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Terms in this set (416)
The practical nurse (PN) is monitoring a child who is Answer: A
manifesting signs of shock after a motor vehicle collision.
Which finding is most important for the PN to report to the Rationale:
charge nurse? As shock progresses, perfusion in the microcirculation becomes marginal despite
compensatory adjustments, and the signs of decompensated shock become
a) narrowing pulse pressure pronounced, such as tachycardia and narrowing pulse pressure (A). (The difference
b) apprehension between systolic and diastolic blood pressure), which should be reported immediately.
c) irritability (B,C, and D) are not as significant as (A).
d) thirst
The mother of a 9 month old male infant is concerned Answer: B
because he cries whenever she leaves him with a sitter.
What is the best response for the practical nurse (PN) to Rationale:
provide? Healthy attachment is manifested by stranger anxiety in late infancy (B). Pain from
teething expressed by the infant's cries does not occur only when the mother leaves
a) "Have you noticed whether your baby is teething?" the infant with another person (A). The PN should evaluate the infant's developmental
b) "Crying when you leave him in a healthy sign of needs (C) before suggesting the infant may be ill. An infant who manifests stranger
attachment." anxiety is best supported by the mother if the infant is left for shorter periods of time,
c) "Consider taking the baby to the doctor because he may not (D).
be ill."
d) "You could consider leaving the infant more often so he
can adjust."
Which preoperative action is most important for the practical Answer: C
nurse (PN) to implement for a newborn with
meningomyelocele? Rationale:
A meningomyelocele provides a direct entry for bacteria into the central nervous
a) document vital signs system, leading to meningitis. Measures that protect the integrity of the
b) prevent skin breakdown meningomyelocele sac and infection control measures should be implemented to
c) minimize the risk for infection minimize the risk of infection (C). (A,B, and D) should be implemented but do not have
d) monitor neurologic functioning the priority of (C).
, The practical nurse is caring for a 6 year old girl who had Answer: B
surgery 12 hours ago. The child tells the PN that she does
not have pain but a few minutes later, tells her parents that Rationale:
she does. What child development concept is relevant to A child may fear receiving an injection for pain or may believe that pain is a deserved
this situation? punishment for some misdeed, so the pain is denied (D) when the nurse asks the
child, who then readily admits having pain to a parent. This behavior should not be
a) inconsistency in pain reporting suggests that pain not interpreted as (C) but as a valid indication of pain. (A and C) are incorrect
present interpretations of this behavior.
b) a child may have pain yet deny its presence to the nurse
c) truthful reporting of pain should occur by this age
d) children use pain experiences to manipulate their parents
A 6 year old who had a tonsillectomy 12 hours ago is Answer: A
complaining of thirst. What should the practical nurse (PN)
offer? Rationale:
Small amounts of clear liquids without red dyes should be offered to the child.
a) popsicle Popsicles (A) are cold and help soothe a dry throat. Citrus drinks (B and C) are acidic
b) lemonade and irritate the operative site in the posterior oropharynx. Milk (D) thickens oral mucus
c) orange juice which makes swallowing more difficult and causes coughing.
d) chocolate milk
The mother of a male newborn calls the clinic to inquire Answer: A
about the formation of a yellow crust over her son's
circumcision area. What information should the practical Rationale:
nurse (PN) provide? Crust formation is part of the healing process and should be removed (A). (C) is not
indicated at this time. The diaper should be fastened loosely, not tightly (D) which can
a) do not remove the yellow crust from the site place pressure on the incision site. (B) assists in the healing process and should not
b) stop using petroleum around the head of the penis be discontinued.
c) bring him into the clinic
d) tightly fasten the diaper
The mother of a child with croup is having barking, coughing Answer: C
episodes calls the clinic for assistance. What action should
the practical nurse (PN) recommend that the mother Rationale:
implement first? Croup (laryngotracheobronchitis) is a viral infection that causes a "barking" cough and
varying degrees of inspiratory stridor, which often responds to a high humidity
a) take the child outside in the cool air environment. Most children can be managed at home using the stream from a hot
b) bring the child directly to the emergency room shower in a closed bathroom (C) which often stops laryngeal spasm. Increasing the
c) sit with the child in bathroom with a hot shower running child's fluid intake is important (D), but not a priority at this time.Although exposure to
d) have the child drink plenty of fluids cold air (A) also relieves stridor, parents should be encouraged to use mist humidifier
in the child's room. (B) is not necessary unless the child is having increasingly
difficulty breathing that may lead to a compromised airway.
Which finding should the practical nurse confirm with the Answer: A
parents of an infant who is admitted with possible
intussusception? Rationale:
Red currant jelly stools (A) is a sign of intussusception, which causes a mixture of
a) red currant jelly stools stool, mucous, and blood as the intestines telescopes inside itself. (D) is associated
b) clay colored stools with pyloric stenosis. (B) is consistent with biliary obstruction. Infants with
c) constant abdominal pain intussusception usually have periods of severe pain followed by intervals in which they
d) projectile vomiting after meals appear comfortable, not (C).
The practical nurse (PN) is observing a group of children at Answer: B
a day care center to determine whether children are
achieving developmental milestones. Which activity should Rationale:
the PN identify as typical for a 2 year old child's cognitive Although children develop at different rates, a 2 year old typically uses short
development? sentences to express independence and control (B) and has a vocabulary of up to 300
words, not (A). At the age of 2 years, a toddler is developing negativism without
a) has a vocabulary of about 1000 words understanding the concepts of right and wrong (D). A 2 year old engages in solitary
b) uses short sentences to express self play and parallel play but does not initiate or cooperative with other children (C) in
c) initiates play with other children play, which begins with socialization of the preschool child.
d) recognizes right and wrong
The practical nurse (PN) is interviewing a 10 year old girl Answer: C
about school and her extracurricular activities. She
responds, "I like school. I play the flute in the school band, Rationale:
and I take tennis lessons." Based on Erikson's psychosocial Erikson's stage of industry (C) for a school aged child is demonstrated by successful
theory, the PN identifies that this child is in what stage of participation in new skills and peer activities, such as sports and band. (A, B, and D)
development? are achieved in other age groups.
a) identity
b) intimacy
c) industry
d) initiative
The practical nurse (PN) identifies an increased frequency Answer: A
of otitis media (OM) is children who are coming to the clinic.
Based on this finding, which age group should the PN Rationale:
monitor a child for signs and symptoms of OM? Infants and toddlers (A) are most prone to otitis media due to the anatomical structure
of the eustachian tube that allows fluid and microbial entry into the middle ear. (B, C,
a) toddler and D) are most susceptible to acute infectious diseases acquired through
b) preschooler environmental transmission from daycare or school settings.
c) school ager
d) adolescent
The practical nurse (PN) collects information about infant Answer: D
growth and development milestones for infants who come to
the clinic for a well child visit. Which findings should the PN Rationale:
document as normal infant growth and development? Infants gain approximately 1.5 pounds/month until age 5 to 6 months, when the birth
weight doubles, and by 1 year of age, the birth weight usually triples (D). The anterior
a) maternal iron stores persist during the first 12 months of fontanel closes by 12 to 18 months of age, with the average being 14 months, not (B).
life Binocularity begins to develop by 6 weeks of age and should be well established by
b) anterior fontanel closes by 6 to 10 months of age age 4 months, not (C). Maternally derived iron stores ares present for the first 5 to 6
c) binocularity is well established by 8 months of age months and gradually diminish, which results in an expected lowered hemoglobin
d) birth weight double by age 5 months and triples by 1 year levels toward the end of the first 6 months (A).
Which nonfood item is the most common cause of Answer: A
respiratory arrest in young children?
Rationale:
a) latex balloons Nonfood items cause the majority of choking deaths in young children. Latex balloons
b) broken rattles (A), whether partially inflated, uninflated, or popped, are the leading cause of pediatric
c) buttons choking that leads to aspiration of small objects (A,B, and D) because they experience
d) pacifiers the environment by placing objects in the mouth, but (A) is the leading cause of death
causing respiratory obstruction and arrest.
P
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P
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di
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Students
also
studied
Terms in this set (416)
The practical nurse (PN) is monitoring a child who is Answer: A
manifesting signs of shock after a motor vehicle collision.
Which finding is most important for the PN to report to the Rationale:
charge nurse? As shock progresses, perfusion in the microcirculation becomes marginal despite
compensatory adjustments, and the signs of decompensated shock become
a) narrowing pulse pressure pronounced, such as tachycardia and narrowing pulse pressure (A). (The difference
b) apprehension between systolic and diastolic blood pressure), which should be reported immediately.
c) irritability (B,C, and D) are not as significant as (A).
d) thirst
The mother of a 9 month old male infant is concerned Answer: B
because he cries whenever she leaves him with a sitter.
What is the best response for the practical nurse (PN) to Rationale:
provide? Healthy attachment is manifested by stranger anxiety in late infancy (B). Pain from
teething expressed by the infant's cries does not occur only when the mother leaves
a) "Have you noticed whether your baby is teething?" the infant with another person (A). The PN should evaluate the infant's developmental
b) "Crying when you leave him in a healthy sign of needs (C) before suggesting the infant may be ill. An infant who manifests stranger
attachment." anxiety is best supported by the mother if the infant is left for shorter periods of time,
c) "Consider taking the baby to the doctor because he may not (D).
be ill."
d) "You could consider leaving the infant more often so he
can adjust."
Which preoperative action is most important for the practical Answer: C
nurse (PN) to implement for a newborn with
meningomyelocele? Rationale:
A meningomyelocele provides a direct entry for bacteria into the central nervous
a) document vital signs system, leading to meningitis. Measures that protect the integrity of the
b) prevent skin breakdown meningomyelocele sac and infection control measures should be implemented to
c) minimize the risk for infection minimize the risk of infection (C). (A,B, and D) should be implemented but do not have
d) monitor neurologic functioning the priority of (C).
, The practical nurse is caring for a 6 year old girl who had Answer: B
surgery 12 hours ago. The child tells the PN that she does
not have pain but a few minutes later, tells her parents that Rationale:
she does. What child development concept is relevant to A child may fear receiving an injection for pain or may believe that pain is a deserved
this situation? punishment for some misdeed, so the pain is denied (D) when the nurse asks the
child, who then readily admits having pain to a parent. This behavior should not be
a) inconsistency in pain reporting suggests that pain not interpreted as (C) but as a valid indication of pain. (A and C) are incorrect
present interpretations of this behavior.
b) a child may have pain yet deny its presence to the nurse
c) truthful reporting of pain should occur by this age
d) children use pain experiences to manipulate their parents
A 6 year old who had a tonsillectomy 12 hours ago is Answer: A
complaining of thirst. What should the practical nurse (PN)
offer? Rationale:
Small amounts of clear liquids without red dyes should be offered to the child.
a) popsicle Popsicles (A) are cold and help soothe a dry throat. Citrus drinks (B and C) are acidic
b) lemonade and irritate the operative site in the posterior oropharynx. Milk (D) thickens oral mucus
c) orange juice which makes swallowing more difficult and causes coughing.
d) chocolate milk
The mother of a male newborn calls the clinic to inquire Answer: A
about the formation of a yellow crust over her son's
circumcision area. What information should the practical Rationale:
nurse (PN) provide? Crust formation is part of the healing process and should be removed (A). (C) is not
indicated at this time. The diaper should be fastened loosely, not tightly (D) which can
a) do not remove the yellow crust from the site place pressure on the incision site. (B) assists in the healing process and should not
b) stop using petroleum around the head of the penis be discontinued.
c) bring him into the clinic
d) tightly fasten the diaper
The mother of a child with croup is having barking, coughing Answer: C
episodes calls the clinic for assistance. What action should
the practical nurse (PN) recommend that the mother Rationale:
implement first? Croup (laryngotracheobronchitis) is a viral infection that causes a "barking" cough and
varying degrees of inspiratory stridor, which often responds to a high humidity
a) take the child outside in the cool air environment. Most children can be managed at home using the stream from a hot
b) bring the child directly to the emergency room shower in a closed bathroom (C) which often stops laryngeal spasm. Increasing the
c) sit with the child in bathroom with a hot shower running child's fluid intake is important (D), but not a priority at this time.Although exposure to
d) have the child drink plenty of fluids cold air (A) also relieves stridor, parents should be encouraged to use mist humidifier
in the child's room. (B) is not necessary unless the child is having increasingly
difficulty breathing that may lead to a compromised airway.
Which finding should the practical nurse confirm with the Answer: A
parents of an infant who is admitted with possible
intussusception? Rationale:
Red currant jelly stools (A) is a sign of intussusception, which causes a mixture of
a) red currant jelly stools stool, mucous, and blood as the intestines telescopes inside itself. (D) is associated
b) clay colored stools with pyloric stenosis. (B) is consistent with biliary obstruction. Infants with
c) constant abdominal pain intussusception usually have periods of severe pain followed by intervals in which they
d) projectile vomiting after meals appear comfortable, not (C).
The practical nurse (PN) is observing a group of children at Answer: B
a day care center to determine whether children are
achieving developmental milestones. Which activity should Rationale:
the PN identify as typical for a 2 year old child's cognitive Although children develop at different rates, a 2 year old typically uses short
development? sentences to express independence and control (B) and has a vocabulary of up to 300
words, not (A). At the age of 2 years, a toddler is developing negativism without
a) has a vocabulary of about 1000 words understanding the concepts of right and wrong (D). A 2 year old engages in solitary
b) uses short sentences to express self play and parallel play but does not initiate or cooperative with other children (C) in
c) initiates play with other children play, which begins with socialization of the preschool child.
d) recognizes right and wrong
The practical nurse (PN) is interviewing a 10 year old girl Answer: C
about school and her extracurricular activities. She
responds, "I like school. I play the flute in the school band, Rationale:
and I take tennis lessons." Based on Erikson's psychosocial Erikson's stage of industry (C) for a school aged child is demonstrated by successful
theory, the PN identifies that this child is in what stage of participation in new skills and peer activities, such as sports and band. (A, B, and D)
development? are achieved in other age groups.
a) identity
b) intimacy
c) industry
d) initiative
The practical nurse (PN) identifies an increased frequency Answer: A
of otitis media (OM) is children who are coming to the clinic.
Based on this finding, which age group should the PN Rationale:
monitor a child for signs and symptoms of OM? Infants and toddlers (A) are most prone to otitis media due to the anatomical structure
of the eustachian tube that allows fluid and microbial entry into the middle ear. (B, C,
a) toddler and D) are most susceptible to acute infectious diseases acquired through
b) preschooler environmental transmission from daycare or school settings.
c) school ager
d) adolescent
The practical nurse (PN) collects information about infant Answer: D
growth and development milestones for infants who come to
the clinic for a well child visit. Which findings should the PN Rationale:
document as normal infant growth and development? Infants gain approximately 1.5 pounds/month until age 5 to 6 months, when the birth
weight doubles, and by 1 year of age, the birth weight usually triples (D). The anterior
a) maternal iron stores persist during the first 12 months of fontanel closes by 12 to 18 months of age, with the average being 14 months, not (B).
life Binocularity begins to develop by 6 weeks of age and should be well established by
b) anterior fontanel closes by 6 to 10 months of age age 4 months, not (C). Maternally derived iron stores ares present for the first 5 to 6
c) binocularity is well established by 8 months of age months and gradually diminish, which results in an expected lowered hemoglobin
d) birth weight double by age 5 months and triples by 1 year levels toward the end of the first 6 months (A).
Which nonfood item is the most common cause of Answer: A
respiratory arrest in young children?
Rationale:
a) latex balloons Nonfood items cause the majority of choking deaths in young children. Latex balloons
b) broken rattles (A), whether partially inflated, uninflated, or popped, are the leading cause of pediatric
c) buttons choking that leads to aspiration of small objects (A,B, and D) because they experience
d) pacifiers the environment by placing objects in the mouth, but (A) is the leading cause of death
causing respiratory obstruction and arrest.
