ANS: D ANS: A, B, C, D Sets found in the same folderThe nurse is seeing an adolescent boy and his parents in the clinic for the first time. What should the nurse do first? a. Introduce self. ANS: A The first thing that nurses should do is to introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they specify a preferred name. During the initial part of the interview, the nurse should include general conversation to help make the family feel at ease. Clarification of the purpose of the interview and the nurse's role is the next thing that should be done. The interview should take place in an environment as free of distraction as possible. In addition, the nurse should clarify which information will be shared with other members of the health care team and any limits to the confidentiality Which is most likely to encourage parents to talk about their feelings related to their child's illness? a. Be sympathetic. b. Use direct questions. c. Use open-ended questions. d. Avoid periods of silence. ANS: C Closed-ended questions should be avoided when attempting to elicit parents' feelings. Open-ended questions require the parent to respond with more than a brief answer. Sympathy is having feelings or emotions in common with another person rather than understanding those feelings (empathy). Sympathy is not therapeutic in helping the relationship. Direct questions may obtain limited information. In addition, the parent may consider them threatening. Silence can be an effective interviewing tool. It allows sharing of feelings in which two or more people absorb the emotion in depth. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions 3. Which communication technique should the nurse avoid when interviewing children and their families? ANS: B Using stereotyped comments or clichés can block effective communication, and this technique should be avoided. After use of such trite phrases, parents will often not respond. Silence can be an effective interviewing tool. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions. To be effective, the nurse must be able to direct the focus of the interview while allowing maximal freedom of expression. By using open-ended questions, along with guiding questions, the nurse can obtain the necessary information and maintain the relationship with the family. The nurse and parent must collaborate and define the problem that will be the focus of the nursing intervention Which following parameters correlate best with measurements of the body's total protein stores? a. Height ANS: D Upper arm circumference is correlated with measurements of total muscle mass. Muscle serves as the body's major protein reserve and is considered an index of the body's protein stores. Height is reflective of past nutritional status. Weight is indicative of current nutritional status. Skin-fold thickness is a measurement of the body's fat content A nurse is preparing to perform a physical assessment on a toddler. Which approach should the nurse use for this child? a. Always proceed in a head-to-toe direction. ANS: C Parents can remove clothing, and the child can remain on the parent's lap. The nurse should use minimal physical contact initially to gain the child's cooperation. The head-to-toe assessment can be done in older children but usually must be adapted in younger children. Traumatic procedures should always be performed last. These will most likely upset the child and inhibit cooperation. The nurse should introduce the equipment slowly. The child can inspect the equipment, but demonstrations are usually too complex for toddlers. The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother either staying in the room or leaving. This action should be considered: ANS: A When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet: a. indicates they live in poverty. ANS: C The diet that contains vegetable, legumes, and starches may provide sufficient essential amino acids, even though the actual amount of meat or dairy protein is low. Many cultures use diets that contain this combination of foods. It is not indicative of poverty. Combinations of foods contain the essential amino acids necessary for growth. A dietary assessment should be done, but many vegetarian diets are sufficient for growth The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active? ANS: B Asking the adolescent girl whether she is having sex with anyone is a direct question that is well understood. The phrase sexually active is broadly defined and may not provide specific information to the nurse to provide necessary care. The word anyone is preferred to using gender-specific terms such as boyfriend or girlfriend. Because homosexual experimentation may occur, it is preferable to use gender-neutral terms. Questioning about sexual activity should occur when the adolescent is alone 19. When
interviewing the mother of a 3-year-old child, the nurse asks about developmental milestones such as the age of walking without assistance. This should be considered: ANS: C Information about the attainment of developmental milestones is important to obtain. It provides data about the child's growth and development that should be included in the past history. Developmental milestones provide important information about the child's physical, social, and neurologic health and should be included in the history for a 3-year-old child. If pertinent, attainment of milestones by siblings would be included in the family history. The review of systems does not include the developmental milestones
18. Which is most important to document about immunizations in the child's health history? a. Dosage of immunizations received ANS: B
17. The nurse is interviewing the mother of an infant. She reports, "I had a difficult delivery, and my baby was born prematurely." This information should be recorded under which of the following headings? ANS: A The past history refers to information that relates to previous aspects of the child's health, not to the current problem. The mother's difficult delivery and prematurity are important parts of the past history of an infant. The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Unless the chief complaint is directly related to the prematurity, this information is not included in the history of present illness. The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. It would not include the birth information. The review of systems is a specific review of each body system. It does not include the premature birth. Sequelae such as pulmonary dysfunction would be included 16. Where in the health history should the nurse describe all details related to the chief complaint? a. Past history ANS: C
4. . What is the single most important factor to consider when communicating with children? ANS: C The nurse must be aware of the child's developmental stage to engage in effective communication. The use of both verbal and nonverbal communication should be appropriate to the developmental level. Although the child's physical condition is a consideration, developmental level is much more important. The parents' presence is important when communicating with young children but may be detrimental when speaking with adolescents. Nonverbal behaviors will vary in importance, based on the child's developmental level 5. Which approach would be best to use to ensure a positive response from a toddler? ANS: A It is important that the nurse assume a position at the child's level when communicating with the child. By speaking quietly and focusing on the child, the nurse should be able to obtain a positive response. The nurse should engage the child and inform the toddler what is going to occur. If the nurse picks up the child without explanation, the child is most likely going to become upset. The toddler may not understand the meaning of the phrase, "I'm your nurse." If a positive response is desired, the nurse should assume the child's level when speaking if possible. 6. What is an important consideration for the nurse who is communicating with a very young child? ANS: B Using a transition object allows the young child an opportunity to evaluate an unfamiliar person (the nurse). This will facilitate communication with a child this age. Speaking in this manner will tend to increase anxiety in very young children. The nurse must be honest with the child. Attempts at deception will lead to a lack of trust. Whenever possible, the parent should be present for interactions with young children 7. A nurse is preparing to assess a 3-year-old child. What communication technique should the nurse use for this child? ANS: A Because children of this age are able to see things only in terms of themselves, the best approach is to focus communication directly on them. Children should be provided with information about what they can do and how they will feel. With children who are egocentric, experiences of others, analogies, and assurances that the communication is private will not be effective because the child is not capable of understanding 8. The nurse's approach when introducing hospital equipment to a preschooler should be based on which principle? ANS: A 9. A nurse is assigned to four children of different ages. In which age group should the nurse understand that body integrity is a concern? a. Toddler ANS: C 10. An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is to: a. ask her why she wants to know. ANS: C 11. When the nurse interviews an adolescent, which is especially important? ANS: B 12.
The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique might be most helpful? ANS: D Drawing is one of the most valuable forms of communication. Children's drawings tell a great deal about them because they are projections of the child's inner self. It would be difficult for a 6-year-old child who is most likely learning to read to keep a diary. Parents reading fairy tales to the child is a passive activity involving the parent and child. It would not facilitate communication with the nurse. The child is in a stressful situation and is probably uncomfortable with strangers 13. The nurse is meeting a 5-year-old child for the first time and would like
the child to cooperate during a dressing change. The nurse decides to do a simple magic trick using gauze. This should be interpreted as: . ANS: B A magic trick or other simple game may help alleviate anxiety for a 5-year-old. It is an excellent method to build rapport and facilitate cooperation during a procedure. Magic tricks appeal to the natural curiosity of young children. The nurse should establish rapport with the child. Failure to do so may cause the procedure to take longer and be more traumatic. 14. The nurse must assess 10-month-old infant. The infant is sitting on the father's lap and appears to be afraid of the nurse and of what might happen next. Which initial action by the nurse would be most
appropriate? ANS: A Peek-a-boo is an excellent means of initiating communication with infants while maintaining a safe, nonthreatening distance. The child will most likely become upset if separated from his father. As much of the assessment as possible should be done on the father's lap. The nurse should have the father undress the child as needed for the examination 15. The nurse is taking a health history on an adolescent. Which best describes how the chief complaint should be determined? ANS: B The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. Because the adolescent is the focus of the history, this is an appropriate way to determine the chief complaint. A detailed listing of symptoms will make it difficult to determine the chief complaint. The adolescent should be prompted to tell which symptom caused him to seek help at this time. The chief complaint is usually written in the words that the parent or adolescent uses to describe the reason for seeking help. The parent and adolescent may be interviewed separately, but the nurse should determine the reason the adolescent is seeking attention at this time. 33. Where is the best place to observe for the presence of petechiae in dark-skinned individuals? ANS: C Petechiae, small distinct pinpoint hemorrhages, are difficult to see in dark skin unless they are in the mouth or conjunctiva 34. The nurse observes yellow staining in the sclera of eyes, soles of feet, and palms of hands. This should be interpreted as: ANS: C Jaundice is defined as the yellow staining of the skin, usually by bile pigments. Yellow staining is not a normal appearance of the skin. Erythema is redness that results from increased blood flow to the area. Ecchymosis is large, diffuse areas, usually black and blue, caused by hemorrhage of blood into the skin. 35. When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. What is the best
explanation for this? ANS: D 36. During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which is the nurse's most appropriate action? ANS: C 25. A nurse is counseling parents of a child beginning to show signs of being overweight. The nurse accurately relates which
body mass index (BMI)-for-age percentile indicates a risk for being overweight? ANS: C Children who have BMI-for-age greater than or equal to the 85th percentile and less than the 95th percentile are at risk for being overweight. Children in the 9th and 10th percentiles are within normal limits. Children who are greater than or equal to the 95th percentile are considered overweight. 26. The nurse is using the NCHS growth chart for an African-American child. Which statement should the nurse consider? ANS: D The NCHS growth charts can serve as reference guides for all racial or ethnic groups. U.S. African-American children were included in the sample population. The growth chart can be used with the perspective that different groups of children have varying normal distributions on the growth curves. No correction factor exists 27. Which tool measures body fat most accurately? a. Stadiometer ANS: B Calipers are used to measure skin-fold thickness, which is an indicator of body fat content. Stadiometers are used to measure height. Cloth tape measures should not be used because they can stretch. Paper or metal tape measures can be used for recumbent lengths and other body measurements that must be made 28. The nurse is using calipers to measure skin-fold thickness over the triceps muscle in a school-age child. What is the purpose of doing this? a. To measure body fat ANS: A 29. A nurse notes that a 10-month-old infant has a larger head circumference than chest. The nurse interprets this as a normal finding because the head and chest circumference become equal at which age? ANS: C 30. Which would be best for the nurse to use when determining the temperature of a preterm infant under a radiant heater? a. Axillary sensor ANS: A The axillary sensor measures the infrared heat energy radiating from the axilla. It can be used on wet skin, in incubators, or under radiant warmers. Ear thermometry does not show sufficient correlation with established methods of measurement. It should not be used when body temperature must be assessed with precision. Mercury thermometers should never be used. The release of mercury, should the thermometer be broken, can cause harmful vapors. Rectal temperatures should be avoided unless no other suitable way exists for the temperature to be measured 31. What is the earliest age at which a satisfactory radial pulse can be taken in children? ANS: B Satisfactory radial pulses can be used in children older than 2 years. In infants and young children, the apical pulse is more reliable. The apical pulse can be used for assessment at these ages 32. Pulses can be graded according to certain criteria. Which is a description of a normal pulse: a. 0 ANS: D 37. The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action? ANS: A 38.
At what age should the nurse expect the anterior fontanel to close? ANS: D During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is a(n): ANS: A 40. Parents of a newborn are concerned because the infant's eyes often "look crossed" when the infant is looking at an object. The nurse's response is that this is normal based on the knowledge that binocularity is normally present by what age? ANS: B Binocularity is usually achieved by ages 3 to 4 months. 1 month is too young. If binocularity is not achieved by ages 6 to 12 months, the child must be observed for strabismus |