Submission Date: 1/19/2014
Submission Time: 11:38 PM
Points Awarded: 67
Points Missed: 17
Number of Attempts Allowed: Unlimited
Not Scored: 0
Percentage: 79.8%
Pediatrics A
1.ID: 310989347
A 3-week-old newborn is brought to the clinic for follow-up after a home birth. The mother reports that
her child bottle feeds for 5 minutes only and then falls asleep. The nurse auscultates a loud murmur
characteristic of a ventricular septal defect (VSD), and finds the newborn is acyanotic with a respiratory
rate of 64 breaths per minute. What instruction should the nurse provide the mother to ensure the
infant is receiving adequate intake? (Select all that apply.)
Monitor the the infant's weight and number of wet diapers per day. Correct
Increase the infant's intake per feeding by 1 to 2 ounces per week. Correct
Mix the dose of prophylactic antibiotic in a full bottle of formula.
Allow the infant to rest and refeed on demand or every 2 hours. Correct
Use a softer nipple or increase the size of the nipple opening. Correct
Correct responses are (A, B, D, and E). Neonates who have VSD may fatigue quickly during feeding and
ingest inadequate amounts. They should be monitored for weight gain and at least 6 wet diapers per day
(A). A one-month old infant should ingest 2 to 4 ounces of formula per feeding and progress to about 30
ounces per day by 4-months of age (B). Due to fatigue, the infant should rest, but feed at least every 2
hours to ensure adequate intake (D). A softer (preemie) nipple or a larger slit in the nipple (E) helps to
reduce the sucking effort and energy expenditure, thus allowing the infant to ingest more with less
effort. Antibiotic prophylaxis is recommended for infants with VSDs, but should not be mixed in a bottle
of formula (C) because it is difficult to ensure that the total dose is consumed.
Awarded 1.0 points out of 1.0 possible points.
,2.ID: 310949404
A 15-year-old girl tells the school nurse that all of her friends have started their periods and she feels
abnormal because she has not. Which response is best for the nurse provide?
Refer the adolescent to the healthcare provider for a pregnancy screen.
Schedule a conference with her parents to recommend hormone therapy.
Explain that menarche varies and occurs between the ages of 12 and 18 years. Correct
Suggest that she use diversions to help her not worry about delayed menarche.
The nurse should provide a factual and reassuring explanation that focuses on individual variations of
menarche, which can normally occur between 12 and 18 years of age (C). (A) does not address the
adolescent's concern and is judgmental. Menarche is influenced by hereditary, general health, and
nutritional status, so (B) is not indicated. (D) dismisses the adolescent's concerns and does not offer
factual information.
Awarded 1.0 points out of 1.0 possible points.
3.ID: 311008915
Which finding in a 19-year-old female client should trigger further assessment by the nurse?
Menstruation has not occurred. Correct
Reports no tetanus immunization since childhood.
Denies having any wisdom teeth.
History of painful, inward growth on bottom of foot.
Menstruation is an expected secondary sex characteristic that occurs with pubescence and typically
occurs by age 18, so (A) should prompt further investigation to determine the cause of this primary
amenorrhea. Children receive tetanus as part of the DPT childhood immunization series, and a booster is
not typically given until age 16 (B). Wisdom teeth are the third molar teeth of the permanent dentition
and are the last to erupt, so (C) is a normal finding. (D) describes a plantar surface wart, harmless but
painful because of the pressure with walking or standing.
Awarded 1.0 points out of 1.0 possible points.
4.ID: 311023669
,At 8 a.m. the unlicensed assistive personnel (UAP) informs the charge nurse that a female adolescent
client with acute glomerulonephritis has a blood pressure of 210/110. The 4 a.m. blood pressure reading
was 170/88. The client reports to the UAP that she is upset because her boyfriend did not visit last night.
What action should the nurse take first?
Give the client her 9 a.m. prescription for an oral diuretic early.
Administer PRN prescription of nifedipine (Procardia) sublingually. Correct
Notify the healthcare provider and inform the nursing supervisor of the client's condition.
Attempt to calm the client and retake the blood pressure in thirty minutes.
Sublingual Procardia (B) lowers blood pressure very quickly, and this should be done first. (A) may also be
done, but oral diuretics do not work as rapidly as the sublingual antihypertensive. When notifying the
healthcare provider, the first thing he/she will want to know is if the PRN antihypertensive has been
administered (C). (D) does not consider the seriousness of this finding. The nurse should stay with the
client until the blood pressure is reduced.
Awarded 1.0 points out of 1.0 possible points.
5.ID: 310978607
A 3-year-old client with sickle cell anemia is admitted to the Emergency Department with abdominal
pain. The nurse palpates an enlarged liver, an x-ray reveals an enlarged spleen, and a CBC reveals
anemia. These findings indicate which type of crisis?
Aplastic.
Sequestration. Correct
Hyperhemolytic.
Vaso-occlusive.
The findings support a sequestration crisis (B), where blood pools in the spleen, and is characterized by
abdominal pain and anemia. (A and C) crises produce anemia but no abdominal pain or splenic
enlargement. (D) crisis may produce abdominal pain, but no splenic enlargement or exacerbation of
anemia.
Awarded 1.0 points out of 1.0 possible points.
6.ID: 310949434
, A preschool-age child who is hospitalized for hypospadias repair is most strongly influenced by which
behavior?
Ability to communicate verbally.
Response to separation from family.
Concern for body integrity. Correct
Socialization with other children.
The preschooler's major stressor is concern for his body integrity (C). He fears that his "insides will leak
out." A child undergoing surgery to his genitalia is even more concerned about body integrity. The
preschooler is quite verbal, so comprehension of the words he uses or hears may be inaccurate, while
his imagination and fears may fantasize the reality (A). (B) is a concern for all children, but of most
concern to the toddler. (D) is not a prime concern in this situation.
Awarded 1.0 points out of 1.0 possible points.
7.ID: 310950716
The vital signs of a 4-year-old child with polyuria are: BP 80/40, Pulse 118, and Respirations 24. The
child's pedal pulses are present with a volume of +1, and no edema is observed. What action should the
nurse implement first?
Insert an indwelling urinary catheter.
Start an IV infusion of normal saline. Correct
Send a specimen to the lab for urinalysis.
Document the child's vital signs and pulses.
The current vital sign readings and the decreased peripheral pulse volume indicate that the child is
experiencing fluid volume deficit due to the polyuria, so the priority action is to restore fluid volume (B).
(A) is useful in obtaining a precise urine output measure, but is a lower priority than restoring fluid
volume at this time. (C) is not indicated based on the current assessment data, and (D) does not
recognize the need for immediate action to combat the fluid volume deficit.
Awarded 1.0 points out of 1.0 possible points.
8.ID: 310969421
Submission Time: 11:38 PM
Points Awarded: 67
Points Missed: 17
Number of Attempts Allowed: Unlimited
Not Scored: 0
Percentage: 79.8%
Pediatrics A
1.ID: 310989347
A 3-week-old newborn is brought to the clinic for follow-up after a home birth. The mother reports that
her child bottle feeds for 5 minutes only and then falls asleep. The nurse auscultates a loud murmur
characteristic of a ventricular septal defect (VSD), and finds the newborn is acyanotic with a respiratory
rate of 64 breaths per minute. What instruction should the nurse provide the mother to ensure the
infant is receiving adequate intake? (Select all that apply.)
Monitor the the infant's weight and number of wet diapers per day. Correct
Increase the infant's intake per feeding by 1 to 2 ounces per week. Correct
Mix the dose of prophylactic antibiotic in a full bottle of formula.
Allow the infant to rest and refeed on demand or every 2 hours. Correct
Use a softer nipple or increase the size of the nipple opening. Correct
Correct responses are (A, B, D, and E). Neonates who have VSD may fatigue quickly during feeding and
ingest inadequate amounts. They should be monitored for weight gain and at least 6 wet diapers per day
(A). A one-month old infant should ingest 2 to 4 ounces of formula per feeding and progress to about 30
ounces per day by 4-months of age (B). Due to fatigue, the infant should rest, but feed at least every 2
hours to ensure adequate intake (D). A softer (preemie) nipple or a larger slit in the nipple (E) helps to
reduce the sucking effort and energy expenditure, thus allowing the infant to ingest more with less
effort. Antibiotic prophylaxis is recommended for infants with VSDs, but should not be mixed in a bottle
of formula (C) because it is difficult to ensure that the total dose is consumed.
Awarded 1.0 points out of 1.0 possible points.
,2.ID: 310949404
A 15-year-old girl tells the school nurse that all of her friends have started their periods and she feels
abnormal because she has not. Which response is best for the nurse provide?
Refer the adolescent to the healthcare provider for a pregnancy screen.
Schedule a conference with her parents to recommend hormone therapy.
Explain that menarche varies and occurs between the ages of 12 and 18 years. Correct
Suggest that she use diversions to help her not worry about delayed menarche.
The nurse should provide a factual and reassuring explanation that focuses on individual variations of
menarche, which can normally occur between 12 and 18 years of age (C). (A) does not address the
adolescent's concern and is judgmental. Menarche is influenced by hereditary, general health, and
nutritional status, so (B) is not indicated. (D) dismisses the adolescent's concerns and does not offer
factual information.
Awarded 1.0 points out of 1.0 possible points.
3.ID: 311008915
Which finding in a 19-year-old female client should trigger further assessment by the nurse?
Menstruation has not occurred. Correct
Reports no tetanus immunization since childhood.
Denies having any wisdom teeth.
History of painful, inward growth on bottom of foot.
Menstruation is an expected secondary sex characteristic that occurs with pubescence and typically
occurs by age 18, so (A) should prompt further investigation to determine the cause of this primary
amenorrhea. Children receive tetanus as part of the DPT childhood immunization series, and a booster is
not typically given until age 16 (B). Wisdom teeth are the third molar teeth of the permanent dentition
and are the last to erupt, so (C) is a normal finding. (D) describes a plantar surface wart, harmless but
painful because of the pressure with walking or standing.
Awarded 1.0 points out of 1.0 possible points.
4.ID: 311023669
,At 8 a.m. the unlicensed assistive personnel (UAP) informs the charge nurse that a female adolescent
client with acute glomerulonephritis has a blood pressure of 210/110. The 4 a.m. blood pressure reading
was 170/88. The client reports to the UAP that she is upset because her boyfriend did not visit last night.
What action should the nurse take first?
Give the client her 9 a.m. prescription for an oral diuretic early.
Administer PRN prescription of nifedipine (Procardia) sublingually. Correct
Notify the healthcare provider and inform the nursing supervisor of the client's condition.
Attempt to calm the client and retake the blood pressure in thirty minutes.
Sublingual Procardia (B) lowers blood pressure very quickly, and this should be done first. (A) may also be
done, but oral diuretics do not work as rapidly as the sublingual antihypertensive. When notifying the
healthcare provider, the first thing he/she will want to know is if the PRN antihypertensive has been
administered (C). (D) does not consider the seriousness of this finding. The nurse should stay with the
client until the blood pressure is reduced.
Awarded 1.0 points out of 1.0 possible points.
5.ID: 310978607
A 3-year-old client with sickle cell anemia is admitted to the Emergency Department with abdominal
pain. The nurse palpates an enlarged liver, an x-ray reveals an enlarged spleen, and a CBC reveals
anemia. These findings indicate which type of crisis?
Aplastic.
Sequestration. Correct
Hyperhemolytic.
Vaso-occlusive.
The findings support a sequestration crisis (B), where blood pools in the spleen, and is characterized by
abdominal pain and anemia. (A and C) crises produce anemia but no abdominal pain or splenic
enlargement. (D) crisis may produce abdominal pain, but no splenic enlargement or exacerbation of
anemia.
Awarded 1.0 points out of 1.0 possible points.
6.ID: 310949434
, A preschool-age child who is hospitalized for hypospadias repair is most strongly influenced by which
behavior?
Ability to communicate verbally.
Response to separation from family.
Concern for body integrity. Correct
Socialization with other children.
The preschooler's major stressor is concern for his body integrity (C). He fears that his "insides will leak
out." A child undergoing surgery to his genitalia is even more concerned about body integrity. The
preschooler is quite verbal, so comprehension of the words he uses or hears may be inaccurate, while
his imagination and fears may fantasize the reality (A). (B) is a concern for all children, but of most
concern to the toddler. (D) is not a prime concern in this situation.
Awarded 1.0 points out of 1.0 possible points.
7.ID: 310950716
The vital signs of a 4-year-old child with polyuria are: BP 80/40, Pulse 118, and Respirations 24. The
child's pedal pulses are present with a volume of +1, and no edema is observed. What action should the
nurse implement first?
Insert an indwelling urinary catheter.
Start an IV infusion of normal saline. Correct
Send a specimen to the lab for urinalysis.
Document the child's vital signs and pulses.
The current vital sign readings and the decreased peripheral pulse volume indicate that the child is
experiencing fluid volume deficit due to the polyuria, so the priority action is to restore fluid volume (B).
(A) is useful in obtaining a precise urine output measure, but is a lower priority than restoring fluid
volume at this time. (C) is not indicated based on the current assessment data, and (D) does not
recognize the need for immediate action to combat the fluid volume deficit.
Awarded 1.0 points out of 1.0 possible points.
8.ID: 310969421
