it.
4. The nurse knows that dixogin, like other cardiac glycosides, can be extremely toxic. Which of the following is an early sign of digitalis toxicity?
A. Bradycardia
B. Increased activity
C. Respiratory distress
D. Tachycardia
RATIONALE:
>> Bradycardia & vomiting are early signs of digitalis toxicity. In excessive bld drug levels, digoxin depresses sinoatrial node automaticity, markedly slowing the heart rate. Vomiting results from stimulation of the emetic control center in the medulla. Other symptoms of digitalis toxicity include: visual disturbances (yellow-green halos), headache, & fatigue. Increased activity & respiratory distress are not indicative of digitalis toxicity.
5. Karen is scheduled to undergo cardiac catheterization. Which nursing action takes the highest priority immediately after this procedure?
A. Obtaining a complete blood count
B. Increasing her oral fluid intake
C. Performing a neurologic assessment
D. Checking her vital signs
>> The nurse should check V/S q 15 mins after cardiac catheterization by checking the HR for 1` min to detect bradycardia or arrhythmias, checking the pulses for equality, & checking the blood pressure for hypotension (w/c may indicate hemorrhage) . A complete blood count is obtained before cardiac catheterization & may not be necessary afterward. Because Karen has had no oral intake, the nurse should encourage oral fluid intake ; however, this is not a priority because she still may be receiving an IV infusion as a source of hydration. Neurologic assessment is not required after cardiac catheterization.
MUSCULO 5 items
1. The nurse is caring for an 11-year-old patient being treated for a fractured right femur with balanced suspension traction with a Thomas splint and Pearson attachment. The nurse notes that the patient's left leg is externally rotated. The nurse should:
Place a trochanter roll on the outer aspect of the thigh.
Perform resistive range of motion of the left leg.
Adduct and internally rotate the left leg.
Instruct the patient to maintain the left leg in a neutral position.
2. The nurse is caring for a six-year-old boy several hours after the application of a hip spica cast. The patient turns on the call light and complains of pain in his left foot. Which of the following actions should the nurse take FIRST?
1. Elevate the left leg on two pillows.
2. Palpate the cast for warmth and wetness.
3. Administer pain medication as ordered.
4. Check the blanching sign on both feet.
3. A 20-year-old woman with a fracture of the left femur is placed in Buck's traction with a 7-lb weight. The patient keeps sliding down in bed. The nurse should:
1. Elevate The Patient's Left Thigh On Two Pillows.
2. Elevate The Foot Of The Bed On Blocks.
3. Raise The Knee Gatch On The Bed 30º.
4. Instruct The Patient To Remain In The Middle Of The Bed.
4 A brace is ordered for a young teen with scoliosis. The nurse knows that teaching has been effective if the client makes which of the following statements?
"I will have my parents put bed-boards on my bed."
"I should decrease my caloric intake."
"I should only take tub baths."
"I can remove the brace for one hour a day."
5. The nurse is caring for clients in the outpatient clinic. Which of the following messages should the nurse return FIRST?
1. A mother reports that the umbilical cord of her five-day-old infant is dry and hard to the touch.
2. A mother reports that the "soft spot" on the head of her four-day-old infant feels slightly elevated when the baby sleeps.
3. A mother reports that the circumcision of her 3-day-old infant is covered with yellowish exudate.
4. A father reports that he bumped the crib of his two-day-old infant and she violently extended her extremities and returned to them their previous position.
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