Nursing Care of Children Health promotion and Maintenance

Nursing Care of Children Health promotion and Maintenance

Nursing Care of Children Health promotion and Maintenance




1. The parent of a two-year-old child reports feeling frustrated with the fact that her son is saying
no to everything. The nurse should teach the parent that this behavior is a normal expression of
the child’s desire to accomplish which of the following?
a. Finish a project they set out to do.
b. Gratify their oral fixation.

c. Increase their independence.

d. Develop their sense of trust.


Rationale: The drive for independence is expressed by the toddler opposing the desires of those
in authority (tantrums) and attempting to do everything for themselves. The Erickson
developmental stage for this age is “Autonomy vs. Shame and Doubt.”

2. At a well-child visit, the parents report that their toddler occasionally touches and fondles
her genital area. The parents ask the nurse if this behavior is something to be concerned
about. Which of the following is a correct response?
:
a. This is a possible infection or irritation in the genital area

b. This is an early emergence of sexual expression that should be discouraged

c. Your child is probably imitating behaviors that she has observed

d. Awareness of body structures and sensations is normal and expected.


Rationale: Genital self-stimulation by the toddler is normal and expected. It is a new area to
explore, similar to exploring the toes at an earlier age, but it has pleasurable sensations too! It
should be ignored unless the behavior becomes pervasive, and then it should still be ignored and
the child should be distracted to come and do some fun and exciting activity

,Nursing Care of Children Health promotion and Maintenance




3. A nurse is taking the health history of a school-age girl. Which statement by the client’s
mother indicates a need for further teaching regarding the client’s nutritional status?
Select one:
a. “We allow her to pick out a treat at the grocery store for good behavior.”

b. “We increase her protein intake when she’s playing sports.”

c. "She enjoys helping to prepare her snacks in the kitchen.”

d. “She eats a large breakfast every morning.”


Rationale: This statement indicates a need for further teaching. This client’s mother should be
educated about the importance of praising the client’s abilities and skills rather than using
food as a reward, which may lead to an increased risk for obesity.

4. A nurse correctly understands which of the following characteristics is a possible
developmental delay for a 3-month-old client?
Select one:
a. The infant demonstrates stranger anxiety

b. The infant is unable to point to objects

c. The infant is unable to sit with support

d. The infant does not raise his head when placed on his abdomen


Rationale: When placed on the abdomen the 3 month old should attempt to raise his head.
Some sources refer to this as “tummy time” which provides the infant with the stimulation to
strengthen upper body and neck muscles in preparation for good head control when sitting
upright and the some of the muscles required for crawling.


5. A nurse has administered the first DTaP (diphtheria toxoid, tetanus and pertussis)
immunization to a two-month-old infant. For which of the following symptoms should
the nurse teach the parents to seek immediate medical attention?

Select one:
a. The baby develops a localized or generalized rash

, Nursing Care of Children Health promotion and Maintenance

b. The baby has an axillary temperature of 100.4o F. (38o C)

c. The baby develops swelling or redness at the injection site

d. The baby is crying inconsolably for more than three hours


Rationale: Inconsolable crying lasting more than three hours and/or seizures within 48 hours of
vaccination is a sign of encephalopathy that must be treated immediately.




6. A nurse is educating the parents of an infant about symptoms that should be reported to
the provider. What finding should be immediately reported?
Select one:
a. Abdominal distension

b. Mild diarrhea

c. Decreased urine output

d. Difficulty evacuating bowels


Rationale: Decreased urine output indicates dehydration and should be reported immediately
to the provider. Listlessness, sunken eyes, decreased tears, and dry mucous membranes are
other symptoms of dehydration that should be immediately reported.


7. A nurse is changing a dressing on a preschool-aged child who has a healing wound on a
lower extremity. Which of the following nonpharmacologic comfort measures would be
most appropriate for this child?
Select one:
a. Encouraging the child to watch a favorite cartoon on television.

b. Promising the child a special treat in exchange for cooperation.

c. Teaching the child how to go ‘to a different place’ using their imagination.